A Patient with Sinking Skin Flap Syndrome who Underwent Perfusion MRI before and after Cranioplasty Akihito KATO 1 , Hiroyuki MORISHIMA 2 , Goro NAGASHIMA 1,2 1Center of Emergency and Disaster Medicine, Kawasaki Municipal Tama Hospital 2Department of Neurosurgery, Kawasaki Municipal Tama Hospital Keyword: perfusion MRI , sinking skin flap syndrome , cranioplasty , decompressive craniectomy , headache pp.755-760
Published Date 2016/9/10
DOI https://doi.org/10.11477/mf.1436203372
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 Background:Sinking skin flap syndrome(SSFS)manifests as subjective symptoms, such as headache, dizziness, and undue fatigability, in addition to neurologic symptoms, such as hemiplegia, aphasia, and perceived failure, when the skin over a bone defect sinks in the weeks or months following a decompressive craniectomy. Indeed, these symptoms can improve after a cranioplasty.

 Case presentation:A 58-year-old woman presented with a disturbance of consciousness. She was found to have a subarachnoid hemorrhage due to a ruptured right middle cerebral artery aneurysm. She underwent a craniotomy with clipping of the affected artery and a decompressive craniectomy on the same day. Post-operatively, the disturbance of consciousness improved, but the left-sided paralysis persisted. She complained of intractable headaches, was disoriented, and a lack of spontaneity emerged as the skin over the bone defect sank. She underwent cranioplasty on the 43rd day after admission, and the symptoms resolved promptly after surgery. Rehabilitation was canceled at the onset of symptoms, but resumed after the symptoms improved. Based on perfusion MRI, the cerebral blood flow(CBF):cerebral blood volume(CBV)ratio of the affected side increased before and after surgery compared with the healthy side. A lumboperitoneal shunt was placed on the 52nd day after admission to manage the hydrocephalus. She was discharged from the hospital with higher brain dysfunction and a mild state of paralysis.

 Conclusion:The timing of cranioplasty in patients with SSFS has not yet been established, but surgery should be performed before symptoms appear because SSFS impairs rehabilitative efforts.

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