Cognitive Improvements in Sinking Skin Flap Syndrome Using a Negative Pressure Helmet

Sep 30, 2026

Sinking skin flap syndrome, also called syndrome of the trephined, is a rare but serious complication after decompressive craniectomy, where neurological deficits worsen with atmospheric pressure changes. Long-term care usually requires cranioplasty, but temporary measures are needed when reconstruction is delayed, often due to infection or medical instability. This case report presents a minimally invasive negative-pressure helmet approach as a bridge to extend survivability and support cognitive recovery in an affected patient.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages9

Reading Time23 min

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Abstract

Introduction

Case Presentation

How to cite this article

Figure 1: Initial Presentation

Postoperative Course

Figure 2: Acute Sinking Skin Flap Syndrome

Received 10/02/2025 Review began 11/05/2025 Review ended 11/19/2025 Published 12/07/2025 © Copyright 2025 Sabripour et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CCBY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98660 Open Access Case Report Published via Dr. Kiran C. Patel College of Allopathic Medicine (NSUMD) Cognitive Improvements in Sinking Skin Flap Syndrome Using a Negative Pressure Helmet Jian S. Sabripour 1 , Roberto A. Martin 2, Anthony Pasarin 3 , Regina Graham 4, Bryan Lieber 5 1. Food Science and Human Nutrition, University of Florida, Gainesville, USA 2. Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA 3. Surgery, Hospital Corporation of America (HCA) Florida Westside/Northwest Hospitals, Plantation, USA 4. Allopathic Medicine, Nova Southeastern University, Davie, USA 5. Neurological Surgery, Hospital Corporation of America (HCA) Florida Westside/Northwest Hospitals, Plantation, USA Corresponding author: Jian S. Sabripour, [j.sabripour@ufl.edu](j.sabripour@ufl.edu) Abstract Sinking skin flap syndrome, also known as syndrome of the trephined, is a rare but serious complication that can occur following a decompressive craniectomy. It is characterized by neurological deficits that worsen with atmospheric pressure changes affecting the brain. Long-term treatment typically involves cranioplasty; however, temporizing measures are often needed when cranioplasty cannot be performed immediately. This case report introduces a minimally invasive approach using a negative-pressure helmet as a temporary therapeutic device aimed at prolonging survivability and restoring cognitive function in a patient with sinking skin flap syndrome. In this case, the patient presented as a 71-year-old male with a prior craniotomy bone flap that became infected, requiring craniectomy, and developed aggressive syndrome of trephined shortly after surgery. A replacement skull flap was not readily available, and due to infection, placing foreign hardware was suboptimal, but the patient was experiencing significant and worsening mass effect, which warranted urgent intervention. This case demonstrates the life-saving effects of using a negative pressure helmet as an emergency measure to relieve midline shift caused by sinking skin flap syndrome. This method, while novel, may serve to be integrated as a widely used treatment for certain patients with sinking skin flap syndrome. Categories: Neurology, Neurosurgery Keywords: decompressive craniectomy (dc), intracranial pressure, midline shift, negative pressure helmet, sinking skin flap syndrome, syndrome of trephined Introduction Sinking skin flap syndrome (SSFS) is a common and potentially fatal complication observed in patients who have undergone decompressive craniectomy (DC), often due to traumatic brain injury or stroke [1] . The syndrome arises when atmospheric pressure causes the brain to sink at the site of the craniectomy, leading to mass effect and neurologic deficits [2] . Estimates of its prevalence vary, with rates between 13% and 53% reported in large DCs [3] . The definitive treatment for SSFS is cranioplasty; however, some patients are not immediate candidates due to medical instability or other contraindications, such as infection [4] . This report describes a case of acute SSFS successfully managed with an improvised negative pressure helmet (NegPresHelm), which served as a non-invasive bridge to cranioplasty in a patient who could not undergo immediate surgical reconstruction. Case Presentation A 71-year-old cisgender male with poorly controlled diabetes mellitus and a history of traumatic left subdural hematoma underwent a prior craniotomy one year earlier. He presented with worsening aphasia and

FAQs

What is sinking skin flap syndrome and when does it occur?

Sinking skin flap syndrome is a rare complication that can develop after decompressive craniectomy. It occurs when atmospheric pressure causes the brain to sink at the craniectomy site, worsening neurological deficits.

Why might cranioplasty not be performed immediately in these patients?

Cranioplasty may be delayed due to medical instability, contraindications such as infection, or logistical delays in obtaining a custom implant. In such situations, temporary bridging interventions are needed.

How does the negative-pressure helmet function in this case?

The negative-pressure helmet is used as a non-invasive emergency measure to relieve the mass effect and midline shift caused by sinking skin flap syndrome while waiting for definitive reconstruction.

Sep 30, 2026

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