Disclosures: Phillip Ross: No financial relationships or conflicts of interest

Case Diagnosis: Sunken Skin Flap Syndrome (SSFS)

Case Description: Three patients with either a traumatic or non-traumatic brain injury who underwent right hemicraniectomy for intracranial hypertension were admitted to inpatient rehabilitation. During their rehabilitation course, two patients developed significant functional decline and positional headaches, followed by declining mental status and cognition. One patient, who was in a state of unresponsive wakefulness, developed paroxysmal sympathetic hyperactivity that worsened when sitting or when out of bed. Symptom onset was variable, ranging from one to six months after craniectomy. All three patients had a markedly sunken craniectomy site.

Setting: Acute inpatient rehabilitation hospital

Assessment/Results: Computed tomography of the head showed midline shift away from the craniectomy site ranging from 4-13mm. Acutely, all patients received increased hydration and were placed in the Trendelenburg position. Prompt cranioplasty was advocated via direct communication with neurosurgery.

Discussion: SSFS is an uncommon, delayed complication after craniectomy characterized by a functional decline and variable neurologic symptoms that improve after cranioplasty. Neurological symptoms can include positional headaches, hemiparesis, sensory deficits, spasticity, declining mental status, seizures, and autonomic dysfunction. The variable and sometimes vague clinical presentation of SSFS, as highlighted in these cases, can complicate diagnosis and lead to delays in management. Increasing intracranial pressure through fluid administration and placement in the Trendelenburg position can assist with symptoms, while awaiting definitive treatment with cranioplasty.

Conclusion: With patients being transferred to acute inpatient rehabilitation prior to undergoing cranioplasty, physiatrists must consider a diagnosis of SSFS in patients with a history of craniectomy who develop a functional decline and associated neurologic symptoms. The wide clinical spectrum of SSFS presentation can result in delayed diagnosis and management. A high index of suspicion is needed to initiate symptomatic treatment and coordinate cranioplasty with neurosurgery to prevent further neurological decline.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-case-series-examining-the-clinical-spectrum-of-sunken-skin-flap-syndrome/