Neurological Vignette

Received: August 2, 2011

Accepted: August 6, 2011
Published online: September 23, 2011

Eur Neurol 2011;66:227228
DOI: 10.1159/000331939
Cognitive Sinking Skin Flap Syndrome
A.Carota a , M.Pintucci b, F.Zanchi a , E.DAmbrosio a , P.Calabrese c
a
Hildebrand Clinic, Rehabilitation Center, Brissago, and
b
Service of Neurosurgery and c Neurocenter of Southern
Switzerland, Regional Hospital, Lugano, Switzerland
After an assault, a 60-year-old-man was submitted to exten-
sive frontal bone debulking. The postoperative course was un-
eventful without paresis. The patient showed a moderate dysex-
ecutive syndrome with a MMSE score of 23. After 6 weeks of sta-
bility, the patient deteriorated progressively over the following
14 weeks to complete environmental dependency, confabulatory
amnesia and extreme abulia (MMSE 9). Serial CTs showed the
collapse of the frontal lobes (fig.1) under the sinking skin. The
skin flap might engender blood hypoperfusion, axonal stretching
and/or CSF diversion [1]. Neurological dysfunction might reverse
after cranioplasty [2]. This is the first documented case of sinking
skin flap syndrome with pure dysexecutive cognitive deteriora-
tion.
References
1 Joseph V, Reilly P: Syndrome of the trephined. J Neurosurg 2009; 111:
650652.
2 Sarov M, Guichard JP, Chibarro S, et al: Sinking skin flap syndrome
and paradoxical herniation after hemicranectomy for malignant hemi-
spheric infarction. Stroke 2010; 41:560562.
Dr. Antonio Carota
Clinica Hildebrand Centro di Riabilitazione Brissago
Via Crodolo, CH6614 Brissago (Switzerland)
Tel. +41 91 786 8622, E-Mail a.carota @ bluewin.ch

2011 S. Karger AG, Basel

00143022/11/06640227$38.00/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/ene
 a

e f g

Fig. 1. Serial transvere brain CT sections (a day 1 after intervention, b 4-week follow-up, c 8-week follow-up,
d 20-week follow-up) showing the progressive anterior skin flap sinking in the craniotomy site paralleling the
collapse of the frontal lobes. e 3D CT bone reconstruction showing the large craniotomy site including the fron-
tal bones. f The skin flap sinking at the 20-week follow-up. g Sagittal CT section at the 20-week follow-up show-
ing massive frontal lobe flattening.

228 Eur Neurol 2011;66:227228 Carota/Pintucci/Zanchi/DAmbrosio/

Calabrese