Sinking skin flap syndrome presenting as autonomic dysautonomia

Abstract

To demonstrate a rare complication of decompressive Craniotomy and its presentation as dysautonomia Sinking skin flap syndrome is a rare complication of a large decompressive craniotomy surgery. It occurs due to atmospheric pressure exceeding intracranial pressure causing paradoxical herniation. It is often precipitated by CSF drainage procedure. 44 years old gentleman presented with acute left hemiplegia with NIHSS score 12. He was thrombolysed intravenously but unfortunately developed a large basal ganglia hemorrhage the following day. He underwent emergency decompressive craniotomy as he started herniating. Post surgery developed high grade fever for which he required a guarded lumbar puncture done on day 14. His fever and consciousness improved in the next 2 weeks and he was able to communicate and was mobilized to wheel chair. 4th week he started becoming drowsy, unresponsive with episodes of dysautonomia in form of high temperature, severe sweating, tachypnoea and severe tachycardia. CT brain done showed sunken skin flap with paradoxical herniation. Conservative methods failed and replacement of bone flap ultimately helped and patient recovered. Replacement of bone flap is the definitive treatment of sinking skin flap syndrome which if unrecognized can be fatal. Sinking skin flap syndrome is a rare complication of decompressive craniotomy and can present with dysautonomic symptoms. Replacement of bone flap remains definitive treatment