Figure 1
CT brain axial sections
Sinking skin Flap syndrome: A case report of early recognition on CT
SectionNeuroradiology
Case TypeClinical Cases
AuthorsFatima MUBARAK
Connected authors
60 years, male
Clinical History
A 60-year-old male underwent decompressive craniectomy for treatment of acute subdural haematoma followed by ventriculoperitoneal shunt. Following the procedure, depression of the sinking flap became significant, and suffered from right hemiparesis. The valve pressure was changed to medium on the shunt and the patient recovered to his base line
Imaging Findings
On imaging there was herniation of the brain through craniectomy defect with serial sinking of the skin flap and reversal with valve pressure adjustment.
Discussion
Back ground: Decompressive craniectomy is a common procedure nowadays with different indications [1]. Like any other decompressive surgery, it has adverse effects and SSFS is one of them [2]. SSFS was first reported in 1997 by Yamamura et al who calls it a series of neurologic symptoms and signs with skin depression at the site of craniectomy.The pressure gradient takes several weeks to months to develop [3]. Although many theories have been put forward regarding development of SSFS, but commonly it is thought that there are negative gradients between atmospheric and intracranial pressure, aggravated by changes in the CSF compartment following CSF drainage, to be the mechanism of neurological deterioration after craniectomy.
Clinical perspective: The aim of treating SSFS is targeted to the restoration of the pressure exerted by depression of craniectomy site.
Imaging perspective: SSFS can be diagnosed even on CT with typical features of herniated brain through craniectomy defect sinking back.
Outcome: SSFS can be treated by temporarily increasing the shunt pressure using a programmable V-P shunt valve to allow for expansion of a depressed scalp flap and facilitate the subsequent cranioplasty. Adjusting the shunt pressure may facilitate dissection during the subsequent cranioplasty and decreases the incidence of intracranial infection, haematoma, and effusion by eliminating the dead space [4].
Take home message: SSFS diagnosis should be suspected in patients who underwent craniectomy followed by VP shunt. This is a reversible condition if it is diagnosed at the proper time.
Clinical perspective: The aim of treating SSFS is targeted to the restoration of the pressure exerted by depression of craniectomy site.
Imaging perspective: SSFS can be diagnosed even on CT with typical features of herniated brain through craniectomy defect sinking back.
Outcome: SSFS can be treated by temporarily increasing the shunt pressure using a programmable V-P shunt valve to allow for expansion of a depressed scalp flap and facilitate the subsequent cranioplasty. Adjusting the shunt pressure may facilitate dissection during the subsequent cranioplasty and decreases the incidence of intracranial infection, haematoma, and effusion by eliminating the dead space [4].
Take home message: SSFS diagnosis should be suspected in patients who underwent craniectomy followed by VP shunt. This is a reversible condition if it is diagnosed at the proper time.
Differential Diagnosis List
Sinking Skin Flap syndrome
subdural haematoma
Old infarction
Final Diagnosis
Sinking Skin Flap syndrome
References
[1] Timofeev I, Hutchinson PJ (2006) Outcome after surgical decompression of severe traumatic brain injury. Injury 37:1125-1132 (PMID: 17081545)
[2] Akins PT, Guppy KH (2008) Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressivecraniec¬tomy management. Neurocrit Care 9:269-276, 2008 (PMID: 18064408)
[3] Yamaura A, Makino H (1977) Neurological deficits in the presence of the sinking skin flap following decompressive craniectomy. Neurol Med Chir (Tokyo) 17(1 Pt 1):43-53 (PMID: 74031)
[4] Isago T, Nozaki M, Kikuchi Y, Honda T, Nakazawa H (2004) Sinking skin flap syndrome: a case of improved cerebral blood flow after cranio¬plasty. Ann Plast Surg 53:288-292 (PMID: 15480019)
Case information
| URL: | https://www.eurorad.org/case/11757 |
| DOI: | 10.1594/EURORAD/CASE.11757 |
| ISSN: | 1563-4086 |
Figure 2
Post valve adjustment image
Post valve pressure adjustment shows reversal of sinking flap.
In this patient, cranioplasty was not performed only valve pressure was adjusted.
Post valve adjustment image
Post valve pressure adjustment shows reversal of sinking flap.
In this patient, cranioplasty was not performed only valve pressure was adjusted.
Fatima.The Radiology department,Aga khan univeresity hospital.
Fatima.The Radiology department,Aga khan univeresity hospital.