Nonsurgical Management of Syndrome of the Trephined: A Systematic Review

Syndrome of the Trephined (SoT), also known as sunken or sinking skin flap syndrome (SSFS), is a rare sequela of decompressive craniectomy caused by an atmospheric pressure gradient over the underlying brain parenchyma following bone flap removal. Cranioplasty is the definitive treatment of SoT, although some patients are not surgical candidates or require bridging to definitive treatment. This systematic review identified 7 articles describing nonsurgical interventions for patients with SoT. Three treatment modalities emerged: external orthotics, scalp traction, and Trendelenburg positioning. These approaches demonstrated rapid improvements in neurological symptoms, including restored motor function, improved cognition, resolution of midline shifts, and, in some cases, re-expanded brain parenchyma. While these results are limited to case reports and small case series, they demonstrate promising early outcomes for the noninvasive management of Syndrome of the Trephined.