Posttraumatic sinking skin flap syndrome: case report and literature review

Abstract

Background: Post-traumatic Sinking skin flap syndrome (Syndrome of the Trephined) is a rare condition most commonly manifesting after decompressive craniectomy. The syndrome is characterized by a sunken skin flap in addition to a spectrum of heterogeneous neurological symptoms. The pathophysiology is still not fully understood and leaves many questions open. Another piece of the puzzle was added by the discovery of the glymphatic system. Clear guidelines to diagnose SSFS and thus accelerate diagnosis and treatment have not been established yet. The condition usually improves by cranioplasty. Nevertheless, there is still disagreement about the optimal timing of the procedure as well as its impact on the neurological outcome. This paper reports the case of a 38-year-old female who fell headfirst into shallow water and was found unconscious close to the shore. She arrived at the hospital in severe condition and with blood tests indicating alcohol intoxication. Initial imaging studies showed vast and profound head trauma. The patient underwent emergency decompressive craniectomy however the post-operative course was complicated by prolapsed skin over the cranial vault and neurological impairment.

Aim: When researching the topic the lack of thoroughly compiled literature reviews stood out. Therefore the objective of this paper was to compile existing information on SSFS and create a well-structured in-depth overview about SSFS. The implementation of the clinical case was to highlight SSFS as a post-traumatic outcome and demonstrate the successful treatment approach used for this patient.

Method: This thesis is based on a case report of a patient who was treated in Rīgas Austrumu klīniskā univeritātes slimnīca (RAKUS). The added literature research gives a deeper insight into the topic. Publications of medical journals and the contents of books were reviewed and implemented in the writing of this paper.

Results: In this clinical case the patient developed SSFS which was initially treated with a cranioplasty after the DC. Multiple complications concerning CSF disturbances and neurological dysfunction lead to revision cranioplasty with a personalized hydroxyapatite 3D mold. Eventually, the patient’s condition improved and was able to be discharged.

Conclusion: SSFS is a rare condition, yet it may have severe implications if not diagnosed timely. Therefore, universal diagnostic algorithms including specific radiological signs need to be established. Further research on the detailed pathophysiology as well as ideal cranioplasty timing needs to be done. This clinical case shed some light on the successful management of SSFS.