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Final Program

TBI

710 - Dysautonomia as a Rare Manifestation of Syndrome of the Trephined in a Pediatric Patient: A Case Report

Friday, February 20, 2026
5:00 PM - 6:30 PM AST
Case Diagnosis: Syndrome of Trephined

Case Description: A 15-year-old male with severe traumatic brain injury from a motor vehicle collision requiring emergent left hemicraniectomy was admitted to inpatient rehabilitation. Initially, he was impulsive, requiring close supervision and restraints, but demonstrated rapid improvement. Shortly into rehabilitation course, he developed intractable headache, diaphoresis, paroxysmal hypertension and tachycardia. Propranolol was initiated for presumed paroxysmal sympathetic hyperactivity and post-traumatic headache. Within days, he exhibited regression of impulsivity, worsening gait instability, and new urinary incontinence. CT head imaging revealed a new 9 mm midline shift with increased concavity of the craniectomy flap. Given rapid symptom progression and high clinical suspicion for Syndrome of the Trephined (SoT), he was urgently transferred for neurosurgical evaluation. He underwent autologous cranioplasty which resulted in complete resolution of his symptoms. He was discharged home without needing further inpatient rehabilitation.  

Discussions: SoT is an uncommon but important complication arising after decompressive craniectomy. Presentation is variable, but the most common initial features are motor deficits, altered mental status, and cognitive decline. Autonomic dysfunction, including diaphoresis, hypertension and tachycardia, is rarely reported, with only a few cases in the literature. In this case, autonomic instability preceded the development of classic neurological symptoms, representing an atypical course. Proposed mechanisms of SoT include sinking of the scalp flap, cerebral distortion, and disruption of cerebrospinal fluid circulation, which may impair both cortical and autonomic regulation. Recognition of such presentations is critical, as timely cranioplasty often results in recovery. 

Conclusions: SoT remains an underrecognized complication of decompressive craniectomy, with presentations that extend beyond the classic neurologic findings. This case highlights dysautonomia as a rare but important initial manifestation. Clinicians should maintain a high index of suspicion for SoT in patients with prior decompressive craniectomy who develop unexplained autonomic dysfunction, as timely recognition and intervention with cranioplasty can significantly improve functional outcomes.