Burr hole

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Overview

  • Expanding intracranial hematoma is rapidly fatal and requires early therapeutic intervention. Morbidity/mortality significantly increases if treatment delayed more than 1.9 hours.[1]

Indications

  • Epidural or subdural hematoma with midline shift on imaging and unequal pupils on exam.[2]
  • GCS <8
  • Anticipated extended time to assessment/treatment by neurosurgeon.

Contraindications

  • GCS >8
  • Neurosurgery available in reasonable timeframe
  • Lack of imaging-confirmed epidural or subdural hematoma
    • In absence of imaging (e.g. in rural area at facility without CT availability), very high clinical suspicion may be enough.[2]
      • e.g. evidence of severe head trauma and unequal pupils, pt presents awake and talking but rapidly deteriorates in setting of head trauma and unequal pupils, etc.

Equipment Needed

  • Sterile PPE
  • Razor
  • Chlorhexidine or betadine
  • Scalpel
  • Small retractors
  • Drill (manual or air/electric powered)
    • Should have both sharp (penetrator) and dull drill bits or a drill bit with appropriate "clutch" mechanism (preferred)
  • Blunt and sharp hooks
  • Electrocautery (Bovie), if available
  • Sterile saline

Procedure[2][3]

  • Place patient supine
  • Select optimal site based on location of hemorrhage on CT (if unsure, use temporal site)
    • Temporal - 2 finger-breadths above and 2 finger-breadths forward of the auditory canal
    • Parietal - over parietal eminence
    • Frontal - 10 cm above eye in mid-pupillary line
  • Shave scalp widely over selected site
  • Cleanse skin with chlorhexidine or betadine
  • Make ~3cm incision and dissect down to bone with scalpel
  • Dissect periosteum off bone with scalpel
  • Apply retractors to maintain field
  • Apply drill perpendicular to skull and begin drilling while applying firm pressure
    • Have assistant apply gentle saline wash to drilling site
  • Continue drilling until loss of resistance felt or drill bit stops spinning (assuming use of "clutch"-type drill bit)
  • Use hooks to remove any remaining bone fragments
  • If subdural hematoma, elevate dura with sharp hook and make careful incision with scalpel
  • Allow blood to drain freely (gentle suction may be used, but DO NOT suction brain tissue)
  • Once blood flow slows/stops, apply loose dressing. (DO NOT tamponade bleeding)

Follow-up

  • After procedure, pt should be immediately transferred to facility with appropriate neurosurgical availability.

Complications

  • Bleeding
  • Infection
  • Damage to brain parenchyma

See Also

Epidural hemorrhage
Subdural hemorrhage

References

  1. ↑ Mendelow AD, Karmi MZ, Paul KS, Fuller GA, Gillingham FJ. Extradural haematoma: effect of delayed treatment. British Medical Journal. 1979;1(6173):1240-1242.
  2. ↑ 2.0 2.1 2.2 Wilson MH, Wise D, Davies G, Lockey D. Emergency burr holes: “How to do it.” Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2012;20:24. doi:10.1186/1757-7241-20-24.
  3. ↑ MacLellan, K. The occasional burr hole. CJRM 1998;3(4):223-2
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