Pin-site epidural hematoma in an adult case of chronic hydrocephalus with associated thinning of the cranium

Abstract

We report a case of a 22-year-old man presenting with a fourth ventricular tumour and associated chronic obstructive hydrocephalus likely leading to thinning of the cranium. Intraoperatively, he developed an epidural hematoma secondary to a fracture of the temporal bone by application of the three-point skull fixator. This is the second reported adult case of an iatrogenic epidural hematoma secondary to pin-site complications. We advocate the careful placement of the pins and suggest the tightening force be catered individually especially in pediatric patients or patients with chronic hydrocephalus.

Large acute epidural hematoma from head pin fixation fracture

“…Yan reported a similar case in 2007, involving a substantial epidural hematoma following tumor debulking in the posterior fossa. [16] Lang (2001) [6] reported that the average thickness of the skull in the middle of the parietal bone measured 6.32 mm (ranging from 3.5 to 6.8 mm) in adults. Letts et al conducted a biomechanical study revealing that bones with a 2 mm thickness could support a pressure of 160 lb.…”

Pin-site epidural hematoma: A catastrophic complication of cranial fixation in a child

“…A review of literature showing the patient characteristics, pathology for which the surgery was done, and time when this complication was detected of previously reported cases[ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 ] is summarized in Table 1 . The majority of such cases, like in ours, occurred in children with posterior fossa tumors.…”

“…However, as our experience shows, even this may not be a failsafe technique. Other authors have recommended measures such as avoidance of pushing the pins, decreased clamp pressure, steering clear of pin placement in the temporal region, use of conic pins, and use of an intermediary piece and pressure adjusting springs in the clamp[ 3 4 7 8 ] to prevent this occurrence.…”

Epidural hematoma at skull pin fixation sites may cause refractory intraoperative brain bulge

“…Predisposing factors include thin calvarium (children, those pts with longstanding hydrocephalus, eg) and misjudgment of the pressure applied due to pin malfunction [3]. This is a unique case in which hematoma developed at two of the pin insertion sites in the supratentorial compartment (remote from the operative field) in an adult.…”

“…Pin site epidural hematoma is a serious complication that usually presents with neurological deterioration during the postoperative period [1][2][3][4]. Predisposing factors include thin calvarium (children, those pts with longstanding hydrocephalus, eg) and misjudgment of the pressure applied due to pin malfunction [3].…”