Sequela of Sunken Flap Syndrome following Decompressive Craniectomy for Occipital Gunshot Wound: A Case Report

Case Diagnosis: A 31-year-old who was treated for a complex gunshot wound to the head developed midline shift post craniectomy, and three months later developed headaches and fatigue consistent with sunken flap syndrome.

Case Description or Program Description: A 31 year old presented to the emergency department for intracranial hemorrhage due to a gunshot wound to the posterior scalp. He received emergent right sided decompressive craniectomy and hematoma evacuation. The patient’s hospital stay was complicated by prolonged intubation requiring tracheostomy, MSSA pneumonia, and dysphagia requiring gastrostomy tube. On admission to the rehabilitation facility he demonstrated a Berg Balance score of 0/56, and was fully dependent for all ADLs. He demonstrated left sided hemiparesis, increased left sided tone, and left sided neglect. Three months after craniectomy, the patient began to experience headaches and fatigue consistent with sunken flap syndrome. He was prescribed 25mg oral topiramate for headache control and seizure prophylaxis. He continued to have headaches upon waking with changes in attention and mood which improved during his hospitalization.

Setting: Inpatient acute rehabilitation clinic

Assessment/Results: Initially, CT head noted extensive comminuted fracture within right side of calvarium with multiple displaced fracture fragments in the soft tissue of the scalp and adjacent brain parenchyma, several parenchymal hemorrhages, and a midline shift. The patient spent 81 days in acute rehab. At the time of discharge his Berg score was 5/56, requiring moderate to minimum assist on all ADLs, transfers, and gait.

Discussion (relevance): Sunken flap syndrome is a rare complication of craniectomy indicated by sunken skin above the procedure site, midline shift on imaging, and neurological symptoms such as headache, focal deficit, and seizures. This complication most commonly occurs several weeks to months after a large craniectomy, and symptoms can fluctuate with medication management and patient recovery.

Conclusions: Patients with an active craniotomy rarely develop sunken flap syndrome and should be monitored with postoperative CT.