Sinking skin flap syndrome visualized by upright computed tomography

Area of Science:

• Neurosurgery
• Neurology
• Radiology

Background:

• Sinking skin flap syndrome is a known complication following craniectomy.
• It presents as new neurological deficits, often positional, worsening when upright.
• Cranioplasty typically resolves these symptoms.

Observation:

• A 33-year-old male developed hemiparesis in the upright position post-craniectomy.
• Upright computed tomography (CT) revealed significant paradoxical brain herniation and midline shift.
• Supine CT imaging did not show these abnormalities as clearly.

Findings:

• The patient's hemiparesis resolved following cranioplasty.
• Post-cranioplasty CT scans showed resolution of the brain shift.
• Upright CT imaging is crucial for detecting positional brain shift not evident on supine scans.

Implications:

• Upright CT provides objective evaluation of paradoxical herniation and midline shift.
• Clinicians must consider positional brain shift in post-craniectomy patients.
• Early detection and intervention can improve patient outcomes.