1007 - Eyes Wide Open: Gaze Preference as a Clinical Indicator of Sunken Skin Flap Syndrome: A Case Report

Case Diagnosis: Sunken skin flap syndrome (SSFS) following decompressive craniectomy in a 27-year-old male with severe traumatic brain injury.

Case Description: A 27-year-old previously healthy male sustained a severe traumatic brain injury (TBI) as an unrestrained passenger in a motor vehicle accident. His Glasgow Coma Scale (GCS) score was 3 on emergency department (ED) arrival. Imaging demonstrated a left epidural hematoma, left intraparenchymal hemorrhage, and scattered subarachnoid hemorrhages. The patient underwent an emergent decompressive craniectomy and later ventriculoperitoneal (VP) shunt placement. He was admitted to acute inpatient rehabilitation while awaiting cranioplasty.
Approximately 2 months into the patient’s rehabilitation stay, his therapy team noticed a more prominent left gaze preference and subtle decline in therapy performance. A head CT revealed increased concavity of the skin flap, increased rightward midline shift, and decreased ventricular system caliber compared to prior imaging, all findings consistent with SSFS. Neurosurgery was consulted, and his VP shunt was adjusted. Both neuroimaging and functional performance improved significantly, and the patient returned to his baseline within days.

Discussions: Sunken skin flap syndrome is a rare but serious complication following decompressive craniectomy that can result in gross neurological deficits and may lead to coma or death if untreated. Early recognition is essential for timely management. This case emphasizes that SSFS can present with subtle neurological and functional changes such as more pronounced gaze preference and decreased therapy tolerance. Therapists, given their frequent and detailed interactions with patients, may be the first to identify these changes. Prompt recognition and interdisciplinary communication facilitated rapid neurosurgical intervention for this patient, preventing further neurological decline.

Conclusions: Early recognition of SSFS requires the entire rehabilitation team to be aware of potential manifestations. This case highlights the critical role of therapists in detecting subtle clinical changes and underscores the importance of interdisciplinary communication for timely diagnosis and intervention.