Background: Sinking skin flap syndrome (SSFS) is a rare complication of decompressive craniectomy (DC) and causes a wide range of neurological deficits. Its pathophysiology remains debatable, however cranioplasty may decrease the symptoms of SSFS by reducing the direct effect of atmospheric pressure on the brain and allowing the correction of cerebral blood flow (CBF) and cerebral metabolism.

Case Report: A 36-year-old woman underwent DC for a right frontal hematoma and signs of increased intracranial pressure following the resection of a right frontal arteriovenous malformation. Subsequently, she developed SSFS, altered neurological status with a Glasgow Coma Scale (GCS) score of 8/15, and bacterial-resistant meningitis. We applied a custom-shaped negative pressure helmet on the bone defect and used invasive and noninvasive techniques to measure the changes in intracranial pressure, CBF and cerebral oxygen saturation. Despite improvements in the cerebral physiological parameters, the neurological status did not improve (GCS score, 8/15).

Conclusions: To our knowledge, this is the first reported case of SSFS treated with a negative-pressure helmet and subsequent changes in cerebral parameters that were monitored invasively and noninvasively.