- Email: [email protected]
Sinking skin flap syndrome after unilateral cranioplasty and ventriculoperitoneal shunt in a patient with bilateral decompressive craniectomy
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 5 (2016) 6–8
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management journal homepage: www.inat-journal.com
Case report
Sinking skin flap syndrome after unilateral cranioplasty and ventriculoperitoneal shunt in a patient with bilateral decompressive craniectomy Jun Watanabe ⁎, Jun Maruya, Keiichi Nishimaki Department of Neurosurgery, Akita Red Cross Hospital, Akita, Japan
Keywords: Sinking skin flap syndrome Post-traumatic hydrocephalus Cranioplasty Ventriculoperitoneal shunt Complication
1. Introduction Post-traumatic hydrocephalus may occasionally develop in patients with decompressive craniectomy after head injury. However, if additional cranioplasty and ventriculoperitoneal (VP) shunt is required, the optimal timing of both procedures is controversial. Here we described a case of sinking skin flap syndrome (SSFS) following unilateral cranioplasty and VP shunt for post-traumatic hydrocephalus after bilateral decompressive craniectomy. To the best of our knowledge, this is the first case report to document SSFS in the course of bilateral cranioplasty and VP shunt. The surgical timing of both procedures and management of SSFS were further discussed based on literature review. 2. Case report A 60-year-old woman was admitted to our hospital because of severe headache and confusion after accidental head trauma at home. At the emergency room, her consciousness level rapidly deteriorated to a Glasgow Coma Scale (GCS) of 7/15. Computed tomography (CT) showed bilateral temporal contusional hematoma and acute epidural hematoma at the torcular herophili with multiple skull fractures (Fig. 1a). Emergent right decompressive craniectomy and evacuation of right temporoparietal hematoma were performed, and continuous monitoring of intracranial pressure (ICP) was initiated. Postoperative CT showed progression of the left temporal contusional hematoma and acute subdural hematoma (Fig. 1b), which were immediately evacuated. Moreover, intraoperative ICP gradually increased after removal of the hematoma and brain swelling worsened; therefore, decompressive craniectomy was included. A second postoperative CT showed progression of the acute subdural hematoma at the decompression site on the right (Fig. 1c). Thereafter, we evacuated the acute epidural hematoma and carefully performed hemostasis, both of which achieved ⁎ Corresponding author at: Department of Neurosurgery, Akita Red Cross Hospital, 2221 Nawashirosawa, Saruta, Kamikitate, Akita 010-1495, Japan. E-mail address: [email protected] (J. Watanabe).
satisfactory control of ICP. She gradually recovered and was almost awake enough to obey command. CT showed improvement of brain edema and communicating hydrocephalus. Six weeks after the initial surgery, left cranioplasty and VP shunt with the CODMAN HAKIM programmable pressure valve device were performed. The opening pressure was set to 150 mm H2O. The next morning, no neurologic issues were observed and CT showed no obvious abnormal findings (Fig. 1d). However, in the afternoon on the same day, she complained of severe headache after being placed in a head-up position, followed by impaired consciousness and bradycardia. Her right craniectomy site was observed to have markedly sunk. Repeat CT showed marked narrowing of the ventricles and concavity of the scalp on the right craniectomy site, with associated midline shift (Fig. 1e). She was placed in a Trendelenburg position and provided hydration, following which the opening pressure increased to 200 mm H2O and her impaired consciousness improved. However, she was forced to have bed rest because the right craniectomy site would sink when in the head-up position. Seven days after VP shunt, right cranioplasty was performed; thereafter, symptoms were no longer observed regardless of the head position. Follow-up CT showed resolution of the midline shift and without significant complications (Fig. 1f). However, she was yet cognitively impaired and was transferred to a rehabilitation hospital. 3. Discussion The term SSFS is applied to patients with large, concave cranial defects after decompressive craniectomy who experienced neurological deterioration. SSFS may either spontaneously develop or be provoked by extra cerebrospinal fluid (CSF) drainage, lumbar puncture, or VP shunt [1]. To the best of our knowledge, only 14 cases of SSFS caused by VP shunt have been reported in literature (Table 1). All cases had good recovery with appropriate treatment. Some mechanisms of SSFS were reported. First, a mean atmospheric pressure of 1033 cm H2O or 14.7 psi may directly compress the cortical surface of the brain through the scalp flap, and application of a VP shunt may result in excessive sinking of the skin flap. A second mechanism is
http://dx.doi.org/10.1016/j.inat.2016.03.010 2214-7519/© 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
J. Watanabe et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 5 (2016) 6–8
7
Fig. 1. Serial cranial CT scan findings in a 60-year-old woman with sinking skin flap syndrome. a: Preoperatively, there are right temporoparietal hemorrhage, acute epidural hematoma at the torcular herophili, and multiple skull fractures. b: After right decompressive craniectomy, there is progression of the left temporal contusion hematoma and acute subdural hematoma. c: After bilateral decompressive craniectomy, there is progression of the subdural hematoma at the right decompression site. d: Post-ventriculoperitoneal shunt CT 1 day later show resolution of the abnormal findings after ventriculoperitoneal shunt and left cranioplasty. e: Immediately after the patient is placed in the Trendelenburg position, repeat CT (6 h after the CT of the d) reveals rapid narrowing of the ventricles and concavity of the brain on the right craniectomy site. f: After right cranioplasty, the midline shift is shown to have resolved and ventricle size is restored.
aggravation of the negative gradient between the atmosphere and ICP by the changing CSF compartment. CSF drainage in a patient with hydrocephalus may exacerbate this gradient effect; prolonged dehydration and upright position may precipitate this phenomenon [7]. Various treatment methods for SSFS with acute deterioration were reported. Hydration, Trendelenburg positioning, adjustment of valve opening pressure, shunt device clamping, fluid infusion into the intrathecal space, and performing a blood patch have been suggested, but have not been confirmed. However, cranioplasty has been shown to offer improvement [7].
Post-traumatic hydrocephalus may occasionally develop in patients with decompressive craniectomy following head injury. However, if additional VP shunt is required because of shunt-dependent hydrocephalus, the optimal timing of both cranioplasty and VP shunting is controversial. Some authors reported that performing simultaneous procedures were associated with higher infection rate and concluded that cranioplasty and VP shunt should be performed as a staged procedure [1,11]. Another author reported that 30% developed SSFS when cranioplasty was performed following VP shunt and concluded that VP shunt after cranioplasty may have a better outcome [12]. However, if a
Table 1 Summary of sinking skin flap syndrome caused by VPS in the literature. Author (year)
Disease
Symptom
VPS from DC (days)
SSFS from VPS (days)
Valve pressure
Treatment
Outcome
Yamaura (1977) [2] Schiffer (1997) [3] Nakamura (1980) [4] Oh (2008) [5]
Tumor Tumor Trauma ND ND Trauma ND Trauma Trauma Trauma Trauma Trauma Trauma Trauma Trauma
Hemiparesis, aphasia Hemiparesis Hemiparesis, aphasia ND ND Coma ND Somnolence, dysautonomia Hemiparesis, coma Headache, aphasia Hemiparesis, aphasia ND ND ND Headache, bradycardia, coma
42 ND 22 ND ND 28 ND 30 30 120 32 42 124 14 42
238 ND 210 7 7 1 ND 510 120 21 ND ND ND 42 1
ND ND ND Medium Medium 120 mm H2O ND Medium ND ND ND ND ND ND 150 mm H2O
CP CP CP Changing shunt device, CP Changing shunt device, CP Valve adjustment, CP Valve adjustment, CP Changing shunt device CP CP ND ND ND Valve adjustment, CP Valve adjustment, CP
GR GR GR GR GR GR GR GR GR GR GR GR GR GR GR
Han (2008) [6] Akins and Guppy [7] Romeo (2013) [8] Wee (2014) [9] Krishnan (2015) [10] Creutzfeldt (2015) [12]
Our case (2015)
Abbreviations: DC; decompressive craniectomy, CP; cranioplasty, GR; good recovery, SSFS; sinking skin flap syndrome, VPS; ventriculoperitoneal shunt, and ND; no description.
8
J. Watanabe et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 5 (2016) 6–8
patient has persistent bulging of the brain through a craniectomy site, VP shunt should be the first option. The strategy would be more complex if both bilateral cranioplasty and VP shunt are required. Carvi et al. [13] reported 18 patients with such conditions; they first performed one-sided cranioplasty and VP shunt, followed by contralateral cranioplasty a few days later. They mentioned that early combined procedures reduced the number of required surgical procedures, complications, and unsatisfied patients. Moreover, SSFS was not recognized in their report. We decided to perform bilateral cranioplasty as a staged procedure in our case. Because the wound on the right side has already been incised twice, the probability of suture failure was high if simultaneous bilateral procedures were performed. Furthermore, bulging of the brain through the craniectomy site was apparent; therefore, the shunt operation was required before cranioplasty. Thus, we first performed leftsided cranioplasty and VP shunt and planned to perform right-sided cranioplasty after the healing of the left-sided wounds. However, SSFS appeared following the first procedure, and contralateral cranioplasty had to be urgently performed. In our case, posture appeared to be one of the trigger of SSFS. After VP shunt, she was positioned in bed up to 30°; there was no issue until the next morning. However, drainage through VP shunt rapidly progressed in the sitting position. Based on this experience, we presumed that either simultaneous procedures or early combined procedures within a few days may be considered if both bilateral cranioplasty and VP shunt are required. In addition, management of posture may be important to avoid SSFS. Further investigation would be required to clarify the mechanism of SSFS because it does not always appear after a VP shunt procedure in patients with skull defects.
4. Conclusion We reported an unusual case of SSFS after unilateral cranioplasty and VP shunt in a patient with post-traumatic hydrocephalus after bilateral decompressive craniectomy. Neurosurgeons should consider the
sinking skin flap syndrome when managing patients with posttraumatic hydrocephalus with skull defects. Conflicts of interest disclosure None. References [1] P. Schuss, V. Borger, Á. Güresir, H. Vatter, E. Güresir, Cranioplasty and ventriculoperitoneal shunt placement after decompressive craniectomy: staged surgery is associated with fewer postoperative complications, World Neurosurg. 84 (4) (2015) 1051–1054. [2] A. Yamaura, H. Makino, Neurological deficits in the presence of the sinking skin flap following decompressive craniectomy, Neurol. Med. Chir. (Tokyo) 17 (1977) 43–53. [3] J. Schiffer, R. Gur, U. Nisim, L. Pollak, Symptomatic patients after craniectomy, Surg. Neurol. 47 (3) (1997) 231–237. [4] T. Nakamura, T. Takashima, K. Isobe, A. Yamaura, Rapid neurological alteration associated with concave deformity of the skin flap in a craniectomized patient. Case report, Neurol. Med. Chir. (Tokyo) 20 (1) (1980) 89–93. [5] C.H. Oh, C.O. Park, D.K. Hyun, H.C. Park, S.H. Yoon, Comparative study of outcomes between shunting after cranioplasty and in cranioplasty after shunting in large concave flaccid cranial defect with hydrocephalus, J. Korean Neurosurg. Soc. 44 (4) (2008) 211–216. [6] P.Y. Han, J.H. Kim, H.I. Kang, J.S. Kim, "Syndrome of the sinking skin-flap" secondary to the ventriculoperitoneal shunt after craniectomy, J. Korean Neurosurg. Soc. 43 (1) (2008) 51–53. [7] P.T. Akins, K.H. Guppy, Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management, Neurocrit. Care. 9 (2008) 269–276. [8] F.R. Romero, M.A. Zanini, L.G. Ducati, R.C. Gabarra, Sinking skin flap syndrome with delayed dysautonomic syndrome-An atypical presentation, Int. J. Surg. Case Rep. 4 (11) (2013) 1007–1009. [9] H.Y. Wee, J.R. Kuo, Never neglect the atmospheric pressure effect on a brain with a skull defect, Int. Med. Case Rep. J. 7 (2014) 67–69. [10] P. Krishnan, S.R. Chowdhury, Posture-dependent aphasia: focal cortical dysfunction in the sinking scalp flap syndrome, J. Neurosci. Rural. Pract. 6 (2) (2015) 225–227. [11] J. Heo, S.Q. Park, S.J. Cho, J.C. Chang, H.K. Park, Evaluation of simultaneous cranioplasty and ventriculoperitoneal shunt procedures, J. Neurosurg. 121 (2) (2014) 313–318. [12] C.J. Creutzfeldt, M.D. Vilela, M.T. Longstreth Jr., Paradoxical herniation after decompressive craniectomy provoked by lumbar puncture or ventriculoperitoneal shunting, J. Neurosurg. 123 (2015) 1170–1175. [13] Y. Carvi, M.N. Nievas, H.G. Höllerhage, Early combined cranioplasty and programmable shunt in patients with skull bone defects and CSF-circulation disorders, Neurol. Res. 28 (2) (2006) 139–144.
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management journal homepage: www.inat-journal.com
Case report
Sinking skin flap syndrome after unilateral cranioplasty and ventriculoperitoneal shunt in a patient with bilateral decompressive craniectomy Jun Watanabe ⁎, Jun Maruya, Keiichi Nishimaki Department of Neurosurgery, Akita Red Cross Hospital, Akita, Japan
Keywords: Sinking skin flap syndrome Post-traumatic hydrocephalus Cranioplasty Ventriculoperitoneal shunt Complication
1. Introduction Post-traumatic hydrocephalus may occasionally develop in patients with decompressive craniectomy after head injury. However, if additional cranioplasty and ventriculoperitoneal (VP) shunt is required, the optimal timing of both procedures is controversial. Here we described a case of sinking skin flap syndrome (SSFS) following unilateral cranioplasty and VP shunt for post-traumatic hydrocephalus after bilateral decompressive craniectomy. To the best of our knowledge, this is the first case report to document SSFS in the course of bilateral cranioplasty and VP shunt. The surgical timing of both procedures and management of SSFS were further discussed based on literature review. 2. Case report A 60-year-old woman was admitted to our hospital because of severe headache and confusion after accidental head trauma at home. At the emergency room, her consciousness level rapidly deteriorated to a Glasgow Coma Scale (GCS) of 7/15. Computed tomography (CT) showed bilateral temporal contusional hematoma and acute epidural hematoma at the torcular herophili with multiple skull fractures (Fig. 1a). Emergent right decompressive craniectomy and evacuation of right temporoparietal hematoma were performed, and continuous monitoring of intracranial pressure (ICP) was initiated. Postoperative CT showed progression of the left temporal contusional hematoma and acute subdural hematoma (Fig. 1b), which were immediately evacuated. Moreover, intraoperative ICP gradually increased after removal of the hematoma and brain swelling worsened; therefore, decompressive craniectomy was included. A second postoperative CT showed progression of the acute subdural hematoma at the decompression site on the right (Fig. 1c). Thereafter, we evacuated the acute epidural hematoma and carefully performed hemostasis, both of which achieved ⁎ Corresponding author at: Department of Neurosurgery, Akita Red Cross Hospital, 2221 Nawashirosawa, Saruta, Kamikitate, Akita 010-1495, Japan. E-mail address: [email protected] (J. Watanabe).
satisfactory control of ICP. She gradually recovered and was almost awake enough to obey command. CT showed improvement of brain edema and communicating hydrocephalus. Six weeks after the initial surgery, left cranioplasty and VP shunt with the CODMAN HAKIM programmable pressure valve device were performed. The opening pressure was set to 150 mm H2O. The next morning, no neurologic issues were observed and CT showed no obvious abnormal findings (Fig. 1d). However, in the afternoon on the same day, she complained of severe headache after being placed in a head-up position, followed by impaired consciousness and bradycardia. Her right craniectomy site was observed to have markedly sunk. Repeat CT showed marked narrowing of the ventricles and concavity of the scalp on the right craniectomy site, with associated midline shift (Fig. 1e). She was placed in a Trendelenburg position and provided hydration, following which the opening pressure increased to 200 mm H2O and her impaired consciousness improved. However, she was forced to have bed rest because the right craniectomy site would sink when in the head-up position. Seven days after VP shunt, right cranioplasty was performed; thereafter, symptoms were no longer observed regardless of the head position. Follow-up CT showed resolution of the midline shift and without significant complications (Fig. 1f). However, she was yet cognitively impaired and was transferred to a rehabilitation hospital. 3. Discussion The term SSFS is applied to patients with large, concave cranial defects after decompressive craniectomy who experienced neurological deterioration. SSFS may either spontaneously develop or be provoked by extra cerebrospinal fluid (CSF) drainage, lumbar puncture, or VP shunt [1]. To the best of our knowledge, only 14 cases of SSFS caused by VP shunt have been reported in literature (Table 1). All cases had good recovery with appropriate treatment. Some mechanisms of SSFS were reported. First, a mean atmospheric pressure of 1033 cm H2O or 14.7 psi may directly compress the cortical surface of the brain through the scalp flap, and application of a VP shunt may result in excessive sinking of the skin flap. A second mechanism is
http://dx.doi.org/10.1016/j.inat.2016.03.010 2214-7519/© 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
J. Watanabe et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 5 (2016) 6–8
7
Fig. 1. Serial cranial CT scan findings in a 60-year-old woman with sinking skin flap syndrome. a: Preoperatively, there are right temporoparietal hemorrhage, acute epidural hematoma at the torcular herophili, and multiple skull fractures. b: After right decompressive craniectomy, there is progression of the left temporal contusion hematoma and acute subdural hematoma. c: After bilateral decompressive craniectomy, there is progression of the subdural hematoma at the right decompression site. d: Post-ventriculoperitoneal shunt CT 1 day later show resolution of the abnormal findings after ventriculoperitoneal shunt and left cranioplasty. e: Immediately after the patient is placed in the Trendelenburg position, repeat CT (6 h after the CT of the d) reveals rapid narrowing of the ventricles and concavity of the brain on the right craniectomy site. f: After right cranioplasty, the midline shift is shown to have resolved and ventricle size is restored.
aggravation of the negative gradient between the atmosphere and ICP by the changing CSF compartment. CSF drainage in a patient with hydrocephalus may exacerbate this gradient effect; prolonged dehydration and upright position may precipitate this phenomenon [7]. Various treatment methods for SSFS with acute deterioration were reported. Hydration, Trendelenburg positioning, adjustment of valve opening pressure, shunt device clamping, fluid infusion into the intrathecal space, and performing a blood patch have been suggested, but have not been confirmed. However, cranioplasty has been shown to offer improvement [7].
Post-traumatic hydrocephalus may occasionally develop in patients with decompressive craniectomy following head injury. However, if additional VP shunt is required because of shunt-dependent hydrocephalus, the optimal timing of both cranioplasty and VP shunting is controversial. Some authors reported that performing simultaneous procedures were associated with higher infection rate and concluded that cranioplasty and VP shunt should be performed as a staged procedure [1,11]. Another author reported that 30% developed SSFS when cranioplasty was performed following VP shunt and concluded that VP shunt after cranioplasty may have a better outcome [12]. However, if a
Table 1 Summary of sinking skin flap syndrome caused by VPS in the literature. Author (year)
Disease
Symptom
VPS from DC (days)
SSFS from VPS (days)
Valve pressure
Treatment
Outcome
Yamaura (1977) [2] Schiffer (1997) [3] Nakamura (1980) [4] Oh (2008) [5]
Tumor Tumor Trauma ND ND Trauma ND Trauma Trauma Trauma Trauma Trauma Trauma Trauma Trauma
Hemiparesis, aphasia Hemiparesis Hemiparesis, aphasia ND ND Coma ND Somnolence, dysautonomia Hemiparesis, coma Headache, aphasia Hemiparesis, aphasia ND ND ND Headache, bradycardia, coma
42 ND 22 ND ND 28 ND 30 30 120 32 42 124 14 42
238 ND 210 7 7 1 ND 510 120 21 ND ND ND 42 1
ND ND ND Medium Medium 120 mm H2O ND Medium ND ND ND ND ND ND 150 mm H2O
CP CP CP Changing shunt device, CP Changing shunt device, CP Valve adjustment, CP Valve adjustment, CP Changing shunt device CP CP ND ND ND Valve adjustment, CP Valve adjustment, CP
GR GR GR GR GR GR GR GR GR GR GR GR GR GR GR
Han (2008) [6] Akins and Guppy [7] Romeo (2013) [8] Wee (2014) [9] Krishnan (2015) [10] Creutzfeldt (2015) [12]
Our case (2015)
Abbreviations: DC; decompressive craniectomy, CP; cranioplasty, GR; good recovery, SSFS; sinking skin flap syndrome, VPS; ventriculoperitoneal shunt, and ND; no description.
8
J. Watanabe et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 5 (2016) 6–8
patient has persistent bulging of the brain through a craniectomy site, VP shunt should be the first option. The strategy would be more complex if both bilateral cranioplasty and VP shunt are required. Carvi et al. [13] reported 18 patients with such conditions; they first performed one-sided cranioplasty and VP shunt, followed by contralateral cranioplasty a few days later. They mentioned that early combined procedures reduced the number of required surgical procedures, complications, and unsatisfied patients. Moreover, SSFS was not recognized in their report. We decided to perform bilateral cranioplasty as a staged procedure in our case. Because the wound on the right side has already been incised twice, the probability of suture failure was high if simultaneous bilateral procedures were performed. Furthermore, bulging of the brain through the craniectomy site was apparent; therefore, the shunt operation was required before cranioplasty. Thus, we first performed leftsided cranioplasty and VP shunt and planned to perform right-sided cranioplasty after the healing of the left-sided wounds. However, SSFS appeared following the first procedure, and contralateral cranioplasty had to be urgently performed. In our case, posture appeared to be one of the trigger of SSFS. After VP shunt, she was positioned in bed up to 30°; there was no issue until the next morning. However, drainage through VP shunt rapidly progressed in the sitting position. Based on this experience, we presumed that either simultaneous procedures or early combined procedures within a few days may be considered if both bilateral cranioplasty and VP shunt are required. In addition, management of posture may be important to avoid SSFS. Further investigation would be required to clarify the mechanism of SSFS because it does not always appear after a VP shunt procedure in patients with skull defects.
4. Conclusion We reported an unusual case of SSFS after unilateral cranioplasty and VP shunt in a patient with post-traumatic hydrocephalus after bilateral decompressive craniectomy. Neurosurgeons should consider the
sinking skin flap syndrome when managing patients with posttraumatic hydrocephalus with skull defects. Conflicts of interest disclosure None. References [1] P. Schuss, V. Borger, Á. Güresir, H. Vatter, E. Güresir, Cranioplasty and ventriculoperitoneal shunt placement after decompressive craniectomy: staged surgery is associated with fewer postoperative complications, World Neurosurg. 84 (4) (2015) 1051–1054. [2] A. Yamaura, H. Makino, Neurological deficits in the presence of the sinking skin flap following decompressive craniectomy, Neurol. Med. Chir. (Tokyo) 17 (1977) 43–53. [3] J. Schiffer, R. Gur, U. Nisim, L. Pollak, Symptomatic patients after craniectomy, Surg. Neurol. 47 (3) (1997) 231–237. [4] T. Nakamura, T. Takashima, K. Isobe, A. Yamaura, Rapid neurological alteration associated with concave deformity of the skin flap in a craniectomized patient. Case report, Neurol. Med. Chir. (Tokyo) 20 (1) (1980) 89–93. [5] C.H. Oh, C.O. Park, D.K. Hyun, H.C. Park, S.H. Yoon, Comparative study of outcomes between shunting after cranioplasty and in cranioplasty after shunting in large concave flaccid cranial defect with hydrocephalus, J. Korean Neurosurg. Soc. 44 (4) (2008) 211–216. [6] P.Y. Han, J.H. Kim, H.I. Kang, J.S. Kim, "Syndrome of the sinking skin-flap" secondary to the ventriculoperitoneal shunt after craniectomy, J. Korean Neurosurg. Soc. 43 (1) (2008) 51–53. [7] P.T. Akins, K.H. Guppy, Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management, Neurocrit. Care. 9 (2008) 269–276. [8] F.R. Romero, M.A. Zanini, L.G. Ducati, R.C. Gabarra, Sinking skin flap syndrome with delayed dysautonomic syndrome-An atypical presentation, Int. J. Surg. Case Rep. 4 (11) (2013) 1007–1009. [9] H.Y. Wee, J.R. Kuo, Never neglect the atmospheric pressure effect on a brain with a skull defect, Int. Med. Case Rep. J. 7 (2014) 67–69. [10] P. Krishnan, S.R. Chowdhury, Posture-dependent aphasia: focal cortical dysfunction in the sinking scalp flap syndrome, J. Neurosci. Rural. Pract. 6 (2) (2015) 225–227. [11] J. Heo, S.Q. Park, S.J. Cho, J.C. Chang, H.K. Park, Evaluation of simultaneous cranioplasty and ventriculoperitoneal shunt procedures, J. Neurosurg. 121 (2) (2014) 313–318. [12] C.J. Creutzfeldt, M.D. Vilela, M.T. Longstreth Jr., Paradoxical herniation after decompressive craniectomy provoked by lumbar puncture or ventriculoperitoneal shunting, J. Neurosurg. 123 (2015) 1170–1175. [13] Y. Carvi, M.N. Nievas, H.G. Höllerhage, Early combined cranioplasty and programmable shunt in patients with skull bone defects and CSF-circulation disorders, Neurol. Res. 28 (2) (2006) 139–144.