Sinking Skin Flap Syndrome: Cause of Secondary Neurological Deterioration

Author(s): Touab Rida, Rabii Andaloussi Mohamed, Mohsani Mohamed, Mounir Khalil, Bensghir Mustapha, Balkhi Hicham

Introduction: Sinking skin flap syndrome is a rare complication of craniectomy, which is performed as a treatment of severe intracranial hypertension.

Cases Reports: The first case is a 55 year old man. Admitted with Glascow score of 13/15, rapid neurological deterioration was noted with a GCS of 9/15, and then anisocoria. CT scan had objectified hemorrhagic contusions, subdural hematoma measured 11 mm and deviation of the median line. The patient was operated with evacuation of the subdural hematoma through a large decompressive craniectomy. In the second month, he presented a cranial deformation with a deepening of the cutaneous plane, with deterioration of the neurological status and a generalized convulsive crisis. The second case is that of a 32 year old man, admitted to the emergency room with 8/15 of GCS with anisocoria. CT scan was showing an 11 mm right subdural hematoma with a hemorrhagic contusion opposite, a 12 mm midline deviation and diffuse cerebral edema. The patient was operated with evacuation of the subdural hematoma through a large craniectomy. The neurological examination after the extubation showed a GCS of 14. Two days later, the patient presented a depression of the right scalp with an aspect of skin flap syndrome on CT scan without significant neurological deterioration.

Conclusion: The role of decompressive craniectomy in neurological improvement in still uncertain, and timing of cranioplasty is more debate: early with unclear neurologic status and preventing the skin flap syndrome or delete after final outcome.