Disclosures: Mark DeCotiis, MD: No financial relationships or conflicts of interest

Case Description: The patient presented to an acute care hospital with GCS score of 6 and CT head scan which revealed a right-sided subdural hemorrhage measuring 7 mm and right-to-left midline shift of 9 mm. During the scanning process, he developed a blown right pupil, necessitating emergent decompressive right craniectomy. He was discharged to our rehabilitation institute on post-operative day 16. Admission assessment revealed significant right-sided weakness, 3/5 in right upper extremity muscle groups, and 4+/5 throughout the right lower extremity. He also developed a profound right-sided temporal concavity and began suffering from severe bitemporal headaches (10/10), refractory to pain medications. The pain worsened with physical activity and upright posture, severely limiting his participation in therapy. Pain was only alleviated by supine positioning.

Setting: Acute Rehabilitation Institute

Patient: 22-year-old male who sustained severe traumatic brain injury following high speed collision motor vehicle accident. Assessment/

Results: CT scan on post-operative day 21 revealed worsening midline shift, now 10 mm. He underwent cranioplasty on post-operative day 36. The following day, CT scan revealed the midline shift improving at 8 mm. He was transferred back to our acute rehabilitation institute 7 days following cranioplasty. On readmission assessment, he was noted to have significant improvement in right-sided weakness, 4+/5 throughout the right upper extremity and 5/5 throughout the right lower extremity. Moreover, the patient complained of a unilateral left temporal headache rated 4/10, alleviated with pain medication and not exacerbated by activity, allowing him to fully participate in therapy.

Discussion: The patient’s worsening midline shift following craniectomy was indicative of paradoxical herniation, a dangerous sequela that may lead to death if allowed to progress. Given his unilateral weakness, the shift was also causing a Kernohan’s notch phenomenon.

Conclusion: Cranioplasty may be an effective means of alleviating paradoxical herniation, Kernohan’s notch phenomenon, and intractable headache secondary to sunken skin flap syndrome following decompressive craniectomy.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/cranioplasty-effectively-improved-paradoxical-herniation-intractable-headache-and-kerohans-notch-phenomenon-in-the-setting-of-sunken-skin-flap-syndrome-a-case-report/