Syndrome of the trephined: theory and facts

Abstract

The pathophysiology behind "the syndrome of the trephined" has been under investigation over the past 50 years. Research related to barometric pressure, cellular metabolism, cerebrospinal fluid (CSF) dynamics, and the vasculature have attempted to decipher the mechanism of disease. These subjects are discussed in five papers along with specific topics related to the syndrome. The symptoms experienced after craniectomy, the resolution of symptoms with cranioplasty as well as CSF, cerebral blood flow, and metabolic studies are presented, respectively, with a review of the theories.

Efficacy and Versatility of the 3-D Titanium Mesh Implant in the Closure of Large Post-Craniectomy Osseous Defects, and its Therapeutic Role in Reversing the Syndrome of the Trephined: Clinical Study of a Case Series and Review of Literature

“…In addition, factors such as the adhesion between the dura on the brain surface and the margins of the bony defect, cicatricial changes and fibrous adhesions occurring between the brain cortex, dura and the overlying scalp flap, cause further traction, torsion, and compression of the brain and other intracranial contents, impeding local blood supply and venous return [33]. The Barometric pressure of the atmosphere overwhelms the intracranial pressure and causes expulsion of CSF from the ventricular system of the brain, resulting in ventricular deformity; a fall in CSF pressure thus reducing its flow and motion; a reduction in the cerebral blood flow and venous return, thus hampering cerebral hemodynamics, perfusion and metabolism [2]. This is the actual pathophysiology of the ''MTS''.…”

“…a fall in GCS, loss of concentration and memory, and delayed motor deficits. Subjective symptoms of the MTS include vague pain and discomfort at the site of the cranial defect, intolerance to vibrations, undue fatigability, headache and dizziness, anxiety and apprehension, mental depression and mood swings [2,33]. The scalp flap overlying the Craniectomy defect often becomes disfigured, indrawn and ''sucked-in'', creating a tense, non-pulsatile, gorge-like pit, hence the alternative name ''SSFS'' [34][35][36].…”

“…Cranioplasty using the excised autologous bone flaps closed in layers, using deep interrupted resorbable sutures for the pericranium and galea, followed by surgical staples for the cutaneous closure. G, H A good cosmetic reconstruction of the cranial defect as well as functional improvement in her motor and cognitive functions as well as her mood and temperament, following the titanium mesh cranioplasty have been documented to sometimes help in reversing the MTS by providing a cranial shield or cover [2,38], thus protecting the brain and cranial contents from the atmospheric pressure. Till date, there have been no documented reports or studies on the effect of Titanium mesh cranioplasty on the functional outcome in patients exhibiting features of the MTS.…”

“…In addition to the cosmetic and protective roles, cranioplasty has also been reported to have a functional and therapeutic role as it sometimes helps to reverse features of a condition called the motor trephine syndrome (MTS) [2], which is characterized by Neurosensory and Motor deficits, that develop due to derangements in Cerebral hemodynamics, Cerebrospinal fluid (CSF) hydrodynamics and shrinkage and displacement of intracranial structures, secondary to large cranial defects [3].…”

Importance of Early Cranioplasty in Reversing the “Syndrome of the Trephine/Motor Trephine Syndrome/Sinking Skin Flap Syndrome”

“…There are various pathophysiological theories for the cause of the neurological and motor deficits seen in SSFS/ MTS [14]: (a) direct cortical compression; (b) hydrodynamically disturbed CSF parameters; (c) haemodynamically reduced CBF, cerebrovascular reserve capacity and venous return due to pressure on the vasculature and brain tissue; (d) disturbed metabolism [15].…”