Sinking Skin Flap Syndrome

a case presentation and review of Sinking Skin Flap Syndrome

1. SUNKEN SKIN FLAP SYNDROME : a case presentation and review Dr Bipin Bhimani Well Care Hospital Rajkot

2. Case presentation Young male patient , 32 years old He had Right MCA territory infract

3. Right MCA Infarct

4. 22/9/13 - moderate size infarct , thrombolysed with IV tPA

5. Next day, malignant MCA infarct

6. 24/9/13 - Malignant MCA infarct decompression craniectomy was done Survived with left hemiparesis , 3/5 MRC Grade power , ambulatory

7. no history of DM/HT/addiction borderline hyperlipidemia 201 mg cholesterol Homoctysteine -32 units (4-12) APLA –negative, HIV – non reactive, TSH- normal, 2D ECHO- normal, carotid doppler - 60% block in right ICA

8. Treatment He was started on Aspirin , clopidogrel , Atorvastatin , Vitamin B6,B12 and Folic acid supplements Cranioplasty was planned , but patient refused

9. 2017 27/5/17 - drowsy, incontinence, memory impairment , nystagmus , upgaze restriction, divergent squint , focal seizure MRI – No new changes, EEG –abnormal in form of right hemisphere focal sharp waves , Levetiracetam was started Stabilized

10. 2018 9/8/18 – complaint of local headache MRI BRAIN (Plain with contrast ) - Static changes CBC- normal CRP-11.0

11. MR BRAIN : ON 9/ 8/ 18

12. Few months later Vague symptoms , occasional fever - ? Sepsis / depressed Psychiatric consultation- antidepressants, antipsychotics were started Deterioration ( drowsy, salivation, tremor )

13. Patient was referred to our center

14. My first Clinical examination ( 27 Nov 18) Drowsy, headache Neck drop Salivation, occasional aspiration while swallowing Tremor of right UL Squint Normal fundi , pupil Left UL/LL old deficits – one grade deterioration Plantar reflex : Right flexor/left extensor Vital parameters : normal

15. Investigations CBC/RBS/ESR-Normal sr creatinine /SGPT/sodium/potassium-Normal CRP-11.0 TSH- Normal Sr Phenytoin level – 8.44 ( normal ) EEG – normal

16. Mr BRAIN – showing sinking skin flap

17. 27/11/18 - Sinking skin flap syndrome was diagnosed Supine position, IV hydration CRANIOPLASTY WAS PLANNED Patient again refused for cranioplasty Few months deteriorated further, patient gave consent and operated on 5/3/19 for cranioplasty Good improvement , no salivation, able to hold neck, walks with minimal support , still has squint and minimal tremor in some position, motor deficits improved 1 MRC grade This patient had Sinking skin flap syndrome with late presentation , and fluctuations

18. Post cranioplasty

19. Evolution: progressive sinking of flap and cranioplasty at last

20. Sinking Skin Flap Syndrome(SSFS) Grant (1939) : psychiatric origin , sense of vulnerability Yamumura and Makino (1977) : Gave the term SSFS and suggested objective findings Syndrome of trephined ( in Trauma ,stroke or tumor cases) Later stage -Paradoxical herniation ( midline shift) Day of symptom presentation: 28-188 days ( Average- 5 months) 11% clinical presentation Further 15% had only radiological presentation

21. Symptoms of SSFS Flat or sunken flap / non pulsatile / non pinchable skin Local pain / headache Orthostatic headache / vertigo Seizure Cognitive and linguistic symptoms Behavioral changes Drowsiness Focal deficits deterioration, incontinence Autonomic symptoms / dysautonomia Midbrain symptoms, parkinsonism, cranial neuropathy Coma, death

22. Rehabilitation arrest is noted in many patients as an only symptoms in one study Failure to hold gain/ recovery

23. Pathophysiology of SSFS Local friction of cortex OPEN BOX THEORY CSF dynamics Cerebral hypoperfusion Cortical glucose metabolism Paradoxical herniation at last

24. Treatment of SSFS Head low ( Trendelenburg position) Head turn to craniotomy side Intravenous hydration To stop mannitol / glycerol etc (To clamp if any VP shunt, to avoid lumbar puncture ) Cranioplasty is the definitive treatment

25. Diagnosis of SSFS 1 : Largely clinical : Sunken flap , cluster of symptoms 2: radiological signs and 3: improvement after cranioplasty Radiological features should have clinical signs/symptoms

26. Prevention of SSFS Prevention : early carnioplasty preferably within 12 weeks

27. Various cases reported in literature Sinking bone flap syndrome when bone flap is partially resorped Bilateral SSFS Improvement of SSFS due to lateral position on decompression craniectomy side Posture dependent aphasia MR perfusion study pre and post cranioplasty

28. Thank you