Sinking Skin Flap Research Articles

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

Abstract 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.

Sinking skin flap syndrome presenting as autonomic dysautonomia

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

Sinking Skin Flap Syndrome or Syndrome of the Trephined: A Report of Two Cases.

Decompressive craniectomy (DC) is commonly performed in patients with intracranial hypertension or brain edema due to traumatic brain injury. Infrequently, neurologic deteriorations accompanied by sunken scalp may occur after DC. We report two patients with traumatic subdural hemorrhage who had neurologic deteriorations accompanied by sunken scalp after DC. Neurologic function improved dramatically in both patients after cranioplasty. Monitoring for neurologic deterioration after craniectomy is advised. For patients showing neurologic deficit with a sunken scalp, early cranioplasty should be considered.

Sinking skin flap syndrome following decompressive craniectomy

A 30 year-old man was admitted to the intensive care unit for severe brain trauma following a motorcycle accident. Brain computed tomography (CT) showed severe left hemorrhagic contusions (Figure 1...

Sinking skin flap syndrome in a patient with giant thrombosed posterior cerebral artery aneurysm: a case report

Abstract Sinking skin flap syndrome is a rare complication following decompressive craniectomy. The pathogenesis is based on disturbed cerebral autoregulation and as a consequence dicreased CBF and cerebral metabolism. This results in neurologic disturbances, i. e. mental changes and focal deficits. The authors present the patient who developed the motor trephine syndrome after decompressive craniectomy following complicated giant posterior cerebral artery aneurysm clipping.

Complicación tras craniectomía descompresiva: el «síndrome del paciente trepanado» de aparición precoz

Decompressive craniectomy has been adopted as a possible therapeutic option for extreme cases of traumatic brain injury and malignant ischemic stroke. The history of decompressive craniectomy, though, involves civilian and military discoveries that have been progressively confused and even forgotten. The syndrome of the trephined was introduced in 1939 as a feeling of tenderness, discomfort, and insecurity located at the site of craniectomy. Forty years later, in 1977, the sinking skin flap syndrome was defined as new-onset neurologic deficits or even coma associated with marked skin depression at the site of craniectomy, indicating urgent need for cranioplasty. These 2 syndromes illustrate the paradigm shift of the indications for cranioplasty, which have evolved from cosmetic reasons in the 1940s to cerebral metabolism improvement in the early 21st century.

Sinking Skin Flap Syndrome Presenting with Cranial Neuropathies (P6.063)

Sinking Skin Flap Syndrome Presenting with Cranial Neuropathies (P6.063)

Sinking Skin Flap Syndrome after Decompressive Craniotomy

Sinking Skin Flap Syndrome after Decompressive Craniotomy

Intraoperative seizures during redo cranioplasty for sinking skin flap syndrome- Role of BIS™ monitor in detection.

Intraoperative seizures during redo cranioplasty for sinking skin flap syndrome- Role of BIS™ monitor in detection.

Review of Cranioplasty after Decompressive Craniectomy.

Cranioplasty is an in evitable operation conducted after decompressive craniectomy (DC). The primary goals of cranioplasty after DC are to protect the brain, achieve a natural appearance and prevent sinking skin flap syndrome (or syndrome of the trephined). Furthermore, restoring patients' functional outcome and supplementing external defects helps patients improve their self-esteem. Although early cranioplasty is preferred in recent year, optimal timing for cranioplasty remains a controversial topic. Autologous bone flaps are the most ideal substitute for cranioplasty. Complications associated with cranioplasty are also variable, however, post-surgical infection is most common. Many new materials and techniques for cranioplasty are introduced. Cost-benefit analysis of these new materials and techniques can result in different outcomes from different healthcare systems.

Reversibility of Murine Motor Deficits Following Hemi-Craniectomy and Cranioplasty.

Hemi-craniectomy is a common surgical procedure which allows the brain to swell and herniate and is often utilized to treat traumatic brain injury. When left untreated the scalp skin typically sinks on the side of the craniectomy creating a phenotype termed "sinking skin flap syndrome." In addition, these same patients often develop long-term neurocognitive deficits termed "syndrome of the trephined" as a result of their craniectomy which reverse when the cranial skull is replaced. The authors hypothesize that a mouse animal model can be developed demonstrating long-term neurologic deficits attributed to hemi-craniectomy skull defects similar to humans with syndrome of the trephined. Thirty C57 mice were randomized among 3 groups: Group 1 = control group (sham surgery), Group 2 = hemi-craniectomy only, and Group 3 = hemi-craniectomy with immediate cranioplasty. Motor deficits were studied using a beam walk test. Statistical comparison of differences among the 3 groups was performed. Beam walk test results demonstrated the craniectomy group had a statistically higher contralateral footfault slip/step ratio when compared with the control group (P <0.05). Comparison of the control group and the cranioplasty group demonstrated contralateral footfault slip/step ratio that was statistically different for 7 days postoperative but no statistical differences thereafter. Comparison of the craniectomy group and the cranioplasty group demonstrated statistically significant differences for 14 days; however, motor deficits were not statistically different than baseline thereafter. No ipsilateral footfault deficits were detected in this study. Motor deficits that are attributed to hemi-craniectomy bone defects alone are demonstrated in a mouse animal model. These motor deficits resemble some symptoms associated with human syndrome of the trephined.

Sinking skin flap syndrome after unilateral cranioplasty and ventriculoperitoneal shunt in a patient with bilateral decompressive craniectomy

• Ventriculoperitoneal (VP) shunt with skull defects may cause sinking skin flap syndrome.

Syndrome of the Trephined: A Systematic Review.

Syndrome of the trephined (SoT) is a rare, important complication of a craniectomy characterized by neurological dysfunction that improves with cranioplasty. Its varied symptoms include motor, cognitive, and language deficits. Its exact characterization appears suboptimal, with differing approaches of evaluation. Accordingly, this topic is in great need of further investigation. To accurately describe SoT and explore methods of an objective diagnosis/evaluation. Electronic searches of PubMed, MEDLINE, Web of Knowledge, and PsycINFO databases used the key words "syndrome of the trephined" and "sinking skin flap." Non-English-language and duplicate articles were eliminated. Title and abstract reviews were selected for relevance. Full-text reviews were selected for articles providing individual characteristics of SoT patients. This review identified that SoT most often occurs in male patients (60%) at 5.1 ± 10.8 months after craniectomy for neurotrauma (38%). The average reported craniectomy is 88.3 ± 34.4 cm and usually exists with a "sunken skin flap" (93%). Symptoms most commonly include motor, cognitive, and language deficits (57%, 41%, 28%, respectively), with improvement after cranioplasty within 3.8 ± 3.9 days. Functional independence with activities of daily living is achieved by 54.9% of patients after 2.9 ± 3.4 months of rehabilitation. However, evaluation of SoT is inconsistent, with only 53% of reports documenting objective studies. SoT is a variable phenomenon associated with a prolonged time to cranioplasty. Due to current weaknesses in objectivity, we hypothesize that SoT is often underdiagnosed and recommend a multifaceted approach for consistent evaluation. SoT is a serious complication that lacks exact characterization and deserves future investigation. Improved understanding and recognition have important implications for early intervention and patient outcomes. ADLs, activities of daily livingCBF, cerebral blood flowSoT, syndrome of the trephinedVP, ventriculoperitoneal.

頭蓋形成術直後の予期せぬ合併症について(Unexpected complications immediately after cranioplasty)

要旨頭蓋形成術直後に脳浮腫と脳出血を認めた症例を報告する。症例は84歳，男性。くも膜下出血に対し開頭クリッピング術，外減圧術が施行され，第58病日に頭蓋形成術が施行された。術中は問題なく手術が終了したが，術直後の頭部CTにて脳浮腫，脳出血を認めた。その後浮腫は進行したが追加手術を施行することなく，浮腫は改善し神経症状は術前と変わらないまで改善し安定した。手術前後でperfusion MRIを施行し，病側の脳血流量・脳血液量が健側比で上昇を認め，無症候性のsinking skin flap syndrome（SSFS）であったと考えられた。頭蓋形成術直後に脳浮腫や脳出血を呈する原因は再灌流，自動調整能の低下，SSFS，皮下ドレーンによる陰圧，静脈鬱滞，正中偏位からの復元による血管損傷，アレルギー反応が原因と考えられる。この合併症による致死率は高い。頭蓋形成術は比較的容易な手術であり，合併症の多くは痙攣，感染，硬膜外血腫であるが，脳浮腫や脳出血が生じることも念頭に置き，術前に十分な説明をする必要があると考えられた。

Decompressive craniectomy and hydrocephalus: proposal of a therapeutic flow chart.

Decompressive craniectomy (DC) may be necessary to save the lives of patients suffering from intracranial hypertension. However, this procedure is not complication-free. Its two main complications are hydrocephalus and the sinking skin-flap syndrome (SSFS). The radiological findings and the clinical evaluation may be not enough to decide when and/or how to treat hydrocephalus in a decompressed patient. SSFS and hydrocephalus may be not unrelated. In fact, a patient affected by hydrocephalus, after the ventriculo-peritoneal shunt, can develop SSFS; on the other hand, SSFS per se can cause hydrocephalus. Treating hydrocephalus in decompressed patients can be challenging. Radiological findings and clinical evaluation may not be enough to define the most appropriate therapeutic strategy. Cerebrospinal fluid (CSF) dynamics and metabolic evaluations can represent important diagnostic tools for assessing the need of a CSF shunt in patients with a poor baseline neurologic status. Based on our experience, we propose a flow chart for treating decompressed patients affected by ventriculomegaly.

A trephined-szindróma - egy alulbecsült és kevéssé értett komplikáció dekompresszív craniectomia után

Decompressive craniectomy (DC) is still a matter of debate, with a numerous complications as expansion of haemorrhagic contusions, external cerebral herniation, subdural hygromas, post-traumatic hydrocephalus (HC). The often overlooked "syndrome of the trephined" (ST) as a delayed complication of DC also known as sinking skin flap sy initially described in 1939.ST is characterised by the neurological changes associated with alteration of the pressure/volume relationship between intracranial pressure (ICP), volume of cerebrospinal fluid (CSF), blood, and brain tissue in patients with large bone defects. This review aims at elucidating the mechanisms responsible for the development of ST, and providing useful tips and red-flag signs for healthcare professionals involved with care of post DC patients. Symptoms identified on time could help to develop appropriate treatment strategies for this suddenly deteriorating, but possible reversible condition. Although the treatment strategy is straightforward, calling for a prompt cranioplasty, the correction of HC through CSF diversion devices might require a lengthy optimisation period. Continuous changes in the setting of the shunting systems or spinal tap might lead to dangerous swinging of the midline structures causing further neurological deterioration. Thus, finding the right balance in terms of clinical management often represents a significant challenge.

Sinking skin flap syndrome and paradoxical herniation secondary to lumbar drainage

ObjectiveDecompressive craniectomy (DC) has been regaining popularity in the field of neurosurgery because it can alleviate intracranial hypertension and brain swelling. Lumbar drainage (LD) is affective in managing numerous neurosurgical circumstances such as aneurysmal subarachnoid hemorrhage, refractory intracranial hypertension, cerebrospinal fluid (CSF) leakage and intraoperative brain relaxation. Sinking skin flap syndrome (SSFS) or paradoxical herniation (PH) is a rare complication and sporadically occurs in patients after DC. Hereby, we report for the first time that DC patients with LD can progress to SSFS or PH. We also evaluated the risk factors for the incidence of SSFS in DC patients with LD. MethodsWe retrospectively assessed 37 patients who underwent DC and LD for cerebrovascular diseases from the First Hospital of Jilin University between January, 2007 and December, 2012. ResultsNine (4 male and 5 female) of 37 patients experienced SSFS or PH following LD. At the last follow-up (mean 9 months, range 6–12 months), eight patients recovered completely due to timely conservative management and one patient died from PH. The mortality rate was 11% (1/9) from the complications of PH or SSFS. Further statistical analysis revealed that mean daily CSF volume was a risk factor for the incidence of SSFS in DC patients with LD. ConclusionsSSFS or PH can be identified in DC patients following LD. Patients that undergo DC and LD should be monitored more intensively. Most patients can completely recover with timely conservative management, bed rest, Trendelenburg position, sufficient intravenous fluid, and temporary clipping of the catheter.

Short-Term Memory Impairment and Left Dorsolateral Prefrontal Cortex Dysfunction in the Orthostatic Position: A Single Case Study of Sinking Skin Flap Syndrome.

We describe the case of a patient who underwent craniectomy for hemorrhage of the left parietal lobe. Three weeks later, orthostatic memory impairment was detected as initial symptom of sinking skin flap syndrome (SSFS). This deficit was examined by neuropsychological testing and associated with a posture-dependent increase in the delta/alpha ratio at the F3 electrode, an electroencephalographic (EEG) index related to brain hypoperfusion. This EEG spectral alteration was detected in a brain region that includes the left dorsolateral prefrontal cortex, an area known to be involved in memory processing; therefore we hypothesize that SSFS induced reversible hypoperfusion of this otherwise undamaged cortical region. Neither of these findings was present after cranioplasty. This case suggests that SSFS may induce neuropsychological deficits potentially influencing outcome in the postacute phase and is further evidence supporting the clinical benefits of early cranioplasty.

Importance of Early Cranioplasty in Reversing the "Syndrome of the Trephine/Motor Trephine Syndrome/Sinking Skin Flap Syndrome".

The "Motor Trephine Syndrome (MTS)" also known as the "Sunken brain and Scalp Flap Syndrome" or the "Sinking Skin Flap Syndrome (SSFS)" or the "Syndrome of the trephined" is an unusual syndrome in which neurological deterioration occurs following removal of a large skull bone flap. This syndrome is associated with sensorimotor deficit and neurological deterioration following decompressive craniectomy which is performed for various neurosurgical conditions involving cerebral swelling causing mass effect. The neurological deterioration can be exacerbated or precipitated by CSF diversion procedures like a Ventriculo-Peritoneal shunt. It was the objective of this study to observe if any improvement in the patient's condition, or if any beneficial effects in his sensorimotor deficit could be gained by performing an early cranioplasty as against after the usual delay of one to two years normally allowed for post-craniectomy cases. A 52 year old male suffered severe head injury in a road traffic accident and underwent a craniectomy and contusectomy of the left Fronto-Temporo-Parietal (FTP) region for treatment of Acute Subdural hematoma (SDH) as well as hemorrhagic and non-hemorrhagic contusions of the brain with severe mass effect. On recovery from this acute event he was bed bound, on tracheostomy, his GCS was E4VTrM4 with residual right sided hemiparesis. Three months later, he developed Hydrocephalus for which a Right Ventriculo-Peritoneal (V-P) shunt was performed. Following this procedure, severe depression of the skin/scalp flap occurred and the neurological recovery was not as expected. He was diagnosed as a case of "Syndrome of the trephined". An immediate Cranioplasty was performed, on the third month following the craniectomy procedure, in an attempt to resolve the rapidly deteriorating neurological status of the patient. In the case presented, following the early Cranioplasty which was performed within three months of the initial craniectomy, the patient's neurological condition and cognitive functions showed a remarkable, immediate and dramatic improvement. The early Cranioplastic repair led to a remarkable clinical recovery of the patient, with improvement in the cognitive behavior and motor deficit with a rapid reversal of the sensorimotor paresis, reflecting an improvement in brain perfusion. Patients with the classical "Motor trephine syndrome/ Sinking skin flap syndrome" following large craniectomy defects, may hugely benefit from an early cranioplasty procedure, with a reversal of features of this syndrome and early recovery of their neurological and cognitive functions. Hence, an early cranioplasty can serve as a therapeutic procedure, rather than merely a cosmetic one.

Sinking Skin Flap Syndrome after Hemicraniectomy and Ventriculo-Peritoneal Shunt Overdrainage

We present a case of sinking skin flap syndrome after hemicraniectomy and insertion of a ventriculo-peritoneal shunt following severe craniocerebral injury. When the neurological status deteriorated due to cerebrospinal fluid overdrainage and resulting midline shift, complete ligation of the vp shunt became a temporary solution before definitive cranioplasty could be performed.