Syndrome of Trephined-Underestimated and Poorly Understood Complication After Decompressive Craniectomy

Abstract

Decompressive craniectomy (DC) is still a matter of debate, with a numerous complications as expansion of haemorrhagic contusions, external cerebral herniation, subdural hygromas, post-traumatic hydrocephalus (HC). The often overlooked "syndrome of the trephined" (ST) as a delayed complication of DC also known as sinking skin flap sy initially described in 1939.ST is characterised by the neurological changes associated with alteration of the pressure/volume relationship between intracranial pressure (ICP), volume of cerebrospinal fluid (CSF), blood, and brain tissue in patients with large bone defects. This review aims at elucidating the mechanisms responsible for the development of ST, and providing useful tips and red-flag signs for healthcare professionals involved with care of post DC patients. Symptoms identified on time could help to develop appropriate treatment strategies for this suddenly deteriorating, but possible reversible condition. Although the treatment strategy is straightforward, calling for a prompt cranioplasty, the correction of HC through CSF diversion devices might require a lengthy optimisation period. Continuous changes in the setting of the shunting systems or spinal tap might lead to dangerous swinging of the midline structures causing further neurological deterioration. Thus, finding the right balance in terms of clinical management often represents a significant challenge.

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

“…Thus, all components of the cranium such as blood, brain tissue, and CSF are in a state of equilibrium with one another such that any increase in one component must be matched with the same intensity decrease in another. In SSFS, neurologic changes are associated with alteration of the pressure/volume relationship in which these components lose their equilibrium, thus resulting in a significant pressure change and the resulting sinking of the skin flap seen on imaging [ 3 ].…”

Regression of Liquorodynamic Disorders and Ventriculoperitoneal Shunt Overdrain Syndrome Clinic in a Patient After Severe Brain Injury with Posttraumatic Hydrocephalus and a Giant Cranial Bones Defect After Cranioplasty: Case Report

“…В ряде современных работ продемонстрировано, что наличие дефекта костей свода черепа вызывает нарушения микроциркуляции и ликвородинамики как в зоне дефекта, так и в контралатеральном полушарии головного мозга. Закрытие дефекта, восстановление объемных соотношений интракраниального содержимого приводит к регрессу этих нарушений и улучшению неврологического статуса пациентов [7][8][9][10][11].…”

Clinical Significance of Isolated Third Cranial Nerve Palsy in Traumatic Brain Injury: A Detailed Description of Four Different Mechanisms of Injury through the Analysis of Our Case Series and Review of the Literature

“…During the terminal stage of herniation, where the medulla is affected, the diffuse hypoxia continues to sustain mydriasis; therefore, the damage becomes irreversible. Fixed dilated pupils have thus historically been associated with a very poor prognosis in TBI [11][12][13][14][15].…”