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1638 - Sinking the Narrative: A Case Report on the Benefits of Early Cranioplasty in Patients with Concern for Sunken Skin Flap Syndrome

Thursday, February 27, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

DM

Daniel S. Marte, MD

PGY-2 Resident Physician
Icahn School of Medicine at Mount Sinai
New York, New York, United States

Co-Author(s)

CM

Carolina Mallar, BS

Medical Student
University of Miami
Miami, Florida, United States
Miguel X. Escalon, MD

Program Director
Icahn School of Medicine at Mount Sinai
NY, New York, United States

Case Diagnosis: Sunken Skin Flap Syndrome (SSFS)

Case Description: A 42-year-old with a history of polysubstance use, presented to inpatient rehabilitation after being admitted for a traumatic subdural hemorrhage with midline shift in the setting of an intoxicated fall. This resulted in him undergoing a decompressive hemicraniectomy. Upon admission to rehab, the patient was approximately 4 weeks post-hemicraniectomy. Throughout the admission, he endorsed persistent, non-positional headaches, despite a medication regimen of propranolol, mirtazapine, magnesium, and acetaminophen. Additionally, he endorsed diplopia, blurry vision, and dizziness. Given these symptoms, the patient underwent a medical work-up, which was unremarkable, and a baseline CT-head, which did not show any new acute pathologies or immediate concern for SSFS. Despite being only 7 weeks post-hemicraniectomy, his persistent symptoms allowed him to receive a cranioplasty before the established 3-month post-operative threshold. He was readmitted to rehab 1 week after his cranioplasty and reported total improvement in his symptoms.

Discussions: Current neurosurgical guidelines indicate that cranioplasties should be performed 3-6 months after craniectomies and consider anything less than 3 months to be an early (6 weeks to 3 months post-craniectomy) or ultra-early (less than 6 weeks post-craniectomy) operation. Given the close observation that occurs in acute rehab, patients can be monitored for signs of impending SSFS, even without radiological evidence like paradoxical herniation, sunken skin flap sign, or deviation of midline structures. Symptoms to monitor include a sunken scalp, positional headaches, dysautonomia, altered mental status, seizures, visual changes, and new focal deficits.

Conclusions: Patients admitted to acute rehab prior to receiving a cranioplasty should be monitored for signs of SSFS. If signs of SSFS are present, it may be beneficial to communicate with the neurosurgery department and discuss performing a cranioplasty earlier than 3 months post-craniectomy, as it may improve patients’ symptoms and aid in their overall recovery.