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Peer-reviewedCC BY-NC-ND 4.0Journal of Neurosurgery: Case Lessons

Innovative management of sunken flap syndrome post–decompressive craniectomy: illustrative case

  • Katherine Karahalios1
  • Kristopher G. Hooten2
  • Brian Sindelar3
  • Dean G. Karahalios4
4 affiliations
  1. 1Uniformed Services University F. Edward Hebert School of Medicine, Bethesda, Maryland
  2. 2Department of Neurosurgery, Walter Reed Military Medical Center, Bethesda, Maryland
  3. 3Department of Neurosurgery, North Shore University Health System, Raleigh, North Carolina
  4. 4Department of Neurosurgery, Advocate Health Midwest Region, Downers Grove, Illinois
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Abstract

BACKGROUND: Sunken flap syndrome (SFS), also known as syndrome of the trephined, is a rare complication following decompressive craniectomy characterized by neurological deterioration due to altered cerebral hemodynamics and atmospheric pressure effects on the unprotected brain. Management is typically supportive until definitive treatment with cranioplasty. The authors present a case highlighting neck wrapping as a temporizing strategy to mitigate symptoms and facilitate mobilization.

OBSERVATIONS: A 62-year-old unhelmeted bicyclist presented after a collision with an acute subdural hematoma requiring decompressive craniectomy and hematoma evacuation. Twenty-one days postoperatively, he developed SFS with neurological decline that improved with postural measures including Trendelenburg positioning. Early prosthetic cranioplasty was performed after 2 weeks of conservative management; however, wound dehiscence required removal of the prosthetic flap. The patient subsequently developed recurrent SFS. Neck wrapping was attempted and resulted in resolution of symptoms. A trial using a Q-collar to reproduce this effect was unsuccessful, and symptom control was again achieved with neck wrapping.

LESSONS: Neck wrapping may serve as a simple, noninvasive temporizing measure for symptomatic SFS, allowing patient mobilization and stabilization while awaiting definitive cranioplasty.

https://thejns.org/doi/10.3171/CASE26233

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Cite

BibTeXRIS
BibTeX
@article{karahalios2026innovative,
  title = {{Innovative management of sunken flap syndrome post–decompressive craniectomy: illustrative case}},
  author = {Katherine Karahalios and Kristopher G. Hooten and Brian Sindelar and Dean G. Karahalios},
  journal = {Journal of Neurosurgery: Case Lessons},
  year = {2026},
  month = oct,
  doi = {10.3171/case26233},
  url = {https://doi.org/10.3171/case26233},
  note = {CC BY-NC-ND 4.0},
}
RIS
TY  - JOUR
TI  - Innovative management of sunken flap syndrome post–decompressive craniectomy: illustrative case
AU  - Katherine Karahalios
AU  - Kristopher G. Hooten
AU  - Brian Sindelar
AU  - Dean G. Karahalios
PY  - 2026
DA  - 2026/10/26
JO  - Journal of Neurosurgery: Case Lessons
DO  - 10.3171/case26233
UR  - https://doi.org/10.3171/case26233
AB  - BACKGROUND: Sunken flap syndrome (SFS), also known as syndrome of the trephined, is a rare complication following decompressive craniectomy characterized by neurological deterioration due to altered cerebral hemodynamics and atmospheric pressure effects on the unprotected brain. Management is typically supportive until definitive treatment with cranioplasty. The authors present a case highlighting neck wrapping as a temporizing strategy to mitigate symptoms and facilitate mobilization.  OBSERVATIONS: A 62-year-old unhelmeted bicyclist presented after a collision with an acute subdural hematoma requiring decompressive craniectomy and hematoma evacuation. Twenty-one days postoperatively, he developed SFS with neurological decline that improved with postural measures including Trendelenburg positioning. Early prosthetic cranioplasty was performed after 2 weeks of conservative management; however, wound dehiscence required removal of the prosthetic flap. The patient subsequently developed recurrent SFS. Neck wrapping was attempted and resulted in resolution of symptoms. A trial using a Q-collar to reproduce this effect was unsuccessful, and symptom control was again achieved with neck wrapping.  LESSONS: Neck wrapping may serve as a simple, noninvasive temporizing measure for symptomatic SFS, allowing patient mobilization and stabilization while awaiting definitive cranioplasty.  https://thejns.org/doi/10.3171/CASE26233
SN  - 2694-1902
ER  -