Sinking Skin Flap Syndrome with Delayed Dysautonomic Syndrome-An Atypical Presentation

Overview

Journal Int J Surg Case Rep

Specialty General Surgery

Date 2013 Oct 3

PMID 24083997

Citations 10

Authors

Flavio Ramalho Romero

Marco Antonio Zanini

Luis Gustavo Ducati

Roberto Colichio Gabarra

Affiliations

Soon will be listed here.

Abstract

Introduction: Sinking skin flap syndrome or "syndrome of the trephined" is a rare complication after a large craniectomy, with a sunken skin above the bone defect with neurological symptoms such as severe headache, mental changes, focal deficits, or seizures.

Presentation Of Case: We report a case of 21 years old man with trefinated syndrome showing delayed dysautonomic changes.

Discussion: Our patient had a large bone flap defect and a VP shunt that constitute risk factors to develop this syndrome. Also, there is reabsorption of bone tissue while it is placed in subcutaneous tissue. The principal symptoms of sinking skin flap syndrome are severe headache, mental changes, focal deficits, or seizures. Our patient presented with a delayed dysautonomic syndrome, with signs and symptoms very characteristics. Only few cases of this syndrome were related in literature and none were presented with dysautonomic syndrome.

Conclusion: We reported here a very uncommon case of sinking skill flap syndrome that causes a severe dysautonomic syndrome and worsening the patient condition.

Citing Articles

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

Zhang J, Deng X, Yuan Q, Fu P, Wang M, Wu G CNS Neurosci Ther. 2023; 29(11):3136-3149.

PMID: 37438995 PMC: 10580328. DOI: 10.1111/cns.14347.

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

Tonini S, Jordanovski D, Williams K Cureus. 2022; 14(4):e24458.

PMID: 35497087 PMC: 9037964. DOI: 10.7759/cureus.24458.

A case of autonomic failure in post-craniectomy syndrome of the trephined.

Beeler M, Malone T, Boulter J, Bell R, Rosner M, Cook G Clin Auton Res. 2019; 30(2):177-179.

PMID: 31218555 DOI: 10.1007/s10286-019-00617-9.

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

Garg R, Aggarwal A, Salunke P Asian J Neurosurg. 2018; 13(1):128-129.

PMID: 29492142 PMC: 5820867. DOI: 10.4103/1793-5482.175631.

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

Dwivedi D, Bhatnagar V, Kiran S, Ray A Saudi J Anaesth. 2017; 11(3):359-360.

PMID: 28757846 PMC: 5516508. DOI: 10.4103/sja.SJA_44_17.

References

Do D, Sheen V, Bromfield E . Treatment of paroxysmal sympathetic storm with labetalol. J Neurol Neurosurg Psychiatry. 2001; 69(6):832-3. PMC: 1737162. DOI: 10.1136/jnnp.69.6.832. View

Pranzatelli M, Pavlakis S, Gould R, De Vivo D . Hypothalamic-midbrain dysregulation syndrome: hypertension, hyperthermia, hyperventilation, and decerebration. J Child Neurol. 1991; 6(2):115-22. DOI: 10.1177/088307389100600204. View

Liao C, Kao M . Cranioplasty for patients with severe depressed skull bone defect after cerebrospinal fluid shunting. J Clin Neurosci. 2002; 9(5):553-5. DOI: 10.1054/jocn.2002.1116. View

Kwon S, Cheong J, Kim J, Kim C . Reperfusion injury after autologous cranioplasty in a patient with sinking skin flap syndrome. J Korean Neurosurg Soc. 2012; 51(2):117-9. PMC: 3322209. DOI: 10.3340/jkns.2012.51.2.117. View

Yamaura A, Sato M, Meguro K, Nakamura T, Uemura K . [Cranioplasty following decompressive craniectomy--analysis of 300 cases (author's transl)]. No Shinkei Geka. 1977; 5(4):345-53. View

Lemke D . Riding out the storm: sympathetic storming after traumatic brain injury. J Neurosci Nurs. 2004; 36(1):4-9. View

Sarov M, Guichard J, Chibarro S, Guettard E, Godin O, Yelnik A . Sinking skin flap syndrome and paradoxical herniation after hemicraniectomy for malignant hemispheric infarction. Stroke. 2010; 41(3):560-2. DOI: 10.1161/STROKEAHA.109.568543. View

Isago T, Nozaki M, Kikuchi Y, Honda T, Nakazawa H . Sinking skin flap syndrome: a case of improved cerebral blood flow after cranioplasty. Ann Plast Surg. 2004; 53(3):288-92. DOI: 10.1097/01.sap.0000106433.89983.72. View

Sakamoto S, Eguchi K, Kiura Y, Arita K, Kurisu K . CT perfusion imaging in the syndrome of the sinking skin flap before and after cranioplasty. Clin Neurol Neurosurg. 2005; 108(6):583-5. DOI: 10.1016/j.clineuro.2005.03.012. View

10.

Akins P, Guppy K . Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management. Neurocrit Care. 2007; 9(2):269-76. DOI: 10.1007/s12028-007-9033-z. View

11.

Schwab S, Erbguth F, Aschoff A, Orberk E, Spranger M, Hacke W . ["Paradoxical" herniation after decompressive trephining]. Nervenarzt. 1998; 69(10):896-900. DOI: 10.1007/s001150050360. View

12.

Kelley G, Johnson P . Sinking brain syndrome: craniotomy can precipitate brainstem herniation in CSF hypovolemia. Neurology. 2004; 62(1):157. DOI: 10.1212/wnl.62.1.157. View

13.

Gooch M, Gin G, Kenning T, German J . Complications of cranioplasty following decompressive craniectomy: analysis of 62 cases. Neurosurg Focus. 2009; 26(6):E9. DOI: 10.3171/2009.3.FOCUS0962. View