British Journal of Neurosurgery
ISSN: 0268-8697 (Print) 1360-046X (Online) Journal homepage: http://www.tandfonline.com/loi/ibjn20
Sinking skin flap syndrome following decompressive craniectomy Clément Cholet, Arthur André & Bruno Law-Ye To cite this article: Clément Cholet, Arthur André & Bruno Law-Ye (2017): Sinking skin flap syndrome following decompressive craniectomy, British Journal of Neurosurgery, DOI: 10.1080/02688697.2017.1390065 To link to this article: http://dx.doi.org/10.1080/02688697.2017.1390065
Published online: 11 Oct 2017.
Submit your article to this journal
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ibjn20 Download by: [UNIVERSITY OF ADELAIDE LIBRARIES]
Date: 12 October 2017, At: 02:14
BRITISH JOURNAL OF NEUROSURGERY, 2017 https://doi.org/10.1080/02688697.2017.1390065
NEUROSURGICAL IMAGE
Sinking skin flap syndrome following decompressive craniectomy Clement Choleta
, Arthur Andreb,c and Bruno Law-Yea,c
Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 02:14 12 October 2017
a Neuroradiology Department, University Hospital Pitie-Salp^etriere, AP-HP, Paris, France; bNeurosurgery Department, University Hospital PitieSalp^etriere, AP-HP, Paris, France; cSorbonne Universites - Universite Pierre et Marie Curie (UPMC), Paris VI, Paris, France
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(A)). The patient suffered from intracranial hypertension (ICP ¼ 55 mmHg), secondary to brain edema. On day 4, he benefited from ventricular drainage and left decompressive hemicraniectomy. Continuous external ventricular drainage was then introduced because of persistent hydrocephalus (Figure 1(C)). Sixty-eight days later, a CT revealed a paradoxical
herniation of the left hemisphere with midline shift (Figure 1(E), Figure 2), consistent with sinking skin flap syndrome (SSFS) or ‘syndrome of the trephined’. SSFS is a rare condition following craniectomy, characterized by paradoxical brain herniation. Clinical symptoms include sensorimotor impairment, headaches, and vigilance disorders and can worsen during orthostatism.1 SSFS usually occurs 3 to 5 months after craniectomy.2 While the main mechanism is direct transmission of atmospheric pressure to intracranial cavity,
Figure 1. Timeline of SSFS. CT images, axial views. (A) Left frontal hemorrhagic contusions resulting from the initial trauma and left decompressive craniectomy. (B and C) Progressive hydrocephalus was observed when the external ventricular drainage was clamped, eventually leading to external brain herniation. (D) Moderate invagination of the scalp without mass effect or midline shift. (E) SSFS with midline shift and compression of the ventricles. (F) MRI axial FLAIR image showing the SSFS with midline shift and ventricular displacement.
CONTACT Clement Cholet 75013, Paris, France
[email protected]
ß 2017 The Neurosurgical Foundation
University Hospital Pitie-Salp^etriere, AP-HP, Neuroradiology Department, 47-83 Boulevard de l’H^opital,
2
C. CHOLET ET AL.
defect.3 Cranioplasty should be performed before onset of symptoms as they limit rehabilitation.4 While SSFP usually resolves after cranioplasty,1 our patient eventually died from respiratory complications.
Disclosure statement All the authors declare they have no conflicts of interest to disclose.
ORCID
Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 02:14 12 October 2017
Clement Cholet
http://orcid.org/0000-0002-1370-1514
References 1. 2. Figure 2. 3D reconstruction of brain CT demonstrating scalp invagination inside the skull bone defect.
decreased cerebral blood flow resulting from microarterial circulation impairment, brain compression, and CSF pressure decrease may also contribute.1 SSFS may be triggered by CSF drainage as its depletion elevates the pressure gradient across the craniectomy
3.
4.
Annan M, De Toffol B, Hommet C, Mondon K. Sinking skin flap syndrome (or Syndrome of the trephined): a review. Br J Neurosurg 2015;29:314–8. Sarov M, Guichard J-P, Chibarro S, et al. Sinking skin flap syndrome and paradoxical herniation after hemicraniectomy for malignant hemispheric infarction. Stroke 2010;41:560–2. Ji H, Chen W, Yang X, et al. Paradoxical herniation after unilateral decompressive craniectomy: a retrospective analysis of clinical characteristics and effectiveness of therapeutic measures. Turk Neurosurg 2017;27:192–200. Kato A, Morishima H, Nagashima G. [A patient with sinking skin flap syndrome who underwent perfusion mri before and after cranioplasty]. No Shinkei Geka 2016;44:755–60.
ISSN: 0268-8697 (Print) 1360-046X (Online) Journal homepage: http://www.tandfonline.com/loi/ibjn20
Sinking skin flap syndrome following decompressive craniectomy Clément Cholet, Arthur André & Bruno Law-Ye To cite this article: Clément Cholet, Arthur André & Bruno Law-Ye (2017): Sinking skin flap syndrome following decompressive craniectomy, British Journal of Neurosurgery, DOI: 10.1080/02688697.2017.1390065 To link to this article: http://dx.doi.org/10.1080/02688697.2017.1390065
Published online: 11 Oct 2017.
Submit your article to this journal
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ibjn20 Download by: [UNIVERSITY OF ADELAIDE LIBRARIES]
Date: 12 October 2017, At: 02:14
BRITISH JOURNAL OF NEUROSURGERY, 2017 https://doi.org/10.1080/02688697.2017.1390065
NEUROSURGICAL IMAGE
Sinking skin flap syndrome following decompressive craniectomy Clement Choleta
, Arthur Andreb,c and Bruno Law-Yea,c
Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 02:14 12 October 2017
a Neuroradiology Department, University Hospital Pitie-Salp^etriere, AP-HP, Paris, France; bNeurosurgery Department, University Hospital PitieSalp^etriere, AP-HP, Paris, France; cSorbonne Universites - Universite Pierre et Marie Curie (UPMC), Paris VI, Paris, France
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(A)). The patient suffered from intracranial hypertension (ICP ¼ 55 mmHg), secondary to brain edema. On day 4, he benefited from ventricular drainage and left decompressive hemicraniectomy. Continuous external ventricular drainage was then introduced because of persistent hydrocephalus (Figure 1(C)). Sixty-eight days later, a CT revealed a paradoxical
herniation of the left hemisphere with midline shift (Figure 1(E), Figure 2), consistent with sinking skin flap syndrome (SSFS) or ‘syndrome of the trephined’. SSFS is a rare condition following craniectomy, characterized by paradoxical brain herniation. Clinical symptoms include sensorimotor impairment, headaches, and vigilance disorders and can worsen during orthostatism.1 SSFS usually occurs 3 to 5 months after craniectomy.2 While the main mechanism is direct transmission of atmospheric pressure to intracranial cavity,
Figure 1. Timeline of SSFS. CT images, axial views. (A) Left frontal hemorrhagic contusions resulting from the initial trauma and left decompressive craniectomy. (B and C) Progressive hydrocephalus was observed when the external ventricular drainage was clamped, eventually leading to external brain herniation. (D) Moderate invagination of the scalp without mass effect or midline shift. (E) SSFS with midline shift and compression of the ventricles. (F) MRI axial FLAIR image showing the SSFS with midline shift and ventricular displacement.
CONTACT Clement Cholet 75013, Paris, France
[email protected]
ß 2017 The Neurosurgical Foundation
University Hospital Pitie-Salp^etriere, AP-HP, Neuroradiology Department, 47-83 Boulevard de l’H^opital,
2
C. CHOLET ET AL.
defect.3 Cranioplasty should be performed before onset of symptoms as they limit rehabilitation.4 While SSFP usually resolves after cranioplasty,1 our patient eventually died from respiratory complications.
Disclosure statement All the authors declare they have no conflicts of interest to disclose.
ORCID
Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 02:14 12 October 2017
Clement Cholet
http://orcid.org/0000-0002-1370-1514
References 1. 2. Figure 2. 3D reconstruction of brain CT demonstrating scalp invagination inside the skull bone defect.
decreased cerebral blood flow resulting from microarterial circulation impairment, brain compression, and CSF pressure decrease may also contribute.1 SSFS may be triggered by CSF drainage as its depletion elevates the pressure gradient across the craniectomy
3.
4.
Annan M, De Toffol B, Hommet C, Mondon K. Sinking skin flap syndrome (or Syndrome of the trephined): a review. Br J Neurosurg 2015;29:314–8. Sarov M, Guichard J-P, Chibarro S, et al. Sinking skin flap syndrome and paradoxical herniation after hemicraniectomy for malignant hemispheric infarction. Stroke 2010;41:560–2. Ji H, Chen W, Yang X, et al. Paradoxical herniation after unilateral decompressive craniectomy: a retrospective analysis of clinical characteristics and effectiveness of therapeutic measures. Turk Neurosurg 2017;27:192–200. Kato A, Morishima H, Nagashima G. [A patient with sinking skin flap syndrome who underwent perfusion mri before and after cranioplasty]. No Shinkei Geka 2016;44:755–60.
