Syndrome of the Trephined

Ashayeri, Kimberly; Jackson, Eric M.; Huang, Judy; Brem, Henry; Gordon, Chad R.

doi:10.1227/neu.0000000000001366

Cited by 189 publications

(149 citation statements)

References 51 publications

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“…In 1939 Grant and Norcross have introduced the term "syndrome of the trephined" as a combination of symptoms including headaches, mental and speech disturbances, sensory and visual changes, fatigue, and dizziness in patients with cranial defects [7]. It has been summarized that in SOT the symptoms usually begin weeks to months after the craniectomy with no relation to the location of the primary intracranial lesion and an improvement was observed after a cranioplastic surgery [4,7,9,10]. Later, in 1977, a neurological deterioration with a presence of a concave deformity of the skin flap above the cranial bone defect in post-DC patients has been reported by Yamaura and Makino and named "sinking skin flap syndrome".…”

Section: Discussionmentioning

confidence: 99%

“…This external force causes the concave deformity of the skin with a distortion of the meninges, compression of the subarachnoid space and the underlying brain tissue, thus altering the cerebral blood inflow and venous outflow, cerebral metabolism, and CSF flow velocity and resorption [3,4,8,27,28]. Due to an almost direct transmission of the atmospheric pressure onto the intracranial space the ICP tends to equalize with the atmospheric pressure (1033cm of H 2 0) and if a rapid change of the intracranial compartment volume occurs, such as during the upright position, dehydration or during a CSF leak the intracranial contents may be pushed downwards through the tentorial notch and foramen magnum leading to an aggravation of present symptoms and even to a paradoxical cerebral herniation [3,8,10,15,25,28]. The CSF dynamics is typically restored after the cranioplastic surgery which results in normalisation of the ICP [4,8].…”

Section: Discussionmentioning

confidence: 99%

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Sinking Skin Flap Syndrome and Paradoxical Herniation Provoked by a Malfunction of External Lumbar Drainage and CSF Leak

Hanko

Snopko

Opšenák

et al. 2019

Acta Medica Martiniana

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The sinking skin flap syndrome represents a less-frequent complication in patients after a decompressive craniectomy. It is defined as a neurological deterioration accompanied by a flat or concave deformity of the craniectomy-related skin flap. The underlying brain parenchyma is distorted correspondingly with its blood flow and metabolism being impaired and cerebrospinal fluid hydrodynamics being disturbed, thus causing cerebral dysfunction and neurological symptomatology. The most important options for reversal of this syndrome include Trendelenburg position, maintaining of the cerebrospinal fluid balance, and cranioplasty as a definite solution. We present a patient who underwent a decompressive craniectomy complicated by a cerebrospinal fluid leak in the operative wound treated by means of an external lumbar drainage. Subsequently he developed the sinking skin flap syndrome and a paradoxical cerebral herniation after the drainage system malfunction with a massive cerebrospinal fluid leak at the site of the lumbar drain insertion parallel to the drain itself. His symptoms were, however, successfully alleviated by a positional change, rehydration, and interruption of the lumbar drainage. This illustrational case suggests that clinicians should be aware that patients after decompressive craniectomy may develop a sinking skin flap syndrome as it may either represent an acute risk of a paradoxical brain herniation or complicate the further postoperative care if developed in a chronic way.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Sinking Skin Flap Syndrome and Paradoxical Herniation Provoked by a Malfunction of External Lumbar Drainage and CSF Leak

Hanko

Snopko

Opšenák

et al. 2019

Acta Medica Martiniana

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“…25 The main advantage of early cranioplasty is that it prevents syndrome of the trephined. 26,27 In all patients who underwent cranioplasty in this series, cranioplasty was conducted within 3 months without any complications. The materials used for the cranioplasty included hydroxyapatite blocks, titanium mesh, and alumina ceramics.…”

Section: Discussionmentioning

confidence: 99%

“…31,32 Immediate cranial reconstruction is especially advantageous for patients with VP shunts since their skin flaps are likely to shrink due to atmospheric pressure, which can contribute to the development of syndrome of the trephined. 26,27 …”

Section: Discussionmentioning

confidence: 99%

Versatility of the Latissimus Dorsi Free Flap during the Treatment of Complex Postcraniotomy Surgical Site Infections

Yoshioka

2017

Plastic and Reconstructive Surgery - Global Open

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Background:Some intractable cases of postcraniotomy infection, which can involve compromised skin, an open frontal air sinus, and residual epidural dead space, have been reported. In such cases, reconstructing the scalp and skull is challenging.Methods:Between 2009 and 2016, the author treated 12 patients with recalcitrant postcraniotomy surgical site infections with latissimus dorsi (LD) free flaps. The patients’ ages ranged from 37 to 79 years (mean, 63.5 years), and their underlying diseases included subarachnoid hemorrhaging (n = 5), brain tumors (n = 4), and cerebral arteriovenous malformations (n = 3).Results:The LD free flap was used for scalp reconstruction in 3 cases, scalp reconstruction and separation of the intracranial and nasal cavities in 5 cases, and the obliteration of epidural dead space in 4 cases. Debridement followed by staged cranial reconstruction was carried out in 8 cases, and single-stage cranial reconstruction was conducted in 2 cases. The bone defects of the other 2 cases, which were small, were filled with LD musculo-adipose free flaps. The postoperative local appearance of the wounds was acceptable in every case, and no complications occurred.Conclusions:The LD free flap is a versatile tool for the treatment of complex postcraniotomy surgical site infections. This vascularized muscle flap is useful for controlling local infections because of its abundant vascularity. Moreover, its variety of uses means that it can resolve several problems in cases involving complex cranial wounds.

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“…Over the past half century, neurosurgical and emergency care increasingly improved, and this procedure has become a routine surgery in neurosurgery department 4 5. However, reconstructing the cranial defect brings many challenges to surgeons, and search for ideal materials is throughout the development of reconstructive procedures 6–9…”

Section: Introductionmentioning

confidence: 99%

Evaluation of titanium mesh cranioplasty and polyetheretherketone cranioplasty: protocol for a multicentre, assessor-blinded, randomised controlled trial

Yang

Yuan

et al. 2019

BMJ Open

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IntroductionCranioplasty is a common surgery in neurosurgery department. However, restoring the integrity of skull brings many challenges to surgeons, and the selection of ideal implant materials is throughout the history of cranioplasty. Although titanium mesh was still preferred by many neurosurgeons in cranial reconstruction, the new polyetheretherketone (PEEK) material, for example, is gaining popularity for craniofacial reconstruction today. There remain limited data that compare the outcome of PEEK cranioplasty and titanium mesh cranioplasty. It is necessary to conduct a study to compare outcome of different materials for cranioplasty.Methods/designIn this multicentre, assessor-blinded, randomised controlled study, we will randomise 140 patients in a 1:1 ratio to PEEK cranioplasty versus titanium cranioplasty. Eligible patients are adults who were diagnosed with cranial defect (due to severe traumatic brain injury, ischaemic stroke, haemorrhagic stroke, infiltrative tumour and so on), the defect size is over 25 cm2, and they need to agree to participate in this trial. Instead of standard examinations, the enrolled patients receive neurological, motor, cognitive function and cerebral hemodynamics examinations as well as cosmetic evaluation. The procedures are repeated 3, 6 months after cranioplasty. The primary outcome, defined as infection or implant exposure after surgery, is the implant failure rate within 6 months. Secondary outcomes include postoperative complication rates, neurological outcomes, motor function, cerebral hemodynamics, cosmetic outcome and the total cost over a 6-month period.Ethics and disseminationThis trial protocol has been approved by Biomedical Research Ethics Committee of West China Hospital of Sichuan University. All patients will be fully informed the implant materials, potential complications after surgery, responsibilities during the trial, and they will sign the informed consent before joining in this trial. If the patient’s cognitive function is impaired, the patient’s next of kin would be carefully informed. The results will be disseminated through academic conferences, student theses and will be published in a peer-reviewed journal.Trail registration numberChiCTR1900024625; Pre-results.

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Syndrome of the Trephined

Abstract: ADLs, activities of daily livingCBF, cerebral blood flowSoT, syndrome of the trephinedVP, ventriculoperitoneal.

Cited by 189 publications

References 51 publications

Sinking Skin Flap Syndrome and Paradoxical Herniation Provoked by a Malfunction of External Lumbar Drainage and CSF Leak

Sinking Skin Flap Syndrome and Paradoxical Herniation Provoked by a Malfunction of External Lumbar Drainage and CSF Leak

Versatility of the Latissimus Dorsi Free Flap during the Treatment of Complex Postcraniotomy Surgical Site Infections

Evaluation of titanium mesh cranioplasty and polyetheretherketone cranioplasty: protocol for a multicentre, assessor-blinded, randomised controlled trial

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