Clarification for Sinking Skin Flap Syndrome (SSFS)/Syndrome of Trephined

[Masato Kobayashi]

I wanted to clarify conservative management for SSFS and reference this article – Hakmi, H., Joseph, D. K., Sohail, A., Tessler, L., Baltazar, G., & Stright, A. (2020). Sinking skin flap syndrome in the multi-trauma patient: a paradoxical management to TBI post craniectomy. Journal of surgical case reports, 2020(6), rjaa172. https://doi.org/10.1093/jscr/rjaa172.

It may be a typo, but the article’s abstract suggests reverse Trendelenburg (which seems correct), but later in the article states standard Trendelenburg as conservative management. Just to understand and clarify, SSFS is due to a higher ICP imposed by atmospheric pressure, correct? So ideally having the patient in the most upright position (reverse Trendelenburg) would partially resolve this as opposed to a dependent head position which would further increase ICP?

The case-based question referring to SFSS threw me off a bit due to the verbiage issues.

Thank you!

[Chrissy Durrough Lugge]

Hi Masato! I think the article you referenced has a typo in the abstract. Trendelendburg (head down) is the optimal position for managing SSFS. SSFS occurs when atmospheric pressure is high relative to ICP (so ICP is relatively low). The medical team would, therefore, want to increase ICP by placing the patient’s head in a dependent position and pushing fluids.

[Masato Kobayashi]

Got it, thank you for the clarification. So SSFS is an issue of low ICP.

Thank you!

[Jenna Bueltel]

I would like to add to this discussion question. I was thrown off by this series of questions in general as this was a new syndrome to me. I did not get exposure to it in the Brain Injury lecture, slides, or articles presented in NCS prep course. There were also a lot of questions in this practice exam asking on guidelines and parameters to be taken before/after spinal taps and shunts. I feel like I am lacking in this area. Are there any other resources to study for this? Are there any other syndromes or diagnosis associated with brain injury that we should be exposed to before we take the NCS exam?

[Chrissy Durrough Lugge]

Hi Jenna! This condition is not covered in the lectures. Covering everything that could appear on the exam would yield itself to very overwhelming lectures. I tried to home in on the things most likely to appear on the exam. Some other topics are covered in the exams and case quizzes to give you a little review of niche topics and/or an idea of some of the curveballs you might see on the NCS exam. I wouldn’t necessarily aim to become an expert on this one – it is meant more to test how well you can reason through a topic with which you’re unfamiliar.

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