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Diaz-Segarra N, Jasey N. Improved rehabilitation efficiency after cranioplasty in patients with sunken skin flap syndrome: a case series. Brain Inj 2024; 38:61-67. [PMID: 38334121 DOI: 10.1080/02699052.2024.2309261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 01/19/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE Sunken Skin Flap Syndrome (SSFS) is an uncommon, delayed complication after craniectomy characterized by a functional plateau or decline with variable neurologic symptoms, improving after cranioplasty. SSFS negatively impacts the rehabilitation course, with subjective reports of functional improvement after cranioplasty. However, no studies have assessed the impact of cranioplasty on functional recovery rate. This case series aims to analyze SSFS manifestations and management while awaiting cranioplasty. Also, to assess the role of cranioplasty on rehabilitation outcomes and recovery rate in SSFS patients. METHODS Four patients were identified with SSFS in inpatient rehabilitation. Each patient had unique clinical manifestations, with multiple strategies used for symptomatic control. Patients spent an average of 23 days in rehabilitation with SSFS symptoms before cranioplasty. After cranioplasty, all patients had SSFS symptom resolution. Comparing change in functional independence measure (FIM) scores and FIM efficiency pre-and post-cranioplasty rehabilitation course, a mean improvement of 23 and 0.72 occurred after cranioplasty, respectively. CONCLUSION A diagnosis of SSFS should be considered in craniectomy patients exhibiting functional decline or plateau with associated neurological symptoms. This study suggests that FIM and FIM efficiency increases in SSFS patients after cranioplasty, supporting prompt cranioplasty to improve functional outcomes and minimize rehabilitation delays.
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Affiliation(s)
- Nicole Diaz-Segarra
- Kessler Institute for Rehabilitation, Department of Physical Medicine and Rehabilitation, West Orange, New Jersey, USA
- Sunnyview Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Schenectady, New York, USA
- James A. Eddy Research Institute, Sunnyview Rehabilitation Hospital, Schenectady, New York, USA
| | - Neil Jasey
- Kessler Institute for Rehabilitation, Department of Physical Medicine and Rehabilitation, West Orange, New Jersey, USA
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2
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Jeon MJ, Kim ST. Acute Onset of Syndrome of the Trephined After Lumboperitoneal Shunt Placement: A Case Report. Korean J Neurotrauma 2023; 19:376-383. [PMID: 37840606 PMCID: PMC10567524 DOI: 10.13004/kjnt.2023.19.e36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/28/2023] [Accepted: 07/04/2023] [Indexed: 10/17/2023] Open
Abstract
Decompressive craniectomy is widely recognized as a life-saving emergency operation for the treatment of increased intracranial pressure; however, it can lead to severe complications, such as "syndrome of the trephined." Cerebrospinal fluid diversion, particularly after lumboperitoneal shunting, can affect the occurrence of this disease and worsen the symptoms. We report an acute case of this syndrome after lumboperitoneal shunting in a patient who had previously undergone decompressive craniectomy. The patient rapidly fell from a Glasgow Coma Scale (GCS) of 14 to a comatose state and a GCS of 4 only in 2 days. After cranioplasty, the patient recovered fully; however, this took a prolonged period.
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Affiliation(s)
- Min Je Jeon
- Department of Neurosurgery, Busan Paik Hospital, Inje University, School of Medicine, Busan, Korea
| | - Sung-Tae Kim
- Department of Neurosurgery, Busan Paik Hospital, Inje University, School of Medicine, Busan, Korea
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3
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Santander X, Hidalgo YG, Flores JC, Gómez-Jordana B. Sinking skin syndrome in a decompressive craniectomy series: Clinical and radiological features. Surg Neurol Int 2022; 13:422. [PMID: 36324973 PMCID: PMC9610374 DOI: 10.25259/sni_582_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background: The sinking skin syndrome (SSS) is a particular complication after a decompressive craniectomy (DC). It still remains a poorly understood and underestimated entity. Methods: Retrospective case series of craniectomized patients with and without SSS. Clinical and radiological features (DC diameter, shape of craniectomy flap, and midline deviation) were described and relative volumes of intracranial loss were quantified. Results: Twenty-seven patients (63% with SSS). The most common indication for DC was traumatic brain injury: 48.15%. The p50 diameter of DC was 12.8 cm for patients with SSS and 11.1 cm for patients without (Z score = 0.32). DC area was 81.5 cm2 for patients with SSS and 71.43 cm2 for patients without the syndrome (Z score = 0.61). According to the shape of the craniectomy flap, we classified our patients as: «same level» (51.8%), «sunken» (25.9%), and «extracranial herniation» (14.8%). Two patients (7.4%) had paradoxical herniation. Midline deviation was present in 12 (70.6%) patients with SSS. The 3rd ventricle volume average was 1.2 cc for patients with SSS versus 2.35 cc for patients without (Z score = 0.04). About 94.11% of patients (16 out of 17) clearly improved after replacement of the cranial defect. Conclusion: In our series, low 3rd ventricle volumes had a good relation with SSS. The presence of a sunken flap does not guarantee SSS per se and we propose the following radiologic description: A = sunken, B = same level, C = extracranial herniation, and D = paradoxical. Replacement of the skull defect is the main treatment.
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Affiliation(s)
- Xavier Santander
- Department of Neurosurgery, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | - Yolanda García Hidalgo
- Department of Radiology, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | - José Carlos Flores
- Department of Radiology, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | - Blanca Gómez-Jordana
- Department of Neurosurgery, University Hospital Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
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4
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Mustroph CM, Stewart CM, Mann LM, Saberian S, Deibert CP, Thompson PW. Systematic Review of Syndrome of the Trephined and Reconstructive Implications. J Craniofac Surg 2022; 33:e647-e652. [PMID: 36054899 DOI: 10.1097/scs.0000000000008724] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/23/2022] [Indexed: 11/25/2022] Open
Abstract
Syndrome of the trephined (SoT) is a severe complication following decompressive craniectomy resulting in neurological decline which can progress to aphasia, catatonia, and even death. While cranioplasty can reverse neurological symptoms of SoT, awareness of SoT is poor outside of the neurosurgery community. The authors performed a systematic review of the literature on SoT with a focus on reconstructive implications. Search terms "syndrome of the trephined" and "sunken flap syndrome" were applied to PubMed to identify primary studies through October 2021. Full-text review yielded 11 articles discussing SoT and reconstructive techniques or implications with 56 patients undergoing cranial reconstruction. Average age of the patients was 41.8±9.5 years. Sixty-three percent of the patients were male. The most common indication for craniectomy was traumatic brain injury (43%), followed by tumor resection (23%), intracerebral hemorrhage (11%), and aneurysmal subarachnoid hemorrhage (2%). Patients most commonly suffered from motor deficits (52%), decreased wakefulness (30%), depression or anxiety (21%), speech deficits (16%), headache (16%), and cognitive difficulties (2%). Time until presentation of symptoms following decompression was 4.4±8.9 months. Patients typically underwent cranioplasty with polyetheretherketone (48%), titanium mesh (21%), split thickness calvarial bone (16%), full thickness calvarial bone (14%), or split thickness rib graft (4%). Eight percent of patients required free tissue transfer for soft tissue coverage. Traumatic Brain Injury (TBI) was a risk factor for development of SoT when adjusting for age and sex (odds ratio: 8.2, 95% confidence interval: 1.2-8.9). No difference significant difference was observed between length until initial improvement of neurological symptoms following autologous versus allograft reconstruction (P=0.47). SoT can be a neurologically devastating complication of decompressive craniectomy which can resolve following urgent cranioplasty. Familiarity with this syndrome and its reconstructive implications is critical for the plastic surgery provider, who may be called upon to assist with these urgent cases.
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5
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Yoshida K, Toda M, Yamada Y, Yamada M, Yokoyama Y, Tsutsumi K, Fujiwara H, Kosugi K, Jinzaki M. Cranial defect and pneumocephalus are associated with significant postneurosurgical positional brain shift: evaluation using upright computed tomography. Sci Rep 2022; 12:10482. [PMID: 35729166 PMCID: PMC9213471 DOI: 10.1038/s41598-022-13276-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 05/23/2022] [Indexed: 11/24/2022] Open
Abstract
Only few studies have assessed brain shift caused by positional change. This study aimed to identify factors correlated with a large postneurosurgical positional brain shift (PBS). Sixty-seven patients who underwent neurosurgical procedures had upright computed tomography (CT) scan using settings similar to those of conventional supine CT. The presence of a clinically significant PBS, defined as a brain shift of ≥ 5 mm caused by positional change, was evaluated. The clinical and radiological findings were investigated to identify factors associated with a larger PBS. As a result, twenty-one patients had a clinically significant PBS. The univariate analysis showed that supratentorial lesion location, intra-axial lesion type, craniectomy procedure, and residual intracranial air were the predictors of PBS. Based on the multivariate analysis, craniectomy procedure (p < 0.001) and residual intracranial air volume (p = 0.004) were the predictors of PBS. In a sub-analysis of post-craniectomy patients, PBS was larger in patients with supratentorial craniectomy site and parenchymal brain injury. A large craniectomy area and long interval from craniectomy were correlated with the extent of PBS. In conclusion, patients who undergo craniectomy and those with residual intracranial air can present with a large PBS. In post-craniectomy patients, the predisposing factors of a large PBS are supratentorial craniectomy, presence of parenchymal injury, large skull defect area, and long interval from craniectomy. These findings can contribute to safe mobilization among postneurosurgical patients and the risk assessment of sinking skin flap syndrome.
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Affiliation(s)
- Keisuke Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan.,Department of Neurosurgery, Mihara Memorial Hospital, Gunma, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoshitake Yamada
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Yamada
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Yoichi Yokoyama
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Kei Tsutsumi
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Hirokazu Fujiwara
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Kenzo Kosugi
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Jinzaki
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan.
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6
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Tanioka S, Nishida K, Tanaka K, Ishida F, Suzuki H. Taste disorder as a sole manifestation of syndrome of the trephined. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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7
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Historical vignette portraying the difference between the “sinking skin flap syndrome” and the “syndrome of the trephined” in decompressive craniectomy. World Neurosurg 2022; 162:11-14. [DOI: 10.1016/j.wneu.2022.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 11/19/2022]
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8
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Ovaitt A, Fort M, Withrow K, Hughley B. Sinking skin flap syndrome in head and neck reconstruction: A case report. OTOLARYNGOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.xocr.2021.100330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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9
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Syndrome of the trephined: clinical spectrum, risk factors, and impact of cranioplasty on neurologic recovery in a prospective cohort. Neurosurg Rev 2021; 45:1431-1443. [PMID: 34618250 PMCID: PMC8976790 DOI: 10.1007/s10143-021-01655-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/09/2021] [Accepted: 09/24/2021] [Indexed: 01/18/2023]
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.
Graphical abstract ![]()
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10
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Wetzel-Weaver A, Bertero G, Aleton E, Turlan JL. Syndrome of the Trephined and ParoxySmal Sympathetic Hyperactivity in a 17-year-old minimally conscious state patient: A Case Report. Brain Inj 2021; 35:1480-1483. [PMID: 34586939 DOI: 10.1080/02699052.2021.1972448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Purpose: Syndrome of the Trephined (SoT) is one of the most unknown complications of the Decompressive Craniectomy (DC) after Traumatic Brain Injury (TBI). A combination of neurological clinical criteria and radiological signs after DC is necessary to make its diagnosis. In our case, as the patient was in a minimally conscious state (MCS), it was impossible to clinically assess any neurological deterioration according to the criteria found in the literature. There is no description of clinical diagnostic criteria suitable for patients with MCS apart from the visible 'Skin Flap.'Method: A 17-year-old patient sustained a severe TBI. Two months after the TBI and a DC he exhibited an MCS with a Glasgow Coma Scale (GCS) of 7 and a Wessex Head Injury Matrix (WHIM) of 5. He presented several paroxysmal sympathetic hyperactivity (PSH) episodes a day and developed a sinking skin flap. A cranioplasty was performed. Then, we noticed the gradual disappearance of PSH episodes plus an improvement of the CRS and the WHIM. Results: The evolution of the WHIM data revealed a statistically significant difference (p 0.0047). Conclusion: Further studies should be conducted to assess whether the WHIM and the frequency of PSH episodes may be part of the diagnostic criteria for SoT in MCS patients.
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Affiliation(s)
- Audrey Wetzel-Weaver
- Department of Research, Clinique Romande De Réadaptation, Sion, Switzerland.,Department of Physical and Rehabilitation Medicine, Hopital Fribourgeois Hfr, Fribourg, Switzerland
| | - Giulio Bertero
- Department of Research, Clinique Romande De Réadaptation, Sion, Switzerland
| | - Etienne Aleton
- Department of Neurorehabilitation, Clinique Romande de Readaptation, Sion, Switzerland
| | - Jean Luc Turlan
- Department of Research, Clinique Romande De Réadaptation, Sion, Switzerland.,Department of Neurorehabilitation, Clinique Romande de Readaptation, Sion, Switzerland
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11
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Rare Neurologic Deterioration to GCS 3 in a Patient with the Syndrome of the Trephined. Can J Neurol Sci 2021; 49:310-312. [PMID: 33947491 DOI: 10.1017/cjn.2021.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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12
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Abstract
Large hemispheric infarcts occur in up to 10% of all ischemic strokes and can cause devastating disability. Significant research and clinical efforts have been made in hopes of mitigating the morbidity and mortality of this disease. Areas of interest include identifying predictors of malignant edema, optimizing medical and surgical techniques, selecting the patient population that would benefit most from decompressive hemicraniectomy, and studying the impact on quality of life of those who survive. Decompressive surgery can be a life-saving measure, and here we discuss the most up-to-date literature and provide a review on the surgical management of large hemispheric ischemic strokes.
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Affiliation(s)
- Jessica Lin
- Division of Neurocritical Care, Department of Neurology, New York University Langone Health (J.L., J.A.F.), New York, NY.,Department of Neurology, Bellevue Hospital Center (J.L.), New York, NY
| | - Jennifer A Frontera
- Division of Neurocritical Care, Department of Neurology, New York University Langone Health (J.L., J.A.F.), New York, NY
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13
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Metwali H, Hassanin M, Ibrahim T. A Customized Technique of Cranioplasty for Patients with Large Skull Defects: A Technical Note. World Neurosurg 2021; 148:110-114. [PMID: 33422719 DOI: 10.1016/j.wneu.2020.12.157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In our technical note, we have presented a technique of cranioplasty for large skull defects. METHODS A thin-slice computed tomography scan is performed. A model of the skull is constructed using a desktop 3-dimensional printer from the computed tomography scan. The skull model is filled with towels of soft cotton and inserted in a sterile thin plastic bag. The implant is molded intraoperatively on the skull model under sterile conditions. After surgical exposure of the skull defect, the implant is inserted and fixed using miniplates and miniscrews. The technique was used in 6 patients and described in 2 representative cases. RESULTS The required time and cost are significantly lower than those for other techniques used for preoperative manufacture of implants. No technique-related complications occurred. The radiological and cosmetic results were satisfactory. In the present case series, no early or delayed complications occurred. CONCLUSION The presented technique is simple, safe, and time- and cost-effective. The technique and results are reproducible.
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Affiliation(s)
- Hussam Metwali
- Department of Neurosurgery, Kliniken Nordoberpfalz AG, Weiden, Germany.
| | - Mohamed Hassanin
- Department of Neurosurgery, University Hospital Bergmannsheil, Bochum, Germany
| | - Tamer Ibrahim
- Department of Neurosurgery, University of Alexandria, Alexandria, Egypt
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14
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Martínez-Viñuela I, Paredes-Borrachero I, Rubio-Mellado M, Fernández-García L, Madrid-Sánchez J, García-Bascones M, Díaz-Jiménez M. [Syndrome of the trephined]. Rehabilitacion (Madr) 2021; 55:325-328. [PMID: 33414016 DOI: 10.1016/j.rh.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 11/23/2020] [Accepted: 11/27/2020] [Indexed: 11/15/2022]
Abstract
Syndrome of the trephined (SoT) is the neurological deterioration that occurs after the performance of decompressive craniectomy in which bone is not replaced. The incidence of SoT varies, but this entity seems to be underdiagnosed. It is characterized by symptom reversal after bone replacement, which is the only definitive treatment. We report the case of a patient assessed by the Rehabilitation Service in the Critical Care Unit after a stroke, who had altered level of consciousness and abrupt motor impairment. The patient was diagnosed with SoT. Rehabilitation, with early postural changes, helped to ameliorate the symptoms until the provision of definitive treatment.
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Affiliation(s)
- I Martínez-Viñuela
- Servicio de Medicina Física y Rehabilitación, Complejo Hospitalario de Toledo, Toledo, España.
| | | | - M Rubio-Mellado
- Servicio de Medicina Física y Rehabilitación, Complejo Hospitalario de Toledo, Toledo, España
| | - L Fernández-García
- Servicio de Medicina Física y Rehabilitación, Complejo Hospitalario de Toledo, Toledo, España
| | - J Madrid-Sánchez
- Servicio de Medicina Física y Rehabilitación, Complejo Hospitalario de Toledo, Toledo, España
| | - M García-Bascones
- Servicio de Medicina Física y Rehabilitación, Complejo Hospitalario de Toledo, Toledo, España
| | - M Díaz-Jiménez
- Servicio de Medicina Física y Rehabilitación, Complejo Hospitalario de Toledo, Toledo, España
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15
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Bateman EA, VanderEnde J, Sequeira K, MacKenzie HM. Postural neurologic deficits after decompressive craniectomy: A case series of sinking skin flap syndrome in traumatic brain injury. NeuroRehabilitation 2020; 49:663-672. [PMID: 34744055 DOI: 10.3233/nre-210160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hemicraniectomy to manage raised intracranial pressure following traumatic brain injury (TBI) has improved survival but may increase the incidence of Sinking Skin Flap Syndrome (SSFS). SSFS is a clinical syndrome in which patients with craniectomy develop objective neurologic abnormalities due to the pressure of the atmosphere on the unprotected brain, often presenting with postural headaches and neurologic deficits that localize to the craniectomy site. Previously thought to be a rare complication of craniectomy after TBI, evidence suggests SSFS is under-recognized. OBJECTIVE To describe the clinical and radiographic features leading to diagnosis and the impact of temporizing and definitive management of SSFS on outcomes in inpatients with moderate/severe TBI. METHODS Two patients' symptoms, qualitative behaviour observation, physical and cognitive outcome measures, and neuroimaging pre- and post-temporizing measures and cranioplasty are presented. RESULTS Both patients demonstrated partial improvements with temporizing measures and substantial improvements in functional, cognitive, physical, and rehabilitation outcomes from the cranioplasty and resolution of SSFS. CONCLUSIONS Rehabilitation care providers are critical to the timely diagnosis and management of SSFS, including the use of temporizing measures and advocacy for definitive treatment with cranioplasty. These cases highlight the diverse clinical presentations and importance of SSFS diagnosis to improve patient outcomes.
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Affiliation(s)
- Emma A Bateman
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Parkwood Institute, St Joseph's Health Care London, London, Ontario, Canada
| | - Jordan VanderEnde
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Parkwood Institute, St Joseph's Health Care London, London, Ontario, Canada
| | - Keith Sequeira
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Parkwood Institute, St Joseph's Health Care London, London, Ontario, Canada
| | - Heather M MacKenzie
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Parkwood Institute, St Joseph's Health Care London, London, Ontario, Canada
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Sinking skin flap syndrome visualized by upright computed tomography. Acta Neurochir (Wien) 2020; 162:1825-1828. [PMID: 32572578 DOI: 10.1007/s00701-020-04459-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/11/2020] [Indexed: 10/24/2022]
Abstract
Sinking skin flap syndrome is a craniectomy complication characterized by new neurological dysfunction that typically worsens in the upright position and improves after cranioplasty. We present a 33-year-old man who experienced hemiparesis in the upright position after craniectomy. Upright computed tomography (CT) before cranioplasty showed a remarkable shift of the brain compared to supine CT. After cranioplasty, both symptoms and brain shift on CT resolved. Upright CT enables detection and objective evaluation of paradoxical herniation and midline shift that is not obvious on supine imaging modalities. Clinicians need to be aware of positional brain shift in postcraniectomy patients.
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Sinking Skin Flap Syndrome and Paradoxical Herniation Provoked by a Malfunction of External Lumbar Drainage and CSF Leak. ACTA MEDICA MARTINIANA 2019. [DOI: 10.2478/acm-2019-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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18
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Sinking flap syndrome revisited: the who, when and why. Neurosurg Rev 2019; 43:323-335. [DOI: 10.1007/s10143-019-01148-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/18/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023]
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Rapid Decline of A 52-Year-Old Woman With Brain Injury During Acute Rehabilitation. Am J Phys Med Rehabil 2019; 99:e44-e45. [PMID: 31211702 DOI: 10.1097/phm.0000000000001246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Sinking Skin Flap Syndrome: Phenomenon of Neurological Deterioration after Decompressive Craniectomy. Case Rep Med 2018; 2018:9805395. [PMID: 30425745 PMCID: PMC6218751 DOI: 10.1155/2018/9805395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/04/2018] [Indexed: 11/18/2022] Open
Abstract
Sinking skin flap syndrome is rare phenomenon that occurs in patients with large craniectomies. Alteration in normal anatomy and pathophysiology can result in wide variety of symptoms including altered mental status, hemodynamic instability, and dysautonomias. Management is largely conservative. We here present a case of a patient with large craniectomy who was admitted to our hospital with pneumonia. Later on, he developed worsening mental status and CT head revealed sinking skin flap with significant midline shift. This is a very rare case of neurological deterioration after craniectomies, commonly known as sinking skin flap syndrome. To our knowledge, only few cases have been reported so far.
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Hohenbichler K, Duprez T, Ribeiro Vaz JG, Ferrao Santos S, El Tahry R. Syndrome of the trephined revealed by vertical diplopia. Acta Neurol Belg 2017; 117:737-739. [PMID: 28013486 DOI: 10.1007/s13760-016-0713-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 10/11/2016] [Indexed: 11/29/2022]
Affiliation(s)
- K Hohenbichler
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium.
| | - T Duprez
- Department of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - J G Ribeiro Vaz
- Department of Neurosurgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - S Ferrao Santos
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - R El Tahry
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Av. Hippocrate 10, 1200, Brussels, Belgium
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Vargas MI, Boto J, Delatre BM. Synthetic MR Imaging Sequence in Daily Clinical Practice. AJNR Am J Neuroradiol 2016; 37:E68-E69. [PMID: 27444944 DOI: 10.3174/ajnr.a4895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | - J Boto
- Division of Neuroradiology
| | - B M Delatre
- Division of Radiology Department of Medical Imaging Geneva University Hospital Geneva, Switzerland
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