Eaten Apple Sign: An Illustrative Imaging Finding in Sunken Flap Syndrome

Abstract

Hydrocephalus is one of the most common complications following decompressive craniectomy (DC). In patients with traumatic brain injuries, ventriculoperitoneal shunt is a frequently used cerebrospinal fluid (CSF) diversion procedure to encounter this gruesome complication. Excessive drainage of CSF can sometimes lead to paradoxical herniation of the brain to the opposite side of DC with collapse of the brain parenchyma along with shrinkage of the ventricles, which itself has deleterious effects on the neurological status of the patients, known as sunken flap syndrome. Computed tomography scans of such patients reveal a characteristic finding that the authors describe as the “eaten apple sign.” The authors highlight this characteristic imaging finding in the following index case.