Sinking skin flap syndrome in the multi-trauma patient: a paradoxical management to TBI post craniectomy

Abstract

Sinking skin flap syndrome is a rare syndrome leading to increased intracranial pressure, known to neurosurgeons, yet uncommon and hardly ever reported in trauma patients. In a hospitalized trauma patient with declining neurological status, rarely do we encounter further deterioration by elevating the patients’ head, diuresis and hyperventilation. However, after craniectomy for trauma, a partially boneless cranium may be compressed by the higher atmospheric pressure, that intracranial pressure rises to dangerous levels. For such cases, paradoxical supportive management with intravenous fluid infusion, and reverse Trendelenburg positioning, is used to counteract the higher atmospheric pressure, as a bridge to definitive treatment with cranioplasty. These steps constitute an urgent and easily applied intervention to reduce further neurological deterioration, of which every trauma healthcare provider should be aware.

Intracranial Compliance Assessed by Intracranial Pressure Pulse Waveform

“…All the findings described above have been investigated in animal models or clinical observational studies; however, ICPW changes after ICH treatment surgery have been poorly assessed. Surgery for mass lesion removal or decompressive craniectomy (DC) changes brain architecture and dynamics [14], which makes ICP thresholds also change. In this environment, multimodal monitoring becomes essential to guide therapeutic interventions [6,15,16].…”

Paradoxical Brain Herniation after Cranioplasty: Secondary Sunken Flap Syndrome

“…In patients presenting acutely, the head end is kept down to buy time before cranioplasty which is opposite to other scenarios where head end is kept up to lower ICP. 3 Cranioplasty is the time validated method to correct the abnormalities caused by the SFS. 6 …”

“…First, herniation of the decompressed side of the brain and, second, the treatment is also paradoxical, as it is exactly the opposite of what we do in herniations. 3 Its clinical presentation has a variable spectrum starting from nonspecific symptoms at one end and motor weakness, memory disturbances, confusion, lethargy, and death at the other end. 4 Its pathophysiology is poorly understood and is mainly relied on the pressure differences between the atmosphere and the brain and the changes in cerebrospinal fluid (CSF) flow dynamics.…”

Intracranial Compliance Assessed by Intracranial Pressure Pulse Waveform

“…All the findings described above have been investigated in animal models or clinical observational studies; however, the ICPPW changes after ICH treatment surgery has never been assessed. Surgery for mass lesion removal or decompressive craniectomy (DC) changes brain architecture and dynamics [14]; what makes ICP thresholds also change. In this environment, multimodal monitoring becomes essential to guide therapeutic interventions [15,16].…”