ED BURR HOLE

INTRODUCTION
 Review intracranial herniation syndromes
 Uncal herniation will be the most common in this setting: ipsilateral third nerve palsy and
contralateral motor findings (decorticate is most common); be aware of the Kernohan’s
notch sydnrome where the motor findings are ipsilateral because compression of the
corticospinal tracts against the tentorium on the side opposite to the hematoma
 Note that Epidural and Subdural hematomas can lead to uncal herniation
 As herniation progresses, central/tentorial/tonsillar herniation signs are often seen
 CT head before ED always indicated unless patient is acutely decompensating
 The majority of head injured patients with brain stem signs will have an extra-cerebral
hematoma: ratio of SDH/EDH is 2:1 and posterior fossa hematomas are uncommon
 EDHs almost always occur underneath the location of the fracture
 SDHs are less consistently located underneath the fracture; can be on opposite side
 Intracerebral hematomas are also rare in the early phases after blunt trauma
 How often will you hit the right side?
 Studies show that the correct location of drainage is predicted 80-90% of
the time by (i) ipsilateral F/D pupil (ii) controlateral motor findings (iii) side
of suspected skull fracture (under scalp hematoma or abrasion)
 Medical management is indicated prior to ED burr hole (elevate head of bed, mannitol,
hyperventilate)

INDICATION
 Head trauma, suspected EDH/SDH, acute neurological decompensation, non-responsive
to medical therapy, and neurosurgeon not immediately available
 Note: patients who are immediately unconscious with bilateral F/D pupils, absence of yey
movements, decerebrate posturing, apneic are likely to have sustained a severe diffuse
brain injury and Burr holes are unlikely to help

CONTRAINDICATIONS
 Neurosurgery immediately available

PROCEDURE
 PREPARATION
 Shave hair over temple
 Skin prep
 Lidocaine 2% + epinephrine in skin
 INCISION
 Vertical incision 4 cm long
 Location = 3 fingers above tragus, 2 fingers anterior to temporal artery
 Location = 3 up and 2 forward!
 Make incision down to bone
 Scrape muscle and periosteum away from skull with periosteal elevator or
end of scapel blade
 Place self-retaining retractor
 PERFORATOR
 Triangular shaped perforator drill
  You will encounter resistance in the outer table, easy advancement in
diploic space, and resistence when you encounter inner table
 Drill until it “catches” in the inner table
 NOTE that the temporal bone is thinner than you think!!!!
 Use saline irrigation during perforation
 BURR
 Switch to the Burr drill
 Functions to enlarge the hole
 Burr down until thin layer of inner table left
 You can place bone wax to control bleeding from skull
 SEPARATE THE DURA
 Use a periosteal elevator to push the dura away from the inner table
 RONGEUR
 Use the Leksell rongeur to remove the remaining rim of the inner table
 If there is an EDH, generous rongeuring of bone to make a decent sized
hole will aid in draining
 DRAIN THE HEMATOMA
 Epidural blood will be visible; suction blood out
 Sudbural blood will be seen as a tenting of the dura with blue
discoloration; elevate the dura with a hook, make an incision, suction out
the clot
 Irrigate and repeat suction
 No localization of hematoma: consider frontal, parietal, occipital, opposite
side, placement over scalp hematoma/skull fracture
 Parietal location recommended by most as second location: superior and
posterior to pinna
 Occipital location for suspected occipital skull fracture
 CLOSURE
 Ligate the middle meningeal vessels if visualized
 Scrape the temporalis muscle away from the bone
 Suture loosely with drain in place

ADDITIONAL NOTES ON THE PROCEDURE

 The dura is the same color as the skull and may not be obvious to identify
 Clearing the bone dust with irrigation will help to localize dura versus skull
 The temporal bone is thin enough that the pattern of resistance-ease-resistance may not
be appreciated as the perforator enters the skull
 Opening the dura is better performed with a light stroking maneuver rather than a stab
incision
 If the brain herniates out of your burr hole, this suggests there is a hematoma at another
location
 Frontal burr hole: 3 fingers from midline, 3 fingers from hairline
 Parietal burr hole: 3 fingers above ear, 3 fingers behind ear
 Occipital burr hole: position on side, place hole over fracture site; must be below the
superior nuchal line to avoid the transverse sinus; place midway between the superior
nuchal line and the foramen magnum; place midway between the occipital protuburence
and the mastoid if the fracture line is not obvious
COMPLICATIONS
 Wrong location
 Brain laceration/perforation
 Meningitis
 Brain abscess
 Osteomyelitis
 Temporal artery laceration
 Facial nerve laceration
 ED BURR HOLE BOX
INDICATION
 Suspected extra-axial hematoma in the setting of head
trauma and an acutely decompensating patient despite
medical ICP management

CONTRAINDICATION
 Neurosurgeon immediately available

PROCEDURE
 Preparation: shave, prep, drape, local with epinephrine
 Incision: 3up, 2 forward, dissect down to bone
 Perforator: get “bite” into inner table
 Burr: widen the hole
 Elevate the dura: periosteal elevator
 Rongeur the bone: widen the hole with the rongeur
 Suction and irrigation of the EDH hematoma
 SDH: elevate dura, incise dura, suction/irrigate
 Ligate middle meningeal vessels
 Closure

COMPLICATIONS
 Meningitis
 Brain abscess
 Osteomyelitis
 Temporal artery laceration
 Facial nerve laceration
 Wrong location
 Brain perforation