An extreme case of the syndrome of the trephined requiring the use of a novel titanium plate.

INTRODUCTION: Patients with large cranial defects can manifest a secondary neurological deterioration known as the "syndrome of the trephined."

CASE REPORT: This is the case of a 66-year-old female with a left-sided acute subdural hematoma, treated with decompressive craniectomy. Six months later, a cranioplasty was performed. However, it was complicated by an infection requiring removal of the bone plate. A week later, the patient became comatose; her craniectomy flap was sunken. After ruling out all other possible disorders, we suspected an extreme syndrome of the trephined. The patient's neurological status drastically improved after she was placed on a Trendelenburg position regiment. A second cranioplasty was performed only 3 months after the infection using a novel custom designed titanium mesh, the least porous material used in synthetic bone flaps, to decrease the risk of infection. The patient had an excellent recovery; at her 6-month follow-up she was neurologically intact, cosmetically satisfied, and free of infection.

CONCLUSIONS: The treatment of extreme cases of syndrome of the trephined in the setting of a recent infection can be challenging; successful treatment can be achieved by using a custom titanium plate.