title: Radiological signs of the syndrome of the trephined.
abstract: BACKGROUND
  Syndrome of the trephined (ST) is a post-craniectomy complication. It is characterized by the appearance of new neurological symptoms following the craniectomy, which are relieved after cranioplasty. The purpose of our work was to identify radiological signs and imaging biomarkers of the ST.
  
  
  METHODS
  CT images of 32 patients were retrospectively analyzed (ST = 13, controls = 19). While the shapes of craniectomy flap were qualitatively assessed, deviation of the midline structures, relative intracranial cerebrospinal fluid (CSF) volume, and the 3rd ventricle's volume were quantitatively measured.
  
  
  RESULTS
  We did not find between-group differences in the mean age or number of post-craniectomy days. ST was diagnosed during the second post-craniectomy month. The occurrence of a sunken skin flap sign was similar in both groups (69.23 % in ST group, 57.89 % in control group). Occurrence of paradoxical herniation and deviation of the midline structures were not significantly different between groups. Mean relative intracranial CSF volume was significantly smaller in ST patients (ST = 5.59 %, controls = 8.12 %, p = 0.01). ST patients, compared to controls, had also significantly smaller mean 3rd ventricle volumes (ST = 1748 mm(3), controls = 2772.97 mm(3), p = 0.03).
  
  
  CONCLUSIONS
  ST is an infrequent and delayed post-craniectomy complication. The most common radiological findings (paradoxical herniation, deviation of the midline structures, and sunken skin flap sign) might not be specific for ST. Significantly lower 3rd ventricle, and relative intracranial CSF volumes, suggest that altered biophysical CSF properties underlie ST pathophysiology. Therefore, volume measurements of 3rd ventricle could be useful for identification of patients who have higher probability of developing the ST.
authors.affiliation: Service du Développement et de la Croissance, Département de l'enfant et de l'adolescent, HUG, 6 rue Willy-Donzé, CH - 1211, Genève 14, Switzerland. lana.vasung@gmail.com.|Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland. lana.vasung@gmail.com.
authors.forename: Lana
authors.initials: L
authors.lastname: Vasung
authors.affiliation: Division of Radiology, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Marion
authors.initials: M
authors.lastname: Hamard
authors.affiliation: Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Maria Carmen Alcaraz
authors.initials: MCA
authors.lastname: Soto
authors.affiliation: Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Samuel
authors.initials: S
authors.lastname: Sommaruga
authors.affiliation: Division of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Lukas
authors.initials: L
authors.lastname: Sveikata
authors.affiliation: Division of Neurorehabilitation, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Beatrice
authors.initials: B
authors.lastname: Leemann
authors.affiliation: Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Maria Isabel
authors.initials: MI
authors.lastname: Vargas
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001921:Brain / Q000000981:diagnostic imaging* / Q000473:pathology*; D056424:Decompressive Craniectomy / Q000009:adverse effects; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases / Q000000981:diagnostic imaging* / Q000209:etiology; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012868:Skin Abnormalities / Q000000981:diagnostic imaging* / Q000209:etiology / Q000473:pathology; D013577:Syndrome; D014057:Tomography, X-Ray Computed / Q000379:methods*; D014207:Trephining / Q000009:adverse effects*
keywords: CSF; Decompressive craniectomy; Sinking skin flap syndrome; Syndrome of the trephined