Presentation
Severe headaches with a history of pervious craniectomies and VP shunt.
Patient Data
Bilateral decompressive craniectomies and right occipital VP shunt with the tip in the left lateral ventricle.
Bilateral (right more than the left) marked concavity of the frontal hemisphere with medial displacement of the brain parenchyma and left subfalcine herniation.
Features are consistent with paradoxical brain herniation (sinking skin flap syndrome).
Case Discussion
This adult male had significant brain injury/multicompartmental intracranial hemorrhage (not shown), after a road traffic accident. During the admission, the patient developed high intracranial pressure which failed to respond to the ICP lowering agents. Then bilateral frontal craniectomies were performed and a ventriculoperitoneal (VP) shunt was inserted.
Much later the patient developed severe headaches and dizziness. CT performed (this study) showed signs of sinking skin flap syndrome. This occurs due to atmospheric pressure being higher than intracranial pressure.
Although it is an uncommon postoperative complication it needs to be considered in the proper clinical context, keeping in mind most concave craniotomies are symptomatic.
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