Intracerebral Hemorrhagic Infarction after Cranioplasty in a Patient with Sinking Skin Flap Syndrome

One case report of delayed severe intracerebral and intraventricular hemorrhage after cranioplasty

BACKGROUND

Cranioplasty is a relatively simple neurosurgical procedure, and common complications of cranioplasty include dural tears, CSF leakage, infection, epilepsy, epidural hematoma and bone flap resorption. Intracerebral hemorrhage as a complication of cranioplasty is rare, and it is often fatal. The report describes one case of delayed severe intracerebral and intraventricular hemorrhage after an uneventful cranioplasty.

CASE PRESENTATION

A previously healthy 29-year-old man was admitted to our hospital with a traumatic left frontotemporoparietal acute subdural hematoma, an emergency decompressive craniectomy with clot removal was performed. Four months after the surgery, cranioplasty was performed with a titanium mesh, the surgery was uneventful. Six hours after the operation, a CT scan demonstrated no bleeding or edema. In the following 2 days after cranioplasty, the patient did not have any neurological deficits, normal blood pressure was recorded every day, no trauma occurred, and routine laboratory test results were within normal limits. However, on the third day after cranioplasty, the patient suffered a sudden severe headache while playing games on his mobile phone, and then rapidly fell into deep coma; both pupils were fixed and dilated at 5 mm with no response to light. An immediate CT scan revealed a massive intracerebral hematoma and intraventricular hematoma on the left side, and the midline shifted to the right side. Therefore, an ipsilateral decompressive craniectomy was performed with evacuation of the hematoma; the obvious bleeding point was not identified, and no obvious vascular abnormalities were found during the operation. A CT scan on day 3 after reoperation revealed successful decompression, and CT angiography showed no vascular abnormalities. Despite all treatment measures, the patient did not regain consciousness, his neurological situation did not improve after the operation, and the patient lived in a vegetative state.

CONCLUSION

Although intracerebral and intraventricular hemorrhage after cranioplasty is extremely rare, it is often fatal. Aside from hyperperfusion and cerebral autoregulation dysfunction, traction injuries to the fragile vessels due to posttraumatic angiogenesis may also be one of the key factors of complications after cranioplasty.

Postural neurologic deficits after decompressive craniectomy: A case series of sinking skin flap syndrome in traumatic brain injury

BACKGROUND

Hemicraniectomy to manage raised intracranial pressure following traumatic brain injury (TBI) has improved survival but may increase the incidence of Sinking Skin Flap Syndrome (SSFS). SSFS is a clinical syndrome in which patients with craniectomy develop objective neurologic abnormalities due to the pressure of the atmosphere on the unprotected brain, often presenting with postural headaches and neurologic deficits that localize to the craniectomy site. Previously thought to be a rare complication of craniectomy after TBI, evidence suggests SSFS is under-recognized.

OBJECTIVE

To describe the clinical and radiographic features leading to diagnosis and the impact of temporizing and definitive management of SSFS on outcomes in inpatients with moderate/severe TBI.

METHODS

Two patients' symptoms, qualitative behaviour observation, physical and cognitive outcome measures, and neuroimaging pre- and post-temporizing measures and cranioplasty are presented.

RESULTS

Both patients demonstrated partial improvements with temporizing measures and substantial improvements in functional, cognitive, physical, and rehabilitation outcomes from the cranioplasty and resolution of SSFS.

CONCLUSIONS

Rehabilitation care providers are critical to the timely diagnosis and management of SSFS, including the use of temporizing measures and advocacy for definitive treatment with cranioplasty. These cases highlight the diverse clinical presentations and importance of SSFS diagnosis to improve patient outcomes.

Sinking Skin Flap Syndrome and Paradoxical Herniation Provoked by a Malfunction of External Lumbar Drainage and CSF Leak

The sinking skin flap syndrome represents a less-frequent complication in patients after a decompressive craniectomy. It is defined as a neurological deterioration accompanied by a flat or concave deformity of the craniectomy-related skin flap. The underlying brain parenchyma is distorted correspondingly with its blood flow and metabolism being impaired and cerebrospinal fluid hydrodynamics being disturbed, thus causing cerebral dysfunction and neurological symptomatology. The most important options for reversal of this syndrome include Trendelenburg position, maintaining of the cerebrospinal fluid balance, and cranioplasty as a definite solution. We present a patient who underwent a decompressive craniectomy complicated by a cerebrospinal fluid leak in the operative wound treated by means of an external lumbar drainage. Subsequently he developed the sinking skin flap syndrome and a paradoxical cerebral herniation after the drainage system malfunction with a massive cerebrospinal fluid leak at the site of the lumbar drain insertion parallel to the drain itself. His symptoms were, however, successfully alleviated by a positional change, rehydration, and interruption of the lumbar drainage. This illustrational case suggests that clinicians should be aware that patients after decompressive craniectomy may develop a sinking skin flap syndrome as it may either represent an acute risk of a paradoxical brain herniation or complicate the further postoperative care if developed in a chronic way.

Sinking Skin Flap Syndrome After Decompressive Craniectomy: A Case Report

Sinking skin flap syndrome is a rare complication of decompressive craniectomy characterized by a sunken skin flap, neurological deterioration, and paradoxical herniation of the brain. An absent cranium allows for external compression via atmospheric pressure, causing alterations in cerebral blood flow, cerebral spinal fluid flow, and glucose metabolism, which ultimately leads to cortical dysfunction. This case report describes a patient with relatively early onset of variable neurological symptoms and imaging correlation, leading to a diagnosis and definitive therapeutic intervention with cranioplasty. Prompt recognition is critical to avoid potentially devastating neurological outcomes in this rare, but underreported condition.

Massive Brain Swelling and Death After Cranioplasty: A Systematic Review

BACKGROUND

Although cranioplasty is a common procedure, it may cause a variety of complications. Massive brain swelling after cranioplasty (MBSC) is an unusual complication that has been reported more frequently in recent years. Most of the existing information about this condition is speculative and the cause remains unclear.

METHODS

A PubMed and Scopus search adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed to include studies reporting patients with MBSC. Different information was analyzed in these cases to describe the characteristics and identify risk factors for MBSC.

RESULTS

The search yielded 19 articles with a total of 26 patients. All studies were case reports and small case series. In most patients, preoperative intracranial hypotension and a considerable degree of sinking of skin flap were identified; this was the only constant finding observed in these cases. In addition, we propose a grading system to estimate the degree of preoperative sinking of skin flap and an algorithm with recommendations to decrease the incidence of MBSC.

CONCLUSIONS

MBSC is an unusual, highly lethal, and probably underreported condition. The information gathered in this review indicates that MBSC occurs secondary to a cascade of pathologic events triggered by the bone flap implantation. This evidence suggests that the primary pathologic change is a sudden increase in the intracranial pressure acting on a brain chronically exposed to intracranial hypotension.