, Volume 32, Issue 10, pp 1668-1669
Date: 18 Aug 2006

The syndrome of the sunken skin flap: a neglected potentially reversible phenomenon affecting recovery after decompressive craniotomy

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Sir: A 77-year-old woman was admitted to our ICU following a domestic fall with moderate head injury and left acute subdural hematoma (Fig. 1a) that was immediately evacuated without repositioning the large bone flap (Fig. 1b). The patient did not develop intracranial hypertension. Two months later the patient recovered motor autonomy and was allowed home. There the patient fell again, suffering a femur fracture, and underwent a spinal anesthesia for the orthopedic operation. During the next 3 days the patient developed a right hemiparesis, and simultaneously the skin flap begun to be more depressed. Readmitted to rehabilitation, her cognition progressively declined. Her attention level was low and her behavior worsened, with apathy, inertia and depression setting in. The hemiparesis evolved into hemiplegia. Aphasia supervened. Simultaneously the cranium progressively developed a large, profound, concave skull defect covered by tight skin. Fig. 1

a,b Computed tomography in the 77-year o