Woo Peter Yat Ming, Mak Calvin Hoi Kwan, Mak Henry Ka Fung, Tsang Anderson Chun On
Department of Neurosurgery, Kwong Wah Hospital, Hong Kong.
Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong.
J Clin Neurosci. 2020 Jul;77:213-217. doi: 10.1016/j.jocn.2020.05.031. Epub 2020 May 12.
Sinking skin flap syndrome (SSFS) is a complication among long-term survivors of stroke or traumatic brain injury treated by decompressive craniectomy. The syndrome encompasses a wide spectrum of neurological symptoms including cognitive decline, seizures, speech and sensorimotor deficits. Early cranioplasty appears to improve cerebral perfusion, but the efficacy of cranioplasty in neurocognitive outcome in long-standing SSFS patient is unclear. We report a 64-year-old patient who suffered from traumatic brain injury and underwent decompressive craniectomy 18 years ago. She had chronic SSFS with pre-cranioplasty assessments demonstrating severe neurocognitive impairments which were static over time. After cranioplasty with custom-made polyetheretherketone flap to restore the 264 cm skull defect, magnetic resonance perfusion scan with pseudo-continuous arterial spin labelling technique showed a two-fold augmentation of cerebral blood flow in both frontal lobes, as well as areas distal to the sunken skin flap compared to baseline. This is accompanied by improvement of neurocognitive function as assessed by Montreal Cognitive Assessment, Neurobehavioral Cognitive State Examination, and Rivermead Behavioural Memory Test three and six months after cranioplasty. The patient's quality of life and that of her primary carer also showed improvement. This report describes a case of neurocognitive and global cerebral perfusion improvement after cranioplasty in the setting of prolonged SFSS of 18 years, and adds to the growing body of literature supporting the therapeutic role of cranioplasty beyond purely protective or cosmetic indications. The advantages and clinical utility of pCASL MR perfusion in assessing serial CBF before and after cranioplasty is illustrated.
下沉皮瓣综合征（SSFS）是减压颅骨切除术后中风或创伤性脑损伤长期幸存者中的一种并发症。该综合征包括广泛的神经症状，包括认知衰退、癫痫发作、言语和感觉运动障碍。早期颅骨修补术似乎能改善脑灌注，但颅骨修补术对长期存在的SSFS患者神经认知结局的疗效尚不清楚。我们报告一名64岁的患者，她曾遭受创伤性脑损伤，并于18年前接受了减压颅骨切除术。她患有慢性SSFS，颅骨修补术前评估显示存在严重的神经认知障碍，且随时间推移无变化。在用定制的聚醚醚酮皮瓣进行颅骨修补以修复264平方厘米的颅骨缺损后，采用伪连续动脉自旋标记技术的磁共振灌注扫描显示，与基线相比，双侧额叶以及下沉皮瓣远端区域的脑血流量增加了两倍。颅骨修补术后三个月和六个月，通过蒙特利尔认知评估、神经行为认知状态检查和里弗米德行为记忆测试评估，神经认知功能得到改善。患者及其主要照顾者的生活质量也有所提高。本报告描述了一例在长达18年的SFSS情况下颅骨修补术后神经认知和全脑灌注改善的病例，并补充了越来越多支持颅骨修补术超出单纯保护或美容适应症的治疗作用的文献。阐述了pCASL MR灌注在评估颅骨修补术前和术后连续脑血流量方面的优势和临床应用。
