“Sunken brain and scalp flap” syndrome following decompressive “extra-craniectomy”

The sinking brain and scalp syndrome associated with neurological deterioration after decompressive craniectomy in traumatic brain edema is an uncommon condition. The recovery of neurological and imaging deficits following cranioplasty is well known. Although lumbar puncture and ventriculo-peritoneal shunts have been labelled precipitating factors to induce sinking brain syndrome but occasionally “extra” decompressive craniectomy alone may be sufficient to cause it. Clinically the non-pulsatile depressed brain and scalp flap with a marked concavity in an obtunded patient and radiological features like midline shift, paradoxical herniation and 'kidney-bean' shaped brain (Axial CT) are remarkable. It is more like a dehydrated infant with non-pulsatile depressed fontanellae. The cranioplasty has a dramatic effect on the overall recovery of the patient. We present a patient of traumatic brain injury who developed the “non-pulsatile sunken brain syndrome” without VP shunt, lumbar puncture or a external ventricular drainage and recovered completely after cranioplasty. The extra component of craniectomy is likely cause.