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Neurological Rehabilitation

Sinking Skin Flap Syndrome, A Rare Condition, Affecting the Rehabilitation Course Quite Often: A Case Series

Friday, October 24, 2025
12:00 PM - 1:30 PM MT
Location: Kiosk 8

    Poster Presenter(s)

  • Matison Alderman, MD

    Resident physician, PGY-4
    University of Miami/Jackson Health System PM&R Program
    Miami, Florida

    • Co-Author(s)

  • Lance Reccoppa, MD

    Resident Physician
    University of Miami/Jackson Health System PM&R Program
    Miami, Florida

  • Sophia Artamendi, Other

    Medical Student
    Florida International University Herbert Wertheim College of Medicine
    Fort Lauderdale, Florida

    • Author(s)

  • GA

    Gemayaret Alvarez, MD

    Associate Professor
    University of Miami Health System
    Miami, Florida

Disclosure(s):
Sophia Artamendi, Other: No financial relationships to disclose
Background and/or Objectives: Sinking skin flap syndrome (SSFS), also known as syndrome of the trephined, is a delayed complication of hemicraniectomy. This occurs when atmospheric pressure exceeds intracranial pressure resulting in paroxysmal herniation and presents with motor deficits, headaches, seizures and altered mental status. Cranioplasty is currently recognized as the definitive treatment. Currently there are no standardized guidelines for managing SFSS in inpatient rehabilitation. Therefore, delays in discharge and therapy interruptions may occur. We aim to analyze these factors to better understand its impact on rehabilitation outcomes.

Design: Retrospective Case Series

Setting : Acute inpatient rehabilitation

Participants : 3 patients with hemicraniectomy and SSFS admitted to AIR over one year

Interventions: not applicable

Main Outcome Measures: Actual length of stay (LOS) / Estimated (or authorized) length of stay ratios, advanced workup ordered (CT brain, EGG), missed therapy sessions, readmission to acute care, functional status pre and post cranioplasty if applicable

Results: 3 patients were identified as having SSFS during their AIR course, 2 of the patients had stays interrupted for cranioplasty. All patients exceeded their estimated or authorized LOS (19/14, 22/5, 35/20). All patients missed several therapy sessions due to SSFS symptoms or work up. All patients had advance workup ordered with CT brain or EEG.

Conclusions: SSFS is associated with extended inpatient rehabilitation stays, therapy interruptions, and increased need for advanced imaging. Functional outcomes improved in patients who underwent cranioplasty compared to the patient who did not. This reinforced the use of cranioplasty as the primary treatment, but leaves uncertainty regarding the timeframe (i.e., being done before admission to AIR). SSFS is considered rare, but it may go underrecognized. It is important to identify and intervene in this complication early to help optimize rehabilitation and discharge planning. More research is needed about SSFS, as current literature emphasizes its rarity however our experience highlights it’s not rare and has implications on the rehabilitation course.