Published online Sep 07, 2023.
https://doi.org/10.13004/kjnt.2023.19.e39
Epidural Hematoma, a Rare Complication After the Use of Mayfield Clamp: A Case Report and Review of the Literature
Abstract
Herein, we describe a case of epidural hematoma associated with the use of a Mayfield head clamp. An 18-year old patient with an upper brainstem tumour causing obstructive hydrocephalus underwent a routine third ventriculostomy, which unexpectedly revealed an intracranial hemorrhage. We outline potential risk factors, propose an algorithm for preventing complications associated with the use of pin-type fixation, and conducted a structured review of the literature to identify similar clinical scenarios.
INTRODUCTION
Head-immobilization devices (HIDs) play a pivotal role in neurosurgical practice, with the Mayfield clamp and Sugita clamp being among the commonly used types. The Mayfield skull clamp, recognized for its ease of operation, stands out as the most frequently employed rigid head fixation device. Despite its widespread use and generally accepted safety, it has been associated with various complications, many of which may be potentially life-threatening.2) Intracranial hemorrhage is the most commonly reported complication associated with the use of HID, with this case report focusing on epidural hematoma (EDH) directly attributed to the application of the Mayfield clamp.
We conducted a comprehensive literature search using the PubMed database to identify original articles published between 1980 and 2021. The search terms “epidural hematoma AND clamp/pin” were employed to retrieve relevant studies. Eligibility criteria included articles with an English abstract and complications clearly attributed to the Mayfield skull clamp. We identified the clinical backgrounds of the presented cases, types of procedures performed, possible causes, and outcomes (TABLE 1).
TABLE 1
Review of case reports presenting Mayfield clamp related EDH in various clinical situations
CASE REPORT
An 18-year-old male presented to our department with a one month history of headaches, fatigue, and remittent episodes of nausea, primarily in the morning. There was no recent history of head trauma or specific drugs use. Upon physical examination, we observed an additional upward gaze palsy that was more pronounced in the left eye. Computed tomography (CT) and brain magnetic resonance imaging were performed (FIGURE 1), which revealed a lesion indicative of a high-grade tumor. This tumor was found to obstruct the Sylvian aqueduct, leading to obstructive hydrocephalus. We initially introduced external ventricular drainage from the right side to temporarily relieve obstructive hydrocephalus. Subsequently, to definitively treat the hydrocephalus and identify the tumor type, we conducted an endoscopic biopsy and third ventriculostomy. During the procedure, the patient’s head was securely fixed with a three-point Mayfield skull clamp, utilizing Kocher’s point on the left side. No adverse events occurred during the procedure. The patient regained full consciousness and was stable without any new neurological deficits. However, the following day, the patient complained of an increased headache. Although the surgical wound appeared to be healing well, edema developed in the right temporal region, precisely at the site where a single fixation pin had been placed. A CT scan of the head was performed (FIGURE 2), revealing an unexpected EDH in the right temporal region, along with thinning of the temporal squama in the bone window (FIGURE 3). To address this, we performed an acute right-sided temporal craniotomy with hematoma evacuation and hemostasis of the bleeding branch of the middle meningeal artery. The patient’s clinical course was uneventful and he was discharged five days later. Unfortunately, subsequent pathological analysis of the tumor confirmed it to be a glioblastoma multiforme with unfavorable genotypic characteristics, resulting in a poor prognosis. Consequently, the patient underwent further oncological treatment.
FIGURE 1
Non-homogenically enhancing lesion of upper brainstem, causing obstructive hydrocephalus.
FIGURE 2
An epidural, supratentorial collection of blood with significant mass effect. External ventricular drainage placed in left ventricle.
FIGURE 3
Bone window of the skull after endoscopic third ventriculostomy procedure. The yellow arrow is a small fracture of temporal squama. Notice the thickness of the bones of skull.
DISCUSSION
The Mayfield skull clamp, developed by Mayfield and Kees in 1973, is a well-established HID widely used in neurosurgical practice. It employs three pins and offers the advantage of adjustable contact pressure, making it a preferred choice for rigid head fixation. While neurosurgeons use these devices routinely, concrete guidelines for their use and management of associated complications are lacking in the literature. Nevertheless, there are general principles, that must be adhered to during placement to ensure stability and safety, and several comprehensive reviews have attempted to summarize these principles.2, 23)
Rare complications include venous air embolism12, 19) clamp breakage,22) arteriovenous fistula formation,8) temporal aneurysm formation,5) temporal facial nerve branch palsy15) and others. Among these, fractures of the skull with or without intracranial hemorrhage are the most frequently reported complications.2, 23) A recent single-center retrospective study by Hiwatari et al.7) found the incidence of this complication to be approximately 0.29% in adults. However, this figure may be somewhat inaccurate, as this study exclusively examined cases associated with the Sugita head frame. Conversely, according to another study by Vitali and Steinbok,25) the incidence of complications related to Mayfield fixation was more than doubled among pediatric patients (0.65%). We identified 15 separate case reports that included 19 patients diagnosed with EDH attributable to the use of the Mayfield head clamp (TABLE 1). Patients’ ages ranged from 2 to 79 years (median, 19 years).
We identified several risk factors that may play a significant role in adult and pediatric populations.
1) Age: Numerous case reports have included pediatric patients, which is unsurprising. Young individuals often have thinner and less calcified bones, rendering less resistant to pin pressure.23, 25)
2) Type of HID used: While the exact incidence related to different types in adult populations is unknown due to a lack of studies, Hiwatari’s paper7) suggests that Mayfield fixation may be a safer choice based on their findings, which exclusively linked EDH to the Sugita system.
3) Chronic increase in intracranial pressure (ICP): typically occurs in patients with hydrocephalus. As shown in TABLE 1, nine of 15 papers documented hydrocephalus or other elevated ICP.11, 13, 17, 18, 20, 21, 24, 25, 26) Chronic elevation of ICP appears to lead to calvarial bone thinning, increasing fragility.
4) Chronic disease/medication: There are two case reports that mentioned intracranial hemorrhage in patients with chronic renal disease requiring regular dialysis.6, 16) Other cases were connected to use of certain antiepileptic medications.10, 16) However, owing to the limited quality of data, it remains uncertain whether these factors play a significant role.
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5) Pin positioning: Correct pin placement is crucial to ensure both stability and safety. Two major factors must be carefully titrated to ensure correct fixation. This ensures the stability and safety of grasping. Typically, overt stability leads to greater damage, and vice versa. Certain points should always be assessed when applying a clamp to the head:
- Inspect the Clamp: Always check the clamp for damage before use. A single case report mentioned clamp breakage during a procedure, fortunately causing no additional harm to the patient.22)
- Select a Safe Zone: Avoid naturally thinner zones of bones, such as the temporal squama, frontal sinus region, mastoid cell region, or fracture sites. Note the types of procedures during which the hemorrhage occurred (TABLE 1). Most cases involve posterior fossa or cervical spine pathology, likely necessitating pin placement in the temporal region. Careful consideration should be given to avoid major vessels and nerve structures. Avoid inserting pins into the belly of the temporalis muscle, as it can result in extensive bleeding and reduced grasp rigidity. Additionally, antibacterial ointments should be used on of the pins to prevent infections of the pin site and air embolisms when removing the clamp.
- Ensure Correct Force Distribution: Pin placement should mirror the skull’s greatest diameter between opposing pins to prevent “Soccer ball effect,”23) which could increase the risk of slippage. The height of the pin position, that leads to the most stable and rigid grasp, according to Wang et al.26), is the region of the superior temporal line and the diameter can be easily identified by placing a sweat band at this level (FIGURE 4). This position provides not only the best grasp but also the safest position with respect to significant anatomical structures. Initial placement of the two pins, on the lower side of the grasp, helps distribute gravity’s force over a greater area.
- Adjust pressure properly: After the correct placement, an appropriate holding pressure must be applied. From our perspective, this is one of the most significant advantages of the Mayfield system. The pressure can be adjusted to the required level using a side screw. For adults, appropriate pressure range between 27–36 kg (60–80 pounds), which corresponds to numbers 3 and 4 on the scale. However, this situation is complex for children, as adult pins are not recommended for those under 5 years of age.9) This emphasizes the need for alternative methods of fixation for very young individuals, such as the horseshoe headrests or combined systems (FIGURE 5). If an invasive HID is used, the pressure must be adjusted according to patient age.
- Safe removal: When removing the clamp, the patient’s head should always be at the heart level to prevent negative pressure in the upper-body veins, reducing the risk of air embolism. First, we remove the single upper pin, followed by the double pins. If bleeding occurred, the defects were treated with stitches or prolonged pressure.
FIGURE 4
Skull clamp positioning.
The skull pins should be applied within the area covered by the sweatband.
FIGURE 5
An example of non-invasive head fixation.
As shown in TABLE 1, outcomes vary on a case-by-case basis. Some patients experienced permanent neurological deficits post-event, and most required at least one surgical revision, with some even requiring multiple surgical revisions due to a complicated course. To prioritize prevention, it’s crucial to meticulously follow the aforementioned instructions. It is also advisable to check CT scans’ bone windows before applying the clamp (FIGURE 3), particularly when significant hydrocephalus or chronically elevated ICP is present, or in pediatric cases. This practice may aid in identifying regions where pin placement should be avoided.
CONCLUSION
EDH is a rare but potentially serious complication associated with HID use. Our examination has underscored the significance of considering certain factors that elevate the risk of this complication. Specifically, we have identified chronic hydrocephalus, improper pin positioning, younger patient age, and specific clinical scenarios as contributors to this heightened risk. Therefore, neurosurgeons should be vigilant, keeping this knowledge at the forefront of their decision-making processes when confronted with unexpected clinical deterioration, whether during surgery or postoperatively.
Conflict of Interest:The authors have no financial conflicts of interest.
Availability of Data and Materials:Not applicable.
References
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MeSH Terms
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