Case report of MR perfusion imaging in sinking skin flap syndrome: growing evidence for hemodynamic impairment

Andre Kemmling, Thomas Duning, Lars Lemcke, Thomas Niederstadt, Jens Minnerup, Heike Wersching, Martin Marziniak, Andre Kemmling, Thomas Duning, Lars Lemcke, Thomas Niederstadt, Jens Minnerup, Heike Wersching, Martin Marziniak

Abstract

Background: The syndrome of the sinking skin flap (SSSF) with delayed sensorimotor deficits after craniectomy is not well known and often neglected. Among various postulated causes, there is evidence that disturbed brain perfusion may be related to the observed symptoms, and that cranioplasty reliably alleviates these symptoms. We report a case of sinking skin flap syndrome (SSFS) with recovery from neurological sensorimotor deficits after cranioplasty correlated with pre- and postsurgical MR brain perfusion studies.

Case presentation: A 42-year-old woman presented with slowly progressive sensorimotor paresis of her left arm after decompressive extensive craniectomy due to subarachnoid hemorrhage four months ago. Her right cranium showed a "sinking skin flap". After cranioplastic repair of her skull defect, the patient fully recovered from her symptoms. Before cranioplasty, reduced brain perfusion in the right central cortical region was observed in MR-perfusion images. After cranioplasty, a marked increase in brain perfusion was observed which correlated with objective clinical recovery.

Conclusion: There is increasing evidence that impaired blood flow is responsible for delayed motor deficits in patients with sinking skin flap syndrome in the area of compressed brain regions. Symptoms should be evaluated by brain perfusion imaging complementing surgical decision-making.

Figures

Figure 1
Figure 1
MR-perfusion maps and anatomy before (A-D) and after (E-F) cranioplastic repair of a patient with the "sinking skin flap syndrome" with delayed motor deficits. A focal area of hypoperfusion (reduced blood flow and blood volume, and increased mean transit time) is observed in the right parietal cortex (A-C) beneath the skin flap. After cranioplasty, brain perfusion maps show no longer show a significant perfusion deficit.
Figure 2
Figure 2
Brain perfusion in the right hemisphere compared to healthy left side before and after cranioplastic repair in a patient with "sinking skin flap syndrome". Improvement of all three perfusion parameters was observed (relative cerebral blood volume and blood flow increased, relative mean transit time decreased).

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