Paradoxical brain herniation, also known as sinking skin flap syndrome or syndrome of the trephined, is a rare and potentially fatal complication of decompressive craniectomy.
Atmospheric pressure exceeding intracranial pressure at the craniectomy results in displacement of the brain across various intracranial boundaries. This may result in subfalcine and/or transtentorial herniation. It is often triggered by acute imbalance caused by CSF drainage or lumbar puncture.
May range from asymptomatic or mono symptomatic state to acute neurological deterioration.
Large craniectomy with marked concavity of the overlying skin flap, with findings of mass effect such as effacement of the superficial sulci and buckling of the grey-white matter. There may be paradoxical midline shift away from (contralateral to) the craniectomy.
Treatment and prognosis
This is a neurosurgical emergency and necessitates immediate intervention to prevent permanent damage:
- place patient in Trendelenburg position to increase intracranial pressure, with aim of correcting the improper balance between atmospheric and intracranial pressure
- correction of the underlying cause e.g. manipulating CSF drains, lumbar puncture sites
- consider cranioplasty
- 1. Sarov M, Guichard JP, Chibarro S et-al. Sinking skin flap syndrome and paradoxical herniation after hemicraniectomy for malignant hemispheric infarction. Stroke. 2010;41 (3): 560-2. doi:10.1161/STROKEAHA.109.568543 - Pubmed citation
- 2. Jung HJ, Kim DM, Kim SW. Paradoxical transtentorial herniation caused by lumbar puncture after decompressive craniectomy. J Korean Neurosurg Soc. 2012;51 (2): 102-4. doi:10.3340/jkns.2012.51.2.102 - Free text at pubmed - Pubmed citation
- 3. Jadhav AP, Venna N. Teaching NeuroImages: Gravity reverses paradoxical herniation in the sinking brain syndrome. Neurology. 2011;77 (7): e42. doi:10.1212/WNL.0b013e3182299e25 - Pubmed citation
- 4. Akins PT, Guppy KH. Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management. Neurocrit Care. 2008;9 (2): 269-76. doi:10.1007/s12028-007-9033-z - Pubmed citation