Syndrome of the trephined: clinical spectrum, risk factors, and impact of cranioplasty on neurologic recovery in a prospective cohort

Abstract

Syndrome of the trephined (SoT) is an underrecognized complication after decompressive craniectomy. We aimed to investigate SoT incidence, clinical spectrum, risk factors, and the impact of the cranioplasty on neurologic recovery. Patients undergoing a large craniectomy (> 80 cm2) and cranioplasty were prospectively evaluated using modified Rankin score (mRS), cognitive (attention/processing speed, executive function, language, visuospatial), motor (Motricity Index, Jamar dynamometer, postural score, gait assessment), and radiologic evaluation within four days before and after a cranioplasty. The primary outcome was SoT, diagnosed when a neurologic improvement was observed after the cranioplasty. The secondary outcome was a good neurologic outcome (mRS 0–3) 4 days and 90 days after the cranioplasty. Logistic regression models were used to evaluate the risk factors for SoT and the impact of cranioplasty timing on neurologic recovery. We enrolled 40 patients with a large craniectomy; 26 (65%) developed SoT and improved after the cranioplasty. Brain trauma, hemorrhagic lesions, and shifting of brain structures were associated with SoT. After cranioplasty, a shift towards a good outcome was observed within 4 days (p = 0.025) and persisted at 90 days (p = 0.005). Increasing delay to cranioplasty was associated with decreased odds of improvement when adjusting for age and baseline disability (odds ratio 0.96; 95% CI, 0.93–0.99, p = 0.012). In conclusion, SoT is frequent after craniectomy and interferes with neurologic recovery. High suspicion of SoT should be exercised in patients who fail to progress or have a previous trauma, hemorrhage, or shifting of brain structures. Performing the cranioplasty earlier was associated with improved and quantifiable neurologic recovery.

Can Cranioplasty Be Considered a Tool to Improve Cognitive Recovery Following Traumatic Brain Injury? A 5-Years Retrospective Study

“…Only a few studies have strictly focused on cognitive recovery after this surgical procedure, and the assessment was often performed with different tools [4][5][6][7][8]. On the contrary, many studies have aimed to understand the right timing to perform cranioplasty after DC.…”

“…In particular, the impact of cranioplasty on cognitive and motor function is also controversial. Patients with TBI show a wide range of neurocognitive and psychologic deficits after DC [6]. Although several studies have documented clinical improvements after cranioplasty in patients with severe brain injury, the reasons behind the possible mechanisms that induce such clinical improvement are not fully understood [7].…”

Prognosis-Guided Reconstruction of Scalp and Skull Defects in Neurosurgical Patients

“…In these patients, neurosurgery determines the timeline for intervention with a preference to use alloplastic reconstruction. Based on our findings, alloplastic reconstruction appears to be an appropriate choice only in this subset of patients, given the high exposure rate within a short time, to avoid increased donor site morbidity 10 …”

“…Based on our findings, alloplastic reconstruction appears to be an appropriate choice only in this subset of patients, given the high exposure rate within a short time, to avoid increased donor site morbidity. 10 Irradiated patients have been shown to have complication rates between 19% and 21% and are 8 times more likely to require reoperation than nonirradiated patients. 9,11,12 Radiation limits indications for alloplastic reconstruction, as vascularized bone flaps are more resistant to complications of osteoradionecrosis and have better results after multiple failed alloplastic attempts.…”

Custom 3D-Printed External Cranial Orthotic for Prevention and Treatment of Syndrome of the Trephined

“…Syndrome of the Trephined (SoT), sometimes referred to as Sinking Skin Flap Syndrome (SSFS), is an underdiagnosed and often misunderstood result of decompressive craniectomy. 1–4 After undergoing decompressive craniectomy for various pathologies, patients can display symptoms ranging from headaches, dizziness, altered behavior to changes in sensation, and difficulty with ambulation, coordination, and activities of daily living. These are frequently misattributed to sequelae of traumatic brain injury 1–6 …”