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.

References	Case description	Probable cause	Diagnosis, treatment, outcome
Baerts et al.1) (1984)	10yo girl	Age	Evacuation of EDH from small craniotomy. Without neurological deficit.
	Right F-T glioma	Inadequate reduction of holding pressure according to age
	10th day postop headaches, vomiting	Inappropriate pin type
Furuya et al.6) (2021)	67yo male	Renal osteopathy	Emergent intraop. CT scan of the head.
	Chronic kidney disease with need of periodic dialysis		Conservative treatment of epidural haematoma.
	Cervical spondylothic myelopathy with aim to perform laminoplasty		Laminoplasty performed on next day without rigid head fixation.
			No neurol. deficit.
Yan27) (2007)	15yo boy	Age	Emergent CT scan of the head.
	Posterior fossa tumour	Hydrocephalus (chronic raise of ICP)	Outcome/treatment not known.
	Hydrocephalus
Lee and Lin14) (2010)	38yo woman	Position of the pins in areas of physiological thinning (Temporal squama)	CT scan of the head 2nd postop. day.
	Posterior spinal C4-6 instrumented fusion		Emergent left temporal craniotomy and evacuation of the haematoma.
	Headache and nauzea 1st and 2nd postop. day.		Need for surgical revision of craniotomy site 8 days later for CSF leak and pneumocephalus.
			No neurological deficit afterwards.
Naik et al.17) (2011)	40yo woman	Hydrocephalus (Chronic raise of ICP)	Cerebellar parenchyma seemed to be unusually tense intraop., therefore postop CT scan performed.
	Right vestibular schwannoma	Loss of tamponade effect during surgery	Bilateral EDH evacuation from craniotomies.
	Communication hydrocephalus (shunted)		Without new neurological deficit.
Parenrengi et al.18) (2019)	11yo girl	Age	Former surgery stopped.
	Posterior fossa tumour	Hydrocephalus (chronic raise of ICP)	Intraop. emergent CT scan of the head.
	Non-communicating hydrocephalus		Evacuation of right sided epidural haematoma.
			Surgical removal of post. fossa tumour on 5th post op day.
			No neurol. deficit.
Krishnan et al.13) (2016)	12yo girl	Age	Unusual intraop. bulging of cerebellar parenchyma through craniotomy after resection of the tumour.C1 and C2 laminotomy. "Blown pupils" after op.
	Cystic tumour of 4th ventricle	Hydrocephalus (chronic raise of ICP)	Emergent CT scan and evacuation of EDH.
	Hydrocephalus- preop. Introduction of EVD	Pin positioning	Outcome: prolonged intubation, tracheostomy, shunt dependence, posterior fossa pseudomeningocoele residual ataxia, and cerebellar signs.
		Reduction of tamponade effect by intraoperative CSF drainage
Jha et al.11) (2009)	22yo male	Chronic hydrocephalus (thinning of the cranium due to chron. Raised ICP)	Bulging of cerebellar parenchyma intraop. Emergent CT and evacuation. Slow recovery, without permanent deficit.
	4th ventricle tumour
	Obstructive hydrocephalus
Bindra et al.3) (2012)	40yo woman	Reduction of tamponade effect.	Intraop. bulging of the parenchyma refractory to antioedematous therapy. Immediate postop CT scan reveals bilat. EDH.
	Right acoustic schwannoma	Pin positioning	EDH evacuated immediately from burr holes.
		Prolonged fixation	No neurologic deficit.
Vitali and Steinbok25) (2008)	5 paediatric cases- age 2–7 years	Age	Intraop. or postop CT scan of the head.
	Posterior fossa tumours	Thinning of the cranium due to chronic hydrocephalus and raised ICP	Evacuation of EDH either by craniotomy, burr hole, or conservative treatment.
	Hydrocephalus	Pin positioning	One case with residual light right-sided hemiparesis.
		Use of adult pins
		Grasp pressure
Tyagi et al.24) (2019)	22yo male	Chronic hydrocephalus	8H postop. deterioration of consciousness. Acute CT scan reveals large numerous epidural haematomas. Need for 2 surgical revisions.
	Fourth ventricular outlet obstruction	Pin positioning	Outcome: pseudomeningocoele, wound side CSF leak, thecoperitoneal shunt dependence, no motor deficit.
	C1 laminotomy and midline suboccipital craniotomy
Sade and Mohr20) (2015)	24yo male	Chronic raise of ICP	6H post op deterioration of consciousness, right-s. hemiparesis. Acute CT scan of the head.
	Fronto-parietal, Parasagittal meningioma with large surrounding oedema	Pin positioning	Evacuation of EDH from craniotomy. No neurologic deficit.
Serramito-García et al.21) (2009)	19yo male	Hydrocephalus	Not known.
	Endoscopic third ventriculostomy
	Obstructive hydrocephalus
Erbayraktar et al.4) (2001)	23yo male	Excessive grasp pressure.	Emergency CT scan reveals intracranial penetrating injury with epidural haematoma.
	Frontal craniectomy	Defective part of the spring laden pin	Evacuation of haematoma from craniotomy.
			Favourable outcome.
Matouk et al.16) (2012)	79yo male, Chronic renal failure-dialysis dependent	Position of pins	Unusual nesting of single pin when adjusting holding pressure.
	Epilepsy on medication	Renal osteodystrophy	Removing the clamp and immediate CT scan.
	Posterior cervical decompression	Multiple AEDs	Conservative treatment.

Case description summarises background of each of the cases. Probable cause suggests most important factors that might have played a role in EDH formation. Diagnosis, treatment and outcome describes aftermath of each of the cases.¹,³,⁴,⁶,¹¹,¹³,¹⁴,¹⁶,¹⁷,¹⁸,²⁰,²¹,²⁴,²⁵,²⁶⁾

EDH: epidural hematoma, yo: year old, CT: computed tomography, ICP: intracranial pressure, CSF: cerebrospinal fluid, EVD: external ventricular drainage, AED: antiepileptic drugs.

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.

• 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.