Cranioplasty as a therapeutic intervention for refractory postdecompressive craniectomy seizures in combat-traumatic brain injury: A report of two cases

Abstract

Background: Combat-traumatic brain injury from penetrating and blast mechanisms frequently necessitates decompressive craniectomy (DC), leaving patients with large skull defects and retained metallic fragments that substantially elevate seizure risk. Syndrome of the trephined (SoT) and sinking skin flap syndrome (SSFS) are severe neurological complications attributed to disturbed cerebral hemodynamics, atmospheric pressure effects, and altered brain architecture following DC. Patients may develop refractory seizures, altered consciousness, and progressive neurological deficits despite maximal medical therapy. Case Description: We report two young male soldiers (aged 24 and 30 years) who sustained severe combat-traumatic brain injuries (gunshot/shrapnel and mine-blast, respectively) requiring emergency DC. Both patients had retained intracerebral metallic fragments, conferring a high baseline seizure risk. Both developed refractory seizures unresponsive to multidrug antiepileptic therapy, accompanied by progressive neurological deterioration. Case 1 presented with a Glasgow Coma Scale (GCS) score of 7 and persistent tonic seizures despite triple antiepileptic therapy (valproic acid, carbamazepine, and levetiracetam). Case 2 presented with a GCS of 8, decorticate posturing, vegetative state features, refractory seizures, and an 8.7mm midline shift. Both patients underwent cranioplasty with patient-specific 3D-printed titanium implants 62-65-day postinjury. Following cranioplasty, both demonstrated marked clinical improvement, including complete seizure cessation within 5-8 days, reduction in antiepileptic medications, and significant neurological recovery. Case 1 achieved GCS 15 and a Glasgow outcome scale-extended (GOSE) score of 4 at 5 months. Case 2 progressed from a vegetative state to minimally conscious state 12 at 5 weeks, with a GOSE score of 3. Conclusion: These cases highlight SoT and SSFS as potential primary drivers of refractory seizures and neurological deterioration after DC. Early cranioplasty (within 2-3 months) may result in dramatic seizure control and functional recovery, even in patients with severe disorders of consciousness. Cranioplasty should be considered a therapeutic, not merely cosmetic, intervention in such patients. In patients with post-DC refractory seizures and signs of SoT/SSFS, early cranioplasty should be considered a potential disease-modifying therapy.