SUNKEN SKIN FLAP SYNDROME IN THE TRAUMA SETTING: A RARELY SEEN CONDITION

Objectives: Sunken Skin Flap Syndrome (or Syndrome of the Trephined) following a head trauma is rare, but most often results from complications after decompressive craniectomy. This syndrome is most often characterized by neurological dysfunction that improves with cranioplasty. Varied symptoms can include motor, cognitive, and language deficits. Early diagnosis and treatment is critically important to long term neurological improvement. This is a case report of a 49-year-old male who presented to a tertiary trauma center in South Central Appalachia after a witnessed fall down a flight of stairs. Upon arrival to the ED, the patient was unresponsive and intubated with a GCS of 3T, no cough or gag reflex present, and visible hemotympanum to the left ear. His neurological exam improved significantly after being given mannitol. Initial imaging revealed scattered subarachnoid and intraparenchymal hemorrhages, as well as a large subdural hemorrhage (SDH) with 8mm of left to right midline shift, a comminuted occipital fracture, complex skull base fractures, a left mastoid fracture, and a superior left scapula fracture. Neurosurgery was consulted, and they performed an emergency decompressive craniectomy with evacuation of the left sided SDH due to cerebral compression. His skull flap was left off due to cerebral edema. His post operative course was protracted and complicated by the development of sunken flap syndrome one month after his initial surgery, diagnosed by an acute neurological decline and emergent CT imaging. A review of the literature indicates that this is a rarely documented finding, and this case report reviews discusses the critical components of diagnosis and treatment of this unusual and potentially lethal condition.

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