Orthostatic Headaches in the Syndrome of the Trephined: Resolution Following Cranioplasty

Objective.— To draw attention to the syndrome of the trephined as a potential cause for orthostatic headaches without cerebrospinal fluid (CSF) leak. Background.— Orthostatic headaches typically result from CSF leaks but sometimes may occur in conditions without any evidence of CSF leakage. Methods.— A 37‐year‐old right‐handed woman became comatose after a motor vehicle accident with cerebral contusions and massive left cerebral edema. A large frontoparietal craniectomy was carried out. In 5 months, she made good neurologic recovery. Freeze‐preserved bone flap was placed back. In several weeks she was functionally near normal. Two years later, she began to complain of orthostatic headache and gradually additional manifestations appeared including progressive gait unsteadiness, imprecise speech, cognitive difficulties, and an increasing left hemiparesis along with progressive sinking of the skull defect and shift of the midline and ventricular distortion. She underwent removal of resorptive sinking bone flap and construction of an acrylic cranioplasty. Results.— At 6‐month follow‐up, there was complete resolution of the orthostatic headaches, remarkable neurologic improvement along with resolution of midline shift and ventricular distortion. Conclusion.— The syndrome of the trephined is yet another cause of orthostatic headaches without CSF leak.