Innovative management of sunken flap syndrome post–decompressive craniectomy: illustrative case

BACKGROUND: Sunken flap syndrome (SFS), also known as syndrome of the trephined, is a rare complication following decompressive craniectomy characterized by neurological deterioration due to altered cerebral hemodynamics and atmospheric pressure effects on the unprotected brain. Management is typically supportive until definitive treatment with cranioplasty. The authors present a case highlighting neck wrapping as a temporizing strategy to mitigate symptoms and facilitate mobilization. OBSERVATIONS: A 62-year-old unhelmeted bicyclist presented after a collision with an acute subdural hematoma requiring decompressive craniectomy and hematoma evacuation. Twenty-one days postoperatively, he developed SFS with neurological decline that improved with postural measures including Trendelenburg positioning. Early prosthetic cranioplasty was performed after 2 weeks of conservative management; however, wound dehiscence required removal of the prosthetic flap. The patient subsequently developed recurrent SFS. Neck wrapping was attempted and resulted in resolution of symptoms. A trial using a Q-collar to reproduce this effect was unsuccessful, and symptom control was again achieved with neck wrapping. LESSONS: Neck wrapping may serve as a simple, noninvasive temporizing measure for symptomatic SFS, allowing patient mobilization and stabilization while awaiting definitive cranioplasty. https://thejns.org/doi/10.3171/CASE26233.