Sunken Brain Syndrome

A 34-year old Chinese lady presented to the hospital in 2013 with acute left sided weakness and was found to have a right middle cerebral artery territory infarct requiring thrombolysis using intravenous alteplase. Her condition deterioriated post thrombolysis as it was complicated by right subdural hematoma, left parieto-occipital hematoma with mass effect and midline shift, for which she required urgent decompressive craniectomy and insertion of ventriculo-peritoneal (VP) shunt for hydrocephalus. Post-operatively she had severe physical and cognitive impairments. She was discharged home with a caregiver after an extensive period of inpatient rehabilitation. Repeated computed tomography (CT) brain between 2014 to 2016 revealed interval resolution of hematoma and stable hydrocephalus. (Figure 1). In late 2017 she was noted to have right gaze preference. Her Glasgow Coma Scale was 15 with no changes to her cognition or behavior. Blood pressure was 110/60 mmHg and pulse rate was 72/minute. Physical examination revealed concavity on the left temporalparietal region of the head. A repeat CT brain showed a concavity of the left craniectomy site suggestive of sunken brain syndrome (SBS) and progressive hydrocephalus from partial shunt blockage without trans-tentorial herniation (Figure 2). Prompt neurosurgical consult was sought and this was quickly followed with an acrylic cranioplasty and revision of VP shunt. She was reviewed post-operatively with resolution of right gaze preference.