Published: 2016-12-19

Post craniectomy paradoxical brain herniation: a case report with radiological review

Sanjay M. Khaladkar, Raunak Raj, Rajul Bhargava, Rohan Khujat, Amaya Mahajan


Sinking skin flap (SSF) syndrome and paradoxical brain herniation are rare complications after craniectomy. On CT scan, there is shrunken appearance of the skin flap at craniectomy site. The meningogaleal complex is drawn inwards and is resting on underlying deformed brain with resultant concave surface. It results due to altered CSF hydrodynamics. Paradoxical brain herniation is rare complications which occur in patients who undergo cerebrospinal fluid (CSF) drainage procedures like lumbar puncture (LP), external ventricular drainage, ventriculo-peritoneal shunting and post craniectomy. Its early detection on imaging is essential as it is a neurosurgical emergency. We report a case of 75 year old male previously operated for left chronic subdural hematoma in the left fronto-temporo-parietal region presenting with altered consciousness and inability to walk. Plain CT scan showed craniectomy defect in the left fronto-temporo-parietal region with indrawing of meningogaleal complex suggestive of Shrunken Skin Flap. There was mass effect on the left lateral ventricle and third ventricle with shift of the midline structures towards right (1cm) with evidence of subfalcine herniation suggestive of paradoxical brain herniation.


Meningogaleal complex, Mesodiencephalic dysfunction, Post craniectomy, Paradoxical brain herniation, Sinking flap syndrome

Full Text:



Yang XF, Wen L, Shen F, Li G, Lou R, Liu WG, ET AL. Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir (Wien). 2008;150(12):1241-7.

Akins PT, Guppy KH. Sinking skin flaps, paradoxical herniation, and external brain tamponade: a review of decompressive craniectomy management. Neurocrit Care. 2008;9(2):269-76.

Fields JD, Lansberg MG, Skirboll SL, Kurien PA, Wijman CA. Paradoxical transtentorial herniation due to CSF drainage in the presence of a hemicraniectomy Neurology. 2006;67(8):1513-4.

Vilela MD. Delayed paradoxical herniation after a decompressive craniectomy: case report. Surg Neurol. 2008;69(3):293-6.

Sinclair AG, Scoffings DJ. Imaging of the post-operative cranium. Radiographics. 2010;30(2):461-82.

Seinfeld J, Sawyer M, Rabb CH. Successful treatment of paradoxical cerebral herniation by lumbar epidural blood patch placement: technical case report. Neurosurgery. 2007;61(3 Suppl):E175.