Sinking skin flap syndrome and paradoxical herniation secondary to lumbar drainage

Decompressive craniectomy (DC) has been regaining popularity in the field of neurosurgery because it can alleviate intracranial hypertension and brain swelling. Lumbar drainage (LD) is affective in managing numerous neurosurgical circumstances such as aneurysmal subarachnoid hemorrhage, refractory intracranial hypertension, cerebrospinal fluid (CSF) leakage and intraoperative brain relaxation. Sinking skin flap syndrome (SSFS) or paradoxical herniation (PH) is a rare complication and sporadically occurs in patients after DC. Hereby, we report for the first time that DC patients with LD can progress to SSFS or PH. We also evaluated the risk factors for the incidence of SSFS in DC patients with LD.

We retrospectively assessed 37 patients who underwent DC and LD for cerebrovascular diseases from the First Hospital of Jilin University between January, 2007 and December, 2012.

Nine (4 male and 5 female) of 37 patients experienced SSFS or PH following LD. At the last follow-up (mean 9 months, range 6-12 months), eight patients recovered completely due to timely conservative management and one patient died from PH. The mortality rate was 11% (1/9) from the complications of PH or SSFS. Further statistical analysis revealed that mean daily CSF volume was a risk factor for the incidence of SSFS in DC patients with LD.

SSFS or PH can be identified in DC patients following LD. Patients that undergo DC and LD should be monitored more intensively. Most patients can completely recover with timely conservative management, bed rest, Trendelenburg position, sufficient intravenous fluid, and temporary clipping of the catheter.