Sinking skin flap syndrome in a patient with bone resorption after cranioplasty and ventriculoperitoneal shunt placement: illustrative case

BACKGROUND: Sinking skin flap syndrome (SSFS) is an uncommon complication that can follow decompressive craniectomy. Even less common is the development of SSFS following bone resorption after cranioplasty with exacerbation by a ventriculoperitoneal (VP) shunt. OBSERVATIONS: A 56-year-old male sustained a severe traumatic brain injury and subsequently underwent an emergent decompressive craniectomy. After craniectomy, a cranioplasty was performed, and a VP shunt was placed. The patient returned to the emergency department 5 years later with left-sided hemiplegia and seizures. His clinical presentation was attributed to complete bone flap resorption (BFR) complicated by SSFS likely exacerbated by his VP shunt and the resultant mass effect on the underlying brain parenchyma. The patient underwent surgical intervention via synthetic bone flap replacement. Within 6 days, he recovered to his baseline neurological status. LESSONS: SSFS after complete BFR is a rare complication following cranioplasty. To the authors’ knowledge, having a VP shunt in situ to exacerbate the clinical picture has yet to be reported in the literature. In addition to presenting the case, the authors also describe an effective treatment strategy of decompressing the brain and elevating the scalp flap while addressing the redundant tissue, then using a synthetic mesh to reconstruct the calvarial defect while keeping the shunt in situ.