Burr hole

Background

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

Indications

• Epidural or subdural hematoma with midline shift on imaging and unequal pupils on exam.
• 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.
    • 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

• 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