LAUSR

The clinical outcome of decompressive craniectomy carried out in patients refractory to medical (nonsurgical) treatment for elevated intracranial pressure, is still controversial [1]; however, decompressive craniectomy is still performed and the complications associated with it are increasing. In particular, after this procedure some patients were reported to show delayed neurologic deterioration with depressed scalp above the bone defect [2–7]. The sinking skin flap syndrome (SSFS) consists of an area of sunken skin above the bone defect with neurological symptoms, such as severe headache, mental change and focal deficits or seizure [2–6]. The syndrome may induce paradoxical herniation as a consequence of a negative pressure gradient between the atmospheric pressure and the intracranial pressure [3]. In most reported cases, SSFS occurred under controlled intracranial pressure after craniectomy [3, 5, 7]; however, our patient showed an early occurrence of the syndrome accompanying high intracranial pressure. We report a case of paradoxical herniation caused by SSFS with intracranial hypertension.