{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T16:07:47Z","timestamp":1776096467098,"version":"3.50.1"},"reference-count":60,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"4","license":[{"start":{"date-parts":[[2026,1,26]],"date-time":"2026-01-26T00:00:00Z","timestamp":1769385600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2026,1,26]]},"abstract":"\n BACKGROUND<\/jats:title>\n Syringomyelia is most often associated with Chiari malformation, for which posterior fossa decompression is the standard treatment. Treatment failure should raise suspicion for alternative mechanisms, particularly in patients with a history of supratentorial craniectomy. In such cases, sinking skin flap syndrome (SSFS) may alter intracranial-extracranial pressure gradients, impair CSF dynamics, and result in an acquired Chiari malformation with secondary syrinx formation.<\/jats:p>\n <\/jats:sec>\n \n OBSERVATIONS<\/jats:title>\n A 64-year-old man with a remote supratentorial decompressive craniectomy for intracerebral hemorrhage presented with progressive headache, neck pain, and bilateral arm paresthesia. MRI revealed tonsillar herniation with syringomyelia. Posterior fossa decompression led to initial symptom relief and reduction of the syrinx. Three months later, he developed new bilateral leg sensory deficits, and follow-up MRI showed syrinx recurrence despite adequate decompression and no arachnoid adhesions. Because of prior cranioplasty-related infection, he hesitated to undergo further surgery, but ultimately cranioplasty was performed. Postoperatively, symptoms improved, with sustained clinical recovery and syrinx regression confirmed on serial MRI at 12 and 24 months.<\/jats:p>\n <\/jats:sec>\n \n LESSONS<\/jats:title>\n Persistent or recurrent syringomyelia after Chiari decompression should prompt evaluation for acquired causes. SSFS may mimic primary Chiari malformation; in such cases, cranioplasty can restore CSF dynamics and achieve durable syrinx resolution.<\/jats:p>\n \n https:\/\/thejns.org\/doi\/10.3171\/CASE25763<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/case25763","type":"journal-article","created":{"date-parts":[[2026,1,26]],"date-time":"2026-01-26T06:29:20Z","timestamp":1769408960000},"source":"Crossref","is-referenced-by-count":0,"title":["Sinking skin flap syndrome masquerading as Chiari malformation: failed syringomyelia treatment rescued by cranioplasty. Illustrative case"],"prefix":"10.3171","volume":"11","author":[{"given":"Jin-Young","family":"Kim","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Eunpyeong St. Mary\u2019s Hospital, The Catholic University of Korea, Seoul, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jung-Woo","family":"Hur","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Eunpyeong St. Mary\u2019s Hospital, The Catholic University of Korea, Seoul, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jae Taek","family":"Hong","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Eunpyeong St. Mary\u2019s Hospital, The Catholic University of Korea, Seoul, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"6","key":"bib1","series-title":"Eur Spine J","first-page":"1143","article-title":"Syrinx resolution after posterior fossa decompression in patients with scoliosis secondary to Chiari malformation type I","volume":"21","author":"Wu","year":"2012","unstructured":"Wu TZhu ZJiang JSyrinx resolution after posterior fossa decompression in patients with scoliosis secondary to Chiari malformation type I. Eur Spine J. 2012;21(6):1143-1150."},{"issue":"3","key":"bib2","series-title":"Neurospine","first-page":"554","article-title":"Evaluation and surgical planning for craniovertebral junction deformity","volume":"17","author":"Hong","year":"2020","unstructured":"Hong JTKim ISLee HJEvaluation and surgical planning for craniovertebral junction deformity. Neurospine. 2020;17(3):554-567."},{"key":"bib3","series-title":"World Neurosurg","first-page":"e108","article-title":"Clinical analysis of radiologic measurements in patients with basilar invagination","volume":"131","author":"Park","year":"2019","unstructured":"Park JHHong JTLee JBKim IS.Clinical analysis of radiologic measurements in patients with basilar invagination. World Neurosurg. 2019;131:e108-e115."},{"issue":"6","key":"bib4","series-title":"Neurochirurgie","first-page":"101713","article-title":"Spinal cord malformations\u2019s epidemiology in French children: national cross sectional study based on medico-administrative database","volume":"71","author":"Hervet","year":"2025","unstructured":"Hervet CLe Roux CGaborit CSpinal cord malformations\u2019s epidemiology in French children: national cross sectional study based on medico-administrative database. Neurochirurgie. 2025;71(6):101713."},{"issue":"17","key":"bib5","series-title":"J Clin Med","first-page":"6113","article-title":"Chiari 1 malformation, factors that may influence decision making, and introducing the Chiari 1 malformation severity classification system","volume":"14","author":"Holder","year":"2025","unstructured":"Holder SAbbakr MAHaynes ASanusi TD.Chiari 1 malformation, factors that may influence decision making, and introducing the Chiari 1 malformation severity classification system. J Clin Med. 2025;14(17):6113."},{"key":"bib6","series-title":"Neurosurgery","article-title":"Quality-of-life outcomes in adults and children with Chiari 1 malformation and in those managed without surgery: a prospective, multicenter, observational study","author":"Piper","year":"2025","unstructured":"Piper RJAfshari FTSoon WCQuality-of-life outcomes in adults and children with Chiari 1 malformation and in those managed without surgery: a prospective, multicenter, observational study. 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N Engl J Med. 2017;376(22):e46."},{"issue":"5","key":"bib11","series-title":"Br J Neurosurg","first-page":"963","article-title":"Tonsillar herniation as a complication of lumboperitoneal shunt: case report and literature review","volume":"37","author":"Cheng","year":"2023","unstructured":"Cheng CHLin HLChuang HY.Tonsillar herniation as a complication of lumboperitoneal shunt: case report and literature review. Br J Neurosurg. 2023;37(5):963-966."},{"issue":"2","key":"bib12","series-title":"Childs Nerv Syst","first-page":"343","article-title":"Acquired Chiari type I malformation: a late and misunderstood supratentorial over-drainage complication","volume":"39","author":"D\u2019Amico","year":"2023","unstructured":"D\u2019Amico AGiammalva GRFurlanis GMAcquired Chiari type I malformation: a late and misunderstood supratentorial over-drainage complication. 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Br J Neurosurg. 2015;29(3):314-318."},{"issue":"2","key":"bib20","series-title":"Evid Based Spine Care J","first-page":"116","article-title":"Persistent\/Recurrent syringomyelia after Chiari decompression-natural history and management strategies: a systematic review","volume":"4","author":"Schuster","year":"2013","unstructured":"Schuster JMZhang FNorvell DCHermsmeyer JT.Persistent\/Recurrent syringomyelia after Chiari decompression-natural history and management strategies: a systematic review. 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Case Rep Med. 2018;2018:9805395."},{"key":"bib26","series-title":"Surg Neurol Int","first-page":"78","article-title":"Acquired Chiari I malformation due to lumboperitoneal shunt: a case report and review of literature","volume":"10","author":"Hentati","year":"2019","unstructured":"Hentati ABadri MBahri KZammel I.Acquired Chiari I malformation due to lumboperitoneal shunt: a case report and review of literature. Surg Neurol Int. 2019;10:78."},{"key":"bib27","series-title":"World Neurosurg","first-page":"136","article-title":"How war has shaped neurosurgery","volume":"178","author":"Rainone","year":"2023","unstructured":"Rainone GJZelmanovich RLaurent DLucke-Wold B.How war has shaped neurosurgery. World Neurosurg. 2023;178:136-144."},{"issue":"2","key":"bib28","series-title":"Neurosurgery","first-page":"457","article-title":"Origin of syrinx fluid in syringomyelia: a physiological study","volume":"84","author":"Heiss","year":"2019","unstructured":"Heiss JDJarvis KSmith RKOrigin of syrinx fluid in syringomyelia: a physiological study. Neurosurgery. 2019;84(2):457-468."},{"issue":"2","key":"bib29","series-title":"J Neurocrit Care","first-page":"126","article-title":"Negative-pressure helmet restores cerebral hemodynamic parameters in sinking skin flap syndrome: a case report","volume":"15","author":"Watchi","year":"2022","unstructured":"Watchi MQuintard HBijlenga PPugin JNegro TR.Negative-pressure helmet restores cerebral hemodynamic parameters in sinking skin flap syndrome: a case report. J Neurocrit Care. 2022;15(2):126-130."},{"issue":"5","key":"bib30","series-title":"Br J Neurosurg","first-page":"523","article-title":"Cranioplasty: morbidity and failure","volume":"30","author":"Honeybul","year":"2016","unstructured":"Honeybul SHo KM.Cranioplasty: morbidity and failure. Br J Neurosurg. 2016;30(5):523-528."},{"issue":"6","key":"bib1","series-title":"Eur Spine J","first-page":"1143","article-title":"Syrinx resolution after posterior fossa decompression in patients with scoliosis secondary to Chiari malformation type I","volume":"21","author":"Wu","year":"2012","unstructured":"Wu TZhu ZJiang JSyrinx resolution after posterior fossa decompression in patients with scoliosis secondary to Chiari malformation type I. Eur Spine J. 2012;21(6):1143-1150."},{"issue":"3","key":"bib2","series-title":"Neurospine","first-page":"554","article-title":"Evaluation and surgical planning for craniovertebral junction deformity","volume":"17","author":"Hong","year":"2020","unstructured":"Hong JTKim ISLee HJEvaluation and surgical planning for craniovertebral junction deformity. Neurospine. 2020;17(3):554-567."},{"key":"bib3","series-title":"World Neurosurg","first-page":"e108","article-title":"Clinical analysis of radiologic measurements in patients with basilar invagination","volume":"131","author":"Park","year":"2019","unstructured":"Park JHHong JTLee JBKim IS.Clinical analysis of radiologic measurements in patients with basilar invagination. 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Neurochirurgie. 2025;71(6):101713."},{"issue":"17","key":"bib5","series-title":"J Clin Med","first-page":"6113","article-title":"Chiari 1 malformation, factors that may influence decision making, and introducing the Chiari 1 malformation severity classification system","volume":"14","author":"Holder","year":"2025","unstructured":"Holder SAbbakr MAHaynes ASanusi TD.Chiari 1 malformation, factors that may influence decision making, and introducing the Chiari 1 malformation severity classification system. J Clin Med. 2025;14(17):6113."},{"key":"bib6","series-title":"Neurosurgery","article-title":"Quality-of-life outcomes in adults and children with Chiari 1 malformation and in those managed without surgery: a prospective, multicenter, observational study","author":"Piper","year":"2025","unstructured":"Piper RJAfshari FTSoon WCQuality-of-life outcomes in adults and children with Chiari 1 malformation and in those managed without surgery: a prospective, multicenter, observational study. 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