Disclosures: Benjamin T. Buterbaugh, DO: No financial relationships or conflicts of interest

Case Diagnosis: 11-year-old female with syndrome of the trephined

Case Description or Program Description: The patient presented hospital after suffering a subarachnoid hemorrhage with pneumocephalus and multiple skull fractures from a motor vehicle accident. Hospital course was complicated by transtentorial herniation requiring emergent decompressive craniectomy. During her rehabilitation stay, she developed new, severe headaches with multiple episodes of emesis of unexplained origin.

Setting: Academic Pediatric Inpatient Rehabilitation Hospital

Assessment/Results: Examination revealed no focal deficits with noted right sided nystagmus at baseline. Craniectomy site appeared more shrunken than previous days, so urgent CT scan was obtained showing a 5mm leftward midline shift potentially reflecting syndrome of the trephined with no obstruction or herniation present. Neurosurgery was consulted to evaluate the findings and stated with no focal deficits present on exam and imaging without any evidence of intracranial hemorrhage, herniation, or hydrocephalus then no emergent intervention was necessary as these were expected postoperative findings. Patient was closely monitored with increased frequency of neurological checks, new labs which were unremarkable, and negative infectious work-up.

Discussion (relevance): Syndrome of the trephined, sunken flap syndrome, is a feared complication for craniectomy patients. Patients present with signs of neurological deterioration including mood changes, severe headaches, nausea, new focal deficits, or even seizures. Urgent imaging must be obtained to determine the severity, with scans showing the craniectomy defect sunken onto brain tissue “I.e sunken flap” and a deviation of the midline structures, leading to herniation. Urgent neurosurgical consultation should be obtained as patient may require an emergent cranioplasty.

Conclusions: Syndrome of the trephined is a feared complication in craniectomy patients when seen on imaging, but not always a medical emergency. It is important to perform a focused neurological examination, monitor for signs and symptoms of neurological distress, obtain urgent imaging, alert your neurosurgical colleagues of your concern, and provide education to family on signs and symptoms to monitor.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/sunken-flap-syndrome-not-always-a-medical-emergency-a-case-study/