Sinking skin flap syndrome with delayed dysautonomic syndrome-An atypical presentation

Staged or simultaneous operations for ventriculoperitoneal shunt and cranioplasty: Evidence from a meta-analysis

OBJECTIVE

To date, there is no consensus on the surgery strategies of cranioplasty (CP) and ventriculoperitoneal shunt (VPS) placement. This meta-analysis aimed to investigate the safety of staged and simultaneous operation in patients with comorbid cranial defects with hydrocephalus to inform future surgery protocols.

METHODS

A meta-analysis of PubMed, Ovid, Web of Science, and Cochrane Library databases from the inception dates to February 8, 2023 adherent to PRISMA guidelines was conducted. The pooled analyses were conducted using RevMan 5.3 software. The outcomes included postoperative infection, reoperation, shunt obstruction, hematoma, and subdural effusion.

RESULTS

Of the 956 studies initially retrieved, 10 articles encompassing 515 patients were included. Among the total patients, 193 (37.48%) and 322 (62.52%), respectively, underwent simultaneous and staged surgeries. The finding of pooled analysis indicated that staged surgery was associated with lower rate of subdural effusion (14% in the simultaneous groups vs. 5.4% in the staged groups; OR = 2.39, 95% CI: 1.04-5.49, p = 0.04). However, there were no significant differences in overall infection (OR = 1.92, 95% CI: 0.74-4.97, p = 0.18), central nervous system infection (OR = 1.50, 95% CI: 0.68-3.31, p = 0.31), cranioplasty infection (OR = 1.58, 95% CI: 0.50-5.00, p = 0.44), shunt infection (OR = 1.30, 95% CI: 0.38-4.52, p = 0.67), reoperation (OR = 1.51, 95% CI: 0.38-6.00, p = 0.55), shunt obstruction (OR = 0.73, 95% CI: 0.25-2.16, p = 0.57), epidural hematoma (OR = 2.20, 95% CI: 0.62-7.86, p = 0.22), subdural hematoma (OR = 1.20, 95% CI: 0.10-14.19, p = 0.88), and intracranial hematoma (OR = 1.31, 95% CI: 0.42-4.07, p = 0.64). Moreover, subgroup analysis failed to yield new insights.

CONCLUSIONS

Staged surgery is associated with a lower rate of postoperative subdural effusion. However, from the evidence of sensitivity analysis, this result is not stable. Therefore, our conclusion should be viewed with caution, and neurosurgeons in practice should make individualized decisions based on each patient's condition and cerebrospinal fluid tap test.

Systematic Review of Syndrome of the Trephined and Reconstructive Implications

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.

Sinking Skin Flap Syndrome After Decompressive Hemicraniectomy in a Patient With Calvarial Multiple Myeloma Who Underwent a Lumbar Puncture: A Case Report

Sinking skin flap syndrome (SSFS) or “syndrome of the trephined” is a rare complication that can occur after decompressive craniectomy. Disabling neurologic deficits, as well as the impairment of overall mental status with the development of a concave deformity and relaxation of the skin flap, are frequently observed. This usually develops several weeks to months after craniectomy. The pathophysiology of the syndrome includes cerebrospinal fluid (CSF) hypovolemia and the development of an atmospheric pressure gradient that can be worsened by CSF diversion, dehydration, and change in position such as can be seen with a lumbar puncture. We present a case of a 40-four-year-old male with calvarial multiple myeloma three months after craniectomy who developed SSFS two days after lumbar puncture was performed to investigate possible leptomeningeal spread. It is imperative to recognize the syndrome early and proceed with urgent management with measures that initially increase intracranial pressure such as IV hydration and Trendelenburg positioning. In certain cases, proceeding with surgical management, such as epidural patch or cranioplasty, can be life-saving.

Syndrome of the Trephined and ParoxySmal Sympathetic Hyperactivity in a 17-year-old minimally conscious state patient: A Case Report

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.

Acute Paradoxical Herniation: A Case Report

Decompressive craniectomy is used to relieve acute increased intracranial pressure (ICP) when medical therapy has failed. Paradoxical herniation is a rare complication that occurs when the pressure of the intracranial contents falls abnormally below the atmospheric pressure. Symptoms often include neurological deficits, the etiology of which is often mistaken for elevated ICP. This diagnosis requires quick recognition, and treatment requires a change from ICP reduction therapies to those that increase the ICP, and ultimately cranioplasty.

[Syndrome of the trephined]

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.

Postural neurologic deficits after decompressive craniectomy: A case series of sinking skin flap syndrome in traumatic brain injury

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.

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

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.

Importance of Calvaria in Cerebrospinal Fluid Dynamics: A Case of Ventriculomegaly and Sinking Flap Syndrome after Decompressive Craniectomy

Sinking flap syndrome and hydrocephalus are well-known complications of decompressive craniectomy. The underlying pathogenesis and management of these complications are still unclear. We present a case of hydrocephalus and recurrent sinking flap syndrome following decompressive craniectomy. We highlight the pivotal role of calvaria in the management of these complications.

Syndrome of the Trephined: A Systematic Review

BACKGROUND

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.

OBJECTIVE

To accurately describe SoT and explore methods of an objective diagnosis/evaluation.

METHODS

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.

RESULTS

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.

DISCUSSION

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.

CONCLUSION

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.

ABBREVIATIONS

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

Early vs late cranioplasty: what is better?

AIM OF THE STUDY

Cranioplasty is the surgical repair of skull defects, which commonly is performed after traumatic skull injuries due to tumor removal or decompressive craniectomy. Several studies reported improvement in cognitive functions following cranioplasty in patients with severe brain damage. The reasons why exist such clinical improvement is not completely understood, although the increase in cerebrospinal fluid hydrodynamics with the potential improvement of local and global cerebral hemodynamics, blood flow, and metabolism may play a pivotal role. We investigated whether the cranioplasty improved neurological recovery and the whole array of cognitive functions or just some specific domains.

MATERIALS AND METHODS

A total of 30 consecutive brain-injured subjects with craniectomy were enrolled and underwent a structured neuropsychological assessment immediately before the cranioplasty, 1 month after the cranioplasty and 1 year after the surgical procedure.

RESULTS

Our results showed that cranioplasty may facilitate the cognitive recovery, independently from the surgical timing. Particularly, we observed an important cognitive recovery in the period immediately after cranioplasty, while the improvement trend settles after a lapse of time, and the recovery starts to slow down.

CONCLUSIONS

Cranioplasty seems to significantly improve neuropsychological and motor status in the patients with skull defects, independently from cranioplasty timing and patient's clinical status.

Sinking flap syndrome with abdominal pain: an atypical presentation

A 53-year-old man developed significant mass effect secondary to an ischaemic stroke and was treated with decompressive craniectomy. During the first few days postsurgery he developed orthostatic vertigo with nausea. After a month, with increasing mobilisation and rehabilitation, he started reporting of severe abdominal pain. No aetiology could be found despite extensive local work up and the symptoms were resistant to any symptomatic treatment. Within days postcranioplasty there was a complete resolution of all the symptoms.

CONCLUSION

the sinking flap syndrome can cause abdominal pain and orthostatic vertigo.

The Effect of Cranioplasty on Cerebral Hemodynamics as Measured by Perfusion Computed Tomography and Doppler Ultrasonography

Cranioplasties are performed to protect the brain and correct cosmetic defects, but there is growing evidence that this procedure may result in neurological improvement. We prospectively studied cranioplasties performed at our hospital over a 5-year period. The National Institute of Health Stroke Scale and Barthel index were recorded prior to and within 72 h after the cranioplasty. A perfusion computed tomography (PCT) and transcranial Doppler sonography (TCDS) were performed prior to and 72 h after the surgery. For the PCT, regions irrigated by the anterior cerebral artery, the middle cerebral artery (MCA), the posterior cerebral artery, and the basal ganglia were selected, as well as the mean values for the hemisphere. The sonography was performed in the sitting and the supine position for the MCA and internal carotid. The velocities, pulsatility index, resistance index, and Lindegaard ratio (LR) were obtained, as well as a variation value for the LR (ΔLR = LR sitting - LR supine). Fifty-four patients were included in the study. Of these, 23 (42.6%) patients presented with objective improvement. The mean cerebral blood flow of the defective side (m-CBF-d) increased from 101.86 to 117.17 mL/100 g/min (p = 0.064), and the m-CBF of the healthy side (m-CBF-h) increased from 128.14 to 145.73 mL/100 g/min (p = 0.028). With regard to the TCDS, the ΔLR was greater on the defective side prior the surgery in those patients who showed improvement (1.295 vs. -0.714; p = 0.002). Cranioplasty resulted in clinical improvement in 40% of the patients, with an increase in the post-surgical CBF. The larger variations in the LR when the patient is moved from the sitting to the supine position might predict the clinical improvement.

Paradoxical Herniation in the Postcraniectomy Syndrome: Report and Literature Update

Introduction The decompressive craniectomy is a surgical strategy widely used with specific criteria to control the refractory intracranial pressure (ICP). However, it is important to warn about the presence of a postcraniectomy syndrome and analyze the risk-benefit on a long term. Case Report A 72-year-old male patient diagnosed with a subarachnoid hemorrhage secondary to the rupture of an anterior circulation aneurysm that develops vasospasm, secondary ischemia, and edema with signs of herniation that required a decompressive craniectomy on a first step. Afterwards, the aneurysm was approached and he consequently developed hydrocephaly. A ventriculoperitoneal shunt is installed, contralateral to the craniectomy, and progressive sinking of the skin flap, there is neurological deterioration and paradoxical herniation. Its association with the clinical deterioration by bronchoaspiration did not allow the cranioplasty to resolve the ICP decompensation. Conclusions The paradoxical herniation as part of the postcraniectomy syndrome is an increasingly common condition identified in adult patients with cortical atrophy, and who have also been treated with ventricular shunt systems. Timely cranioplasty represents the ideal therapeutic plan once the compromise from the mass effect has resolved to avoid complications derived from the decompressive craniectomy per se.

Sinking skin flap syndrome in glioblastoma

Sinking skin flap syndrome (SSFS) is a rare neurological complication in patients with traumatic haemorrhage, stroke or cerebral oedema who undergo decompressive craniectomy to relieve increased intracranial pressure. Hallmark of SSFS is the sinking of the scalp to a plane lower than the edges of the skull defect in the setting of neurological deterioration. Our objective is to report that SSFS can present after small craniotomy without cerebral cortex compression and to share our diagnostic/therapeutic approach. A 62-year-old woman with a glioblastoma developed SSFS after a small craniectomy and tumour resection without cerebral cortex compression but a decrease in the surgical cavity volume. Brain MRI showed decreased size of the surgical cavity. Interestingly, the patient also developed posterior reversible encephalopathy syndrome (PRES). This case highlights an atypical presentation of SSFS and the possible association with PRES. It also illustrates how an early cranioplasty can successfully reverse SSFS.