Syndrome of trephined: an underreported complication following decompressive craniectomy
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LETTER TO THE EDITOR
Syndrome of trephined: an underreported complication following decompressive craniectomy Jingguo Yang 1 & Junwen Guan 1 Received: 23 June 2020 / Revised: 29 October 2020 / Accepted: 5 November 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
To the editor: Recently, we read the study of Di Rienzo et al. [4], who analyzed potential factors involved in the sinking flap syndrome development and classified the syndrome into 3 subtypes, investigating the risk factors and etiopathogenesis of sinking flap syndrome. However, we noted that there are some aspects of this topic that require further study. First, sinking flap syndrome (also called syndrome of trephined) is an underreported complication after decompressive craniectomy, its incidence remains unclear, and the symptoms of the syndrome are multifarious. In this article, the main diagnostic methods were based on the concave aspect of the decompressive flap. Although the scalp contraction was the most easily identified symptoms of the syndrome of trephined, some patients could (exhibit) neurological decline without concave skin flap [1]. Therefore, the scalp contraction may not be an absolute symptom, and the syndrome of trephined may have a higher incidence than this study reported. To improve the diagnosis, measurement of cognitive function and cerebrospinal fluid measurement such as perfusion study and electroencephalogram should be done more carefully post-decompressive craniectomy. In addition, the multivariate analysis was used to identify potential predictors for sinking flap syndrome. The total number of patients with the syndrome in this study is 43; however, over 10 variables were chosen for multivariable analysis on the basis of previous findings and clinical (constraints). The restricted sample size would limit the statistical analysis [2]. Large series studies are needed in the future. Besides, traumatic brain injury and
patients treated for hydrocephalus were associated with a higher rate of sinking flap syndrome in univariate analysis, but the association was no longer significant in multivariate analysis. However, we have frequently observed the development of post-traumatic hydrocephalus in patients performing decompressive craniectomy [3]. What about interaction terms between traumatic brain injury and post-traumatic hydrocephalus in the multivariable model? Overall, we appreciate Di Rienzo et al. for their work, raising our awareness of the potential risk factors and possible etiopathogenesis for sinking flap syndrome. Our comment in this letter is meant to reassess the diagnosis of this syndrome. Authors’ contributions Conception and design: Yang and Guan. Drafting the article: Yang. Critically revising the article: Guan.
Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research
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