{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,4]],"date-time":"2026-05-04T10:45:56Z","timestamp":1777891556695,"version":"3.51.4"},"reference-count":37,"publisher":"SAGE Publications","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["NRE"],"published-print":{"date-parts":[[2021,12,24]]},"abstract":"<jats:p>BACKGROUND: Hemicraniectomy to manage raised intracranial pressure following traumatic brain injury (TBI) has improved survival but may increase the incidence of Sinking Skin Flap Syndrome (SSFS). SSFS is a clinical syndrome in which patients with craniectomy develop objective neurologic abnormalities due to the pressure of the atmosphere on the unprotected brain, often presenting with postural headaches and neurologic deficits that localize to the craniectomy site. Previously thought to be a rare complication of craniectomy after TBI, evidence suggests SSFS is under-recognized. OBJECTIVE: To describe the clinical and radiographic features leading to diagnosis and the impact of temporizing and definitive management of SSFS on outcomes in inpatients with moderate\/severe TBI. METHODS: Two patients\u2019 symptoms, qualitative behaviour observation, physical and cognitive outcome measures, and neuroimaging pre- and post-temporizing measures and cranioplasty are presented. RESULTS: Both patients demonstrated partial improvements with temporizing measures and substantial improvements in functional, cognitive, physical, and rehabilitation outcomes from the cranioplasty and resolution of SSFS. CONCLUSIONS: Rehabilitation care providers are critical to the timely diagnosis and management of SSFS, including the use of temporizing measures and advocacy for definitive treatment with cranioplasty. These cases highlight the diverse clinical presentations and importance of SSFS diagnosis to improve patient outcomes.<\/jats:p>","DOI":"10.3233\/nre-210160","type":"journal-article","created":{"date-parts":[[2021,11,2]],"date-time":"2021-11-02T17:02:58Z","timestamp":1635872578000},"page":"663-672","source":"Crossref","is-referenced-by-count":2,"title":["Postural neurologic deficits after decompressive craniectomy: A case series of sinking skin flap syndrome in traumatic brain injury"],"prefix":"10.1177","volume":"49","author":[{"given":"Emma A.","family":"Bateman","sequence":"first","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada"},{"name":"Parkwood Institute, St Joseph\u2019s Health Care London, London, ON, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jordan","family":"VanderEnde","sequence":"additional","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada"},{"name":"Parkwood Institute, St Joseph\u2019s Health Care London, London, ON, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Keith","family":"Sequeira","sequence":"additional","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada"},{"name":"Parkwood Institute, St Joseph\u2019s Health Care London, London, ON, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Heather M.","family":"MacKenzie","sequence":"additional","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada"},{"name":"Parkwood Institute, St Joseph\u2019s Health Care London, London, ON, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","reference":[{"issue":"3","key":"10.3233\/NRE-210160_ref1","doi-asserted-by":"crossref","first-page":"314","DOI":"10.3109\/02688697.2015.1012047","article-title":"Sinking skin flap syndrome (or Syndrome of the trephined): A review","volume":"29","author":"Annan,","year":"2015","journal-title":"Br J Neurosurg"},{"issue":"6","key":"10.3233\/NRE-210160_ref2","doi-asserted-by":"crossref","first-page":"1055","DOI":"10.1007\/s00701-012-1333-1","article-title":"The impact of timing of cranioplasty in patients with large cranial defects after decompressive hemicraniectomy","volume":"154","author":"Archavlis,","year":"2012","journal-title":"Acta Neurochir (Wien)"},{"issue":"4","key":"10.3233\/NRE-210160_ref3","doi-asserted-by":"crossref","first-page":"525","DOI":"10.1227\/NEU.0000000000001366","article-title":"Syndrome of the Trephined: A Systematic Review","volume":"79","author":"Ashayeri,","year":"2016","journal-title":"Neurosurgery"},{"key":"10.3233\/NRE-210160_ref4","doi-asserted-by":"crossref","first-page":"366","DOI":"10.1016\/j.wneu.2019.04.090","article-title":"Transtentorial Brain Herniation After Lumbar Drainage in Patient Planned for Cranioplastic Reconstruction: Catastrophic Play Between Atmospheric and Intracranial Pressure","volume":"127","author":"Bhatjiwale,","year":"2019","journal-title":"World Neurosurg"},{"issue":"4","key":"10.3233\/NRE-210160_ref5","doi-asserted-by":"crossref","first-page":"442","DOI":"10.1080\/02688697.2017.1374350","article-title":"Duret hemorrhage complicating a sinking skin flap syndrome","volume":"33","author":"Cardinale,","year":"2019","journal-title":"Br J Neurosurg"},{"issue":"1","key":"10.3233\/NRE-210160_ref6","doi-asserted-by":"crossref","first-page":"9","DOI":"10.13004\/kjnt.2017.13.1.9","article-title":"Review of Cranioplasty after Decompressive Craniectomy","volume":"13","author":"Cho,","year":"2017","journal-title":"Korean J Neurotrauma"},{"issue":"1","key":"10.3233\/NRE-210160_ref7","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1080\/02688697.2017.1390065","article-title":"Sinking skin flap syndrome following decompressive craniectomy","volume":"32","author":"Cholet,","year":"2018","journal-title":"Br J Neurosurg"},{"issue":"4","key":"10.3233\/NRE-210160_ref8","first-page":"389","article-title":"The complications of immobility in the elderly stroke patient","volume":"5","author":"Coletta,","year":"1992","journal-title":"J Am Board Fam Pract"},{"issue":"1","key":"10.3233\/NRE-210160_ref9","doi-asserted-by":"crossref","first-page":"323","DOI":"10.1007\/s10143-019-01148-7","article-title":"Sinking flap syndrome revisited: the who, when and why","volume":"43","author":"Di Rienzo,","year":"2020","journal-title":"Neurosurg Rev"},{"key":"10.3233\/NRE-210160_ref10","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1016\/j.wneu.2018.08.153","article-title":"Novel Temporary Treatment for a Severe Case of Syndrome of Trephined","volume":"120","author":"Dillen,","year":"2018","journal-title":"World Neurosurg"},{"issue":"4","key":"10.3233\/NRE-210160_ref11","doi-asserted-by":"crossref","first-page":"381","DOI":"10.3109\/19390211.2013.830679","article-title":"The CARE guidelines: consensus-based clinical case report guideline development","volume":"10","author":"Gagnier,","year":"2013","journal-title":"J Diet Suppl"},{"issue":"5","key":"10.3233\/NRE-210160_ref12","doi-asserted-by":"crossref","first-page":"1312","DOI":"10.1007\/s00415-020-09695-6","article-title":"Complications in cranioplasty after decompressive craniectomy: timing of the intervention","volume":"267","author":"Goedemans,","year":"2020","journal-title":"J Neurol"},{"issue":"4","key":"10.3233\/NRE-210160_ref13","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1097\/00000658-193910000-00002","article-title":"REPAIR OF CRANIAL DEFECTS BY CRANIOPLASTY","volume":"110","author":"Grant,","year":"1939","journal-title":"Ann Surg"},{"issue":"2","key":"10.3233\/NRE-210160_ref14","doi-asserted-by":"crossref","first-page":"152","DOI":"10.13004\/kjnt.2016.12.2.152","article-title":"Intracerebral Hemorrhagic Infarction after Cranioplasty in a Patient with Sinking Skin Flap Syndrome","volume":"12","author":"Han,","year":"2016","journal-title":"Korean J Neurotrauma"},{"key":"10.3233\/NRE-210160_ref15","doi-asserted-by":"crossref","first-page":"79","DOI":"10.25259\/SNI-235-2019","article-title":"Acute paradoxical brain herniation after decompressive craniectomy for severe traumatic brain injury: A case report","volume":"10","author":"Hiruta,","year":"2019","journal-title":"Surg Neurol Int"},{"issue":"12","key":"10.3233\/NRE-210160_ref16","doi-asserted-by":"crossref","first-page":"1119","DOI":"10.1056\/NEJMoa1605215","article-title":"Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension","volume":"375","author":"Hutchinson,","year":"2016","journal-title":"N Engl J Med"},{"key":"10.3233\/NRE-210160_ref17","doi-asserted-by":"crossref","first-page":"1357","DOI":"10.3389\/fneur.2019.01357","article-title":"Cranioplasty Following Decompressive Craniectomy","volume":"10","author":"Iaccarino,","year":"2019","journal-title":"Front Neurol"},{"issue":"3","key":"10.3233\/NRE-210160_ref18","doi-asserted-by":"crossref","first-page":"666","DOI":"10.1007\/s12663-014-0673-1","article-title":"Importance of Early Cranioplasty in Reversing the \u201cSyndrome of the Trephine\/Motor Trephine Syndrome\/Sinking Skin Flap Syndrome\u201d","volume":"14","author":"Jeyaraj,","year":"2015","journal-title":"J Maxillofac Oral Surg"},{"issue":"2","key":"10.3233\/NRE-210160_ref19","doi-asserted-by":"crossref","first-page":"225","DOI":"10.4103\/0976-3147.150281","article-title":"Posture-dependent aphasia: Focal cortical dysfunction in the sinking scalp flap syndrome","volume":"6","author":"Krishnan,","year":"2015","journal-title":"J Neurosci Rural Pract"},{"key":"10.3233\/NRE-210160_ref20","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1016\/j.wneu.2017.03.022","article-title":"Cranioplasty Complications and Costs: A National Population-Level Analysis Using the MarketScan Longitudinal Database","volume":"102","author":"Li,","year":"2017","journal-title":"World Neurosurg"},{"issue":"2","key":"10.3233\/NRE-210160_ref21","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1007\/s00062-017-0635-3","article-title":"Early Occurrence of Sinking Skin Flap Syndrome in a State of Intracranial Hypertension: Case Report","volume":"28","author":"Lim,","year":"2018","journal-title":"Clin Neuroradiol"},{"issue":"2","key":"10.3233\/NRE-210160_ref22","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1016\/j.maturitas.2011.11.012","article-title":"Sarcopenia in the elderly: diagnosis, physiopathology and treatment","volume":"71","author":"Malafarina,","year":"2012","journal-title":"Maturitas"},{"key":"10.3233\/NRE-210160_ref23","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.jocn.2016.04.017","article-title":"Complications following cranioplasty and relationship to timing: A systematic review and meta-analysis","volume":"33","author":"Malcolm,","year":"2016","journal-title":"J Clin Neurosci"},{"issue":"1","key":"10.3233\/NRE-210160_ref24","doi-asserted-by":"crossref","first-page":"111","DOI":"10.5535\/arm.2019.43.1.111","article-title":"Sinking Skin Flap Syndrome or Syndrome of the Trephined: A Report of Two Cases","volume":"43","author":"Park,","year":"2019","journal-title":"Ann Rehabil Med"},{"issue":"5","key":"10.3233\/NRE-210160_ref25","doi-asserted-by":"crossref","first-page":"708","DOI":"10.1016\/j.wneu.2015.01.014","article-title":"Outcomes of cranioplasty with synthetic materials and autologous bone grafts","volume":"83","author":"Piitulainen,","year":"2015","journal-title":"World Neurosurg"},{"key":"10.3233\/NRE-210160_ref26","doi-asserted-by":"crossref","first-page":"556","DOI":"10.1016\/j.wneu.2018.12.223","article-title":"Letter to the Editor Regarding \u201cNovel Temporary Treatment for a Severe Case of Syndrome of Trephined\u201d","volume":"125","author":"Robles,","year":"2019","journal-title":"World Neurosurg"},{"key":"10.3233\/NRE-210160_ref27","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1016\/j.wneu.2017.12.061","article-title":"Massive Brain Swelling and Death After Cranioplasty: A Systematic Review","volume":"111","author":"Robles,","year":"2018","journal-title":"World Neurosurg"},{"issue":"11","key":"10.3233\/NRE-210160_ref28","doi-asserted-by":"crossref","first-page":"1007","DOI":"10.1016\/j.ijscr.2013.08.013","article-title":"Sinking skin flap syndrome with delayed dysautonomic syndrome-An atypical presentation","volume":"4","author":"Romero,","year":"2013","journal-title":"Int J Surg Case Rep"},{"issue":"3","key":"10.3233\/NRE-210160_ref29","doi-asserted-by":"crossref","first-page":"560","DOI":"10.1161\/STROKEAHA.109.568543","article-title":"Sinking skin flap syndrome and paradoxical herniation after hemicraniectomy for malignant hemispheric infarction","volume":"41","author":"Sarov,","year":"2010","journal-title":"Stroke"},{"issue":"2","key":"10.3233\/NRE-210160_ref30","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1055\/s-0028-1093355","article-title":"Sinking skin flap syndrome (SSFS) - clinical spectrum and impact on rehabilitation","volume":"70","author":"Schorl,","year":"2009","journal-title":"Cent Eur Neurosurg"},{"issue":"2","key":"10.3233\/NRE-210160_ref31","doi-asserted-by":"crossref","first-page":"245","DOI":"10.3171\/JNS\/2008\/109\/8\/0245","article-title":"Reversible monoparesis following decompressive hemicraniectomy for traumatic brain injury","volume":"109","author":"Stiver,","year":"2008","journal-title":"J Neurosurg"},{"issue":"11","key":"10.3233\/NRE-210160_ref32","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1213\/XAA.0000000000000312","article-title":"Epidural Blood Patch Using Manometry for Sinking Skin Flap Syndrome","volume":"6","author":"Turner,","year":"2016","journal-title":"A A Case Rep"},{"issue":"6","key":"10.3233\/NRE-210160_ref33","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1007\/s00234-016-1651-8","article-title":"Radiological signs of the syndrome of the trephined","volume":"58","author":"Vasung,","year":"2016","journal-title":"Neuroradiology"},{"key":"10.3233\/NRE-210160_ref34","first-page":"18","article-title":"Neurocognitive recovery and global cerebral perfusion improvement after cranioplasty in chronic sinking skin flap syndrome of 18 years: Case report using arterial spin labelling magnetic resonance perfusion imaging","author":"Woo,","year":"2020","journal-title":"J Clin Neurosci"},{"issue":"1 Pt 1","key":"10.3233\/NRE-210160_ref35","doi-asserted-by":"crossref","first-page":"43","DOI":"10.2176\/nmc.17pt1.43","article-title":"Neurological deficits in the presence of the sinking skin flap following decompressive craniectomy","volume":"17","author":"Yamaura,","year":"1977","journal-title":"Neurol Med Chir (Tokyo)"},{"key":"10.3233\/NRE-210160_ref36","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1016\/j.clineuro.2015.03.010","article-title":"Sinking skin flap syndrome and paradoxical herniation secondary to lumbar drainage","volume":"133","author":"Zhao,","year":"2015","journal-title":"Clin Neurol Neurosurg"},{"issue":"7","key":"10.3233\/NRE-210160_ref37","doi-asserted-by":"crossref","first-page":"2503","DOI":"10.1177\/0300060518755148","article-title":"Early or late cranioplasty following decompressive craniotomy for traumatic brain injury: A systematic review and meta-analysis","volume":"46","author":"Zheng,","year":"2018","journal-title":"J Int Med Res"}],"container-title":["NeuroRehabilitation"],"original-title":[],"link":[{"URL":"https:\/\/content.iospress.com\/download?id=10.3233\/NRE-210160","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T06:06:22Z","timestamp":1777615582000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/full\/10.3233\/NRE-210160"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,12,24]]},"references-count":37,"journal-issue":{"issue":"4"},"URL":"https:\/\/doi.org\/10.3233\/nre-210160","relation":{},"ISSN":["1053-8135","1878-6448"],"issn-type":[{"value":"1053-8135","type":"print"},{"value":"1878-6448","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,12,24]]}}}