[Sinking skin flap syndrome]

The sinking skin flap syndrome is a complication of decompressive craniectomies. It is of relevance not only due to its frequency, it is often underdiagnosed, but also because of the possibility of reversing the symptoms with the proper treatment.

A 53-year-old female sustained a severe head injury. The initial Glasgow Coma Scale was 6T. The CT scan showed a severe traumatic injury in the left temporal lobe that required a decompressive craniectomy. After surgery the patient developed aphasia and right hemiparesis but progressively improved. Four months after surgery, however, she presented neurological worsening. An MRI showed skin retraction with a mass effect on the brain parenchyma at the craniectomy defect. A cranioplasty was performed and the patient progressively recovered neurologically.

The symptoms of sinking skin flap are headache, dizziness, inappropriate behaviour, neurological functional impairment and/or seizures. The symptoms worsen with the Valsalva manoeuvres and with changes in position. Typically, symptoms 3 to 5 months to appear. Theories to explain these symptoms include a direct atmospheric pressure effect, brain blood flow changes, alteration in cerebrospinal fluid dynamics and metabolic disturbances. Diagnosis is performed through clinical observation but imaging studies are recommended to confirm the diagnosis. The treatment of choice is a cranioplasty. Prognosis is excellent and almost all patients recover completely.