Morning Report 1/31/18 – Sinking Skull Flaps and Sweets!

Thank you, Chuka and Serge, for presenting mini-cases today! Chuka told us about an elderly woman admitted for a RLE DVT who had a recent subdural hematoma s/p craniotomy being treated with heparin bridge to warfarin who developed acute onset L sided weakness.

  • Sinking skull flap Syndrome AKA syndrome of the trephined is a rare complication after a large craniectomy, with a sunken skin above the bone defect with neurological symptoms such as severe headache, mental changes, focal deficits, or seizures. See more below.

Sinking Skull Flap Syndrome – Link to a clinical description with images in an article by Romero et al.

  • Principal symptoms: severe headache mental changes, focal deficits, or seizures
  • Treatment: primary goal is restoration of the pressure exerted by depression of craniectomy site
    • Cranioplasty is the principal surgical treatment that could improve the neurological deficits by decreasing local intracranial pressure and correcting abnormal CSF dynamics, but early restoration of the cranial flap is also associated with risk of infection
    • Conservative management with intrathecal saline infusion and Trendelenberg positioning is thought to be largely ineffective

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Serge shared with us a case of a man with an acute onset of scattered, painful erythematous skin lesions found to have Sweet Syndrome.

  • Sweet syndrome is an acute febrile neutrophilic dermatosis. The clinical syndrome includes:
    • acute onset fever
    • leukocytosis
    • acute, tender, red plaques
    • papillary dermal infiltrate of neutrophils
  • Sweet Syndrome can occur as an idiopathic/primary condition or secondary to an underlying malignancy, infection, autoimmune disease, or medication effect. The malignancy most commonly seen is AML.
  • Treatment includes topical steroids and/or colchicine in addition to treatment of the underlying condition if one is found.

Sinking Skull Flap Syndrome Evernote: https://www.evernote.com/shard/s462/sh/24165039-966c-4c65-9055-b3dc6267062d/ddf9e5ad9eefeffd4e4e8ef06ca9023b

Sweet Syndrome Evernote: https://www.evernote.com/shard/s462/sh/c07c03d3-cd0c-4969-b88f-8c5a35f3c84b/d89c93cd5b2c2572b58a8bb43d6f27af

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