alexa Sinking Skin Flap Syndrome after Hemicraniectomy and Ventriculo-Peritoneal Shunt Overdrainage | Open Access Journals
ISSN: 2155-9562
Journal of Neurology & Neurophysiology
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Sinking Skin Flap Syndrome after Hemicraniectomy and Ventriculo-Peritoneal Shunt Overdrainage

Christiana Ossig1*, Claudia Lindner2, Johannes Gerber3 and Jochen Schaefer1

1Neurology, Medizinische Fakultat Carl Gustav Carus, Technische Universitat Dresden, Fetscherstraße 74, 01307 Dresden, Germany

2Neurosurgery, Medizinische Fakultät Carl Gustav Carus, Technische Universitat Dresden, Fetscherstraße 74, 01307 Dresden, Germany

3Neuroradiology, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany

Corresponding Author:
Christiana Ossig
Division of Neurodegenerative Diseases
Department of Neurology
Dresden University of Technology Fetscherstraße 74
01307 Dresden, Germany
Tel: 0049-351-458-2532
Fax: 0049-351-458-5802
E-mail: [email protected]

Received date: December 10, 2014; Accepted date: February 17, 2015; Published date: March 24, 2015

Citation: Ossig C, Lindner C, Gerber J, Schaefer J (2015) Sinking Skin Flap Syndrome after Hemicraniectomy and Ventriculo-Peritoneal Shunt Overdrainage. J Neurol Neurophysiol 6:272. doi:10.4172/2155-9562.1000272

Copyright: © 2015 Ossig C, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Neurology & Neurophysiology

Abstract

We present a case of sinking skin flap syndrome after hemicraniectomy and insertion of a ventriculo-peritoneal
shunt following severe craniocerebral injury. When the neurological status deteriorated due to cerebrospinal fluid overdrainage and resulting midline shift, complete ligation of the vp shunt became a temporary solution before definitive cranioplasty could be performed.

Keywords

Sinking skin flap syndrome; vp shunt; Shunt overdrainage; Craniectomy; Cranioplasty

Introduction

The sinking skin flap syndrome is a rare complication after hemicraniectomy and is characterized by the occurrence of headache, epileptic seizures, vertigo, dysesthesia, palsy and reduced vigilance [1,2]. It is considered to be caused at the site of the defect by atmospheric pressure, reduced cerebral blood flow (CBF) and altered cerebrospinal fluid (CSF)-pressure – or a combination thereof [1]. Atmospheric pressure may lead to direct cortical compression [2]. Improvement of CBF at the site of the craniectomy and the opposite hemisphere following cranioplasty has been shown by radiological studies including xenon computertomography (CT), perfusion CT, and dynamic CT [3-5]. A decrease in CSF pressure, due to changes in posture, but also caused by overdrainage after shunt insertion, may result in collapse of brain structure [1,6,7].

Case report

A 46-year-old man suffered a brain injury with left-sided subdural and epidural hematoma, requiring left-sided decompressive hemicraniectomy. In addition, a ventriculo-peritoneal (vp) shunt was inserted because of posttraumatic obstructive hydrocephalus using a valve-opening pressure (vop) of 130 mmH2O. Clinically, the patient showed a residual hemiparesis and right-sided hemispasticity. Three months after the accident cranioplasty was performed. Two years later, the cranioplasty dislocated with a skull depression of 2 cm and had to be removed. After refixation, an intracranial large hygroma developed and consequently the vop was increased to 200 mmH2O. Subsequently, an epidural abscess developed and the cranioplasty had to be removed. One week later, the patient presented with a fluctuating level of consciousness and was admitted to our hospital.

On examination, the patient was somnolent and showed a marked right-sided hemiparesis and tetraspasticity. On admission, a CT scan revealed a slit left lateral ventricle and compression of the right lateral ventricle due to midline shift (Figure 1). We suspected overdrainage of the vp shunt and after interdisciplinary discussion complete surgical ligation of the vp shunt was performed leading to major clinical improvement: the patient was awake and was able to interact with his environment using single words and head movements. A follow-up CT scan showed ventricular expansion on the left and reduced midline shift (Figure 2). The patient could be discharged and completed his rehabilitation treatment, before he underwent cranioplasty 6 weeks later (Figure 3). The timepoint for cranioplasty was chosen in regard to the previous epidural abscess and the clinical condition of the patient. During this procedure the ligation was removed and the vop was again set at 200 mm H2O.

Figure

Figure 1: CT Scan on admission

Figure

Figure 2: CT Scan 2 days after shunt ligation

Figure

Figure 3: CT Scan after cranioplasty

Discussion

Vp shunt overdrainage and thus compression of the brain by atmospheric pressure following large hemicraniectomy led to neurological deterioration in our patient. This phenomenon is known as sinking skin flap syndrome (SSFS). The pathogenesis of SSFS in our patient is supported by the observation that only complete surgical ligation of the vp shunt reverted the midline shift and normalized the patient´s level of consciousness. The evidence-based treatment of this syndrome is prompt cranioplasty [8]. In our case, this procedure could not be performed because of the previous infection. Therefore, ligation of the shunt was performed as a temporary solution and resulted in clinical improvement. Slow reduction of the vop is further planned in order to decrease the ventricle size.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Article Usage

  • Total views: 11809
  • [From(publication date):
    February-2015 - Nov 18, 2017]
  • Breakdown by view type
  • HTML page views : 8041
  • PDF downloads : 3768
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
adwords