MILITARY MEDICINE, 171, 1:12, 2006
Cranial Burr Holes and Emergency Craniotomy: Review of
Indications and Technique
Guarantor: LTC Daniel J Donovan, MC USA
Contributors: LTC Daniel J. Donovan, MC USA*; CDR Ross R. Moquin, MC, USN**; LTC(P) James M. Ecklund,
MC USA**
Burr hole craniotomy for posttraumatic intracranial hema-
toma is rarely performed since the advent of computerized
tomography revolutionized the treatment of these patients. It
is still necessary in unique circumstances although, and the
clinical urgency may require surgery by a non-neurosurgeon.
This occurs rarely in rural or overseas locations in peacetime,
but more commonly in combat health support operations
where computed tomography and neurosurgeons are not
widely available. Recent experiences in the Global War on
Terrorism have prompted a detailed review of this procedure.
The nonoperative care, localization of intracranial hematoma,
and surgical technique are outlined here in detail, and results
from the literature are reviewed. This review emphasizes that
burr holes should not be performed at random on head-injured
patients and should be performed only by general surgeons or
other physicians who have undergone formal instruction by
experienced neurosurgeons, and every reasonable attempt to
contact a neurosurgeon should be made first.
Introduction
raumatic head injury causes primary injury to the brain
T itself, but may also result in intracranial hematoma (ICH)
formation. ICH can cause compression of the brain, resulting in
a shift of intracranial structures, cerebral herniation, coma, and
death. It can be located in either the intra-axial compartment
(within the brain itself) or extra-axial, as either an epidural
hematoma (EDH) or subdural hematoma (SDH). EDH occurs in
0.5 to 12.3% of patients with moderate to severe head injury1–6
and SDH in 12 to 18%.6–8 The incidence of both is even higher in
those with brainstem dysfunction or a skull fracture,1,9–11 and
ICH occurs frequently in patients with penetrating injuries.12–15
The clinical outcome depends on many factors, including the
type, location, and size of ICH, as well as the severity of the
associated primary brain injury.1,3,5 Some authors have pro-
posed that a shorter duration of time between injury and hema-
toma evacuation improves ultimate outcome,1,15,16 but other se-
ries have not confirmed this result.3,7,17,18 The overall morbidity
and mortality ranges from 12 to 41% with EDH1,2,17,19 to 57 to
90% with SDH.1,6,7,20 SDH is associated with worse outcome
because it generally is caused by high-velocity injuries, result-
ing in more primary brain injury. Since EDH is usually associ-
*Department of Surgery, Neurosurgery Service, Tripler Army Medical Center, Ho-
nolulu, HI 96859-5000.
†Department of Surgery, Neurosurgery Service, National Capital Consortium,
Walter Reed Army Medical Center, Washington, DC 20307--001 and National Naval
Medical Center, Bethesda, MD 20889.
The opinions or assertions contained herein are the private views of the authors
and are not to be construed as official or as reflecting the views of the Department of
the Army, the Department of the Navy, or the Department of Defense.
This manuscript was received for review in August 2004 and accepted for publica-
tion in January 2005.
Military Medicine, Vol. 171, January 2006
ated with low-velocity injury, it results in little primary injury to
the brain and causes poor outcome only if the expanding hema-
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toma is allowed to compress the brain. Combinations of EDH
and SDH in the same patient may occur. It is evident although
that the patient’s preoperative neurological function correlates
highly with outcome,1,3,4,7,19,21 and that early recognition and
prompt surgical evacuation of ICH avoids preventable death and
dysfunction, especially in those patients who “talk and deterio-
rate.”22
Burr hole craniotomy, or trephination, may be the earliest
form of surgical procedure ever performed.23,24 Archeological
studies of ancient skulls show it was performed in various ways
on several different continents before the dawn of written history
and confirm that many patients survived the procedure.25–27 It
has been practiced extensively throughout the history of medi-
cine, particularly in military conflicts, and the fascinating his-
tory of this procedure has been reviewed in detail elsewhere.27–32
The procedure was expanded, refined, and standardized
throughout World Wars I and II and in civilian practice
thereafter.33–43 With the arrival of computerized tomography
(CT) in the 1970s, the indications for burr holes quickly dwin-
dled. CT is rapid, noninvasive, and provides much more infor-
mation about the location and nature of the brain injury than
burr holes.
Since the development of trauma management and evacua-
tion systems in the United States, the situation is rarely encoun-
tered where a patient with acute neurological deterioration is
unable to undergo CT. In certain rare circumstances, burr hole
craniotomy remains a relatively rapid and frequently effective
treatment for patients who otherwise will likely die. These situ-
ations are much more common in combat health support oper-
ations, particularly at echelons II and III. For example, a patient
injured in a remote area may require burr holes if there is no
access to immediate evacuation or CT, or a multitrauma patient
who develops a unilaterally dilated pupil while under anesthesia
for non-neurological surgery may not be stable for immediate
transport to CT. Because many general surgeons or other non-
neurosurgeons in the military are deployed to remote areas of
the world without the availability of CT or a neurosurgeon, the
authors have occasionally advised such surgeons (via telephone
or radio link) to perform burr holes as a lifesaving measure.
Successful cases have also been reported in the literature.44–46
Such experiences from Operations Enduring Freedom and Iraqi
Freedom have especially spurred renewed interest in reviewing
the anatomy, technique, and indications for this procedure.
However, it must be strongly emphasized that this procedure
should not be performed randomly for all comatose patients, nor
should it be undertaken without contacting a neurosurgeon
first, except in the most dire circumstances.
12
Cranial Burr Holes and Emergency Craniotomy
Methods
Initial Assessment and Stabilization
The injured patient must undergo general resuscitative mea-
sures first, in accordance with a standard trauma protocol such
as that taught by the American College of Surgeons in the
Advanced Trauma Life Support course.47 It must be ensured
that the patient has a patent airway and is breathing, the blood
pressure and pulse are stabilized, and at least a primary survey
is conducted before any consideration of burr holes. A critically
important factor in the outcome for patients with ICH is avoid-
ance of hypoxemia and hypotension.48,49 Improved oxygenation
and blood pressure often improve a patient’s altered mental
status and may even normalize dilated or asymmetric pupils. A
rapid neurological assessment is performed and the Glasgow
Coma Scale score is determined. A detailed secondary survey is
then performed to identify other possible causes of deterioration
and to look for any secondary complications of head injury.50,51
Of paramount importance is maintenance of spinal immobiliza-
tion precautions and assessment with a lateral cervical spine
X-ray if available, since 5 to 10% of head-injured patients also
have an associated cervical spine fracture.
If the patient exhibits signs of increased intracranial pres-
sure, nonsurgical treatment is first delivered. This includes en-
dotracheal intubation, assisted ventilation, elevation of the
head, and administration of osmotic agents such as 0.5 to 1.0
g/kg of a 25% intravenous mannitol solution or a bolus of
hypertonic saline. The patient is then reassessed, since these
measures alone may adequately reduce intracranial pres-
sure48,52 and potentially mitigate the need for surgery. An intra-
venous anticonvulsant agent such as fosphenytoin (18 mg/kg)
is given to reduce the incidence of early seizures.53 Assessment
of coagulation function is extremely helpful if available, since
brain injury may cause coagulopathy,54 and administration of
clotting factors may be required before surgery. Burr holes
should only be considered when all other supportive measures
have been taken, and yet the patient continues to decline. Every
reasonable attempt should be made to contact a neurosurgeon
for consultation.
Any patient who has sustained a traumatic injury and pre-
sents with the classic clinical triad of altered mental status,
asymmetric or poorly reactive pupils, and hemiparesis must be
deemed to have ICH until proven otherwise. These findings can
be mimicked by brain contusion, which will not benefit from
burr holes, but ICH must be ruled out. The “classic” clinical
presentation of EDH is an immediate alteration of sensorium
punctuated by a lucid interval, which is then followed by pro-
gressive neurological decline. A lucid interval can also occur
with either SDH or cerebral contusion although, and less than
one-third of patients with EDH demonstrate such a pattern.2
Most simply decline continuously from the time of injury.
Localization
Penetrating injuries and open, depressed skull fractures are
often readily apparent and may guide the surgeon rapidly to the
location of ICH. Not all fractures have associated ICH however,55
and ICH may also be located opposite to the point of impact,
especially where penetrating fragments have exited or come to
rest near the brain surface.36,37,40,42 Lateralizing findings such as
pupillary abnormalities and hemiparesis are useful indicators,
13
found in more than one-half of the patients with ICH, and 85%
are located ipsilateral to the larger pupil and contralateral to the
hemiparesis.2 These occur when ICH shifts the brain medially
and downward, forcing the temporal lobe against the cerebral
peduncle and the third cranial nerve (Fig. 1, A and B). Since the
third nerve remains ipsilateral and the corticospinal tract
crosses over to the contralateral side of the body, the dilated
pupil and hemiparesis occur on opposite sides of the body. The
remaining 15% of patients have “false” localizing signs, such as
hemiparesis ipsilateral to the dilated pupil. These findings are
caused when the brainstem is shifted over with the temporal
lobe and the contralateral peduncle is compressed against the
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rigid edge of the dural partition called the tentorium cerebelli,
creating “Kernohan’s notch”56 (Fig. 1, C and D). It must be
emphasized that the presence of these physical findings does
not mean that ICH is always present, since they can also occur
with direct injury to the brainstem or cranial nerves.
Adjuncts
The best and most rapid method of establishing the diagnosis
of ICH is CT. The wealth of information collected by CT includes
not only the presence of ICH, but also its location, size, presence
of multiple ICH, cerebral contusion, skull fracture, etc. In the
absence of CT however, a simple X-ray of the skull may provide
important clues to the diagnosis.55 It should always be used for
deteriorating patients when CT is unavailable, especially to vi-
sualize foreign bodies in penetrating injuries . If patients with
the appropriate clinical findings have a skull fracture, especially
near the middle meningeal artery or the dural venous sinuses,
ICH is likely present. In ⬎85% of the patients who have both a
skull fracture and EDH, the clot is located immediately beneath
the fracture site.57 Although a skull fracture may indicate a
possible EDH, it does not confirm it, nor does it mitigate the
possibility of coexisting injuries such as brain contusion or
SDH. The injury causing SDH is more likely to be diffuse, in-
volving a larger area than that causing EDH; therefore, the
hematoma in SDH may not be located directly underneath the
fracture as in EDH. In addition, an expanding blood clot in
the subdural space is not restricted by any barriers and can extend
from one end of the hemisphere to the other. The expansion of
EDH may be limited by the cranial sutures, where the dura mater
is particularly adherent to the inner table of the skull.
Technique
Burr holes are ideally performed in the operating room to
minimize infectious risks and to provide proper lighting and
equipment. Electrocautery, suction, irrigation, headlamp illu-
mination, and loupe magnification are helpful (see Fig. 2 for
complete list of surgical instruments). Since the patient has
already been intubated, anesthesia and antibiotics are now ad-
ministered. General anesthesia is preferred, but hypotension
must be avoided. Local anesthesia may be used alone, but
coughing or other movement during the procedure can be trou-
blesome. The patient should be placed in the supine position
with a shoulder roll ipsilateral to the suspected side of ICH and
the head turned so that the surgical side is facing upward. The
head should be supported with a padded gel roll or horseshoe-
shaped head holder, if available (Fig. 3A). A rapid shave of the
involved scalp will facilitate surgical prep and visualization. A
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Fig. 1. (A and B) Illustration in coronal plane of left temporal epidural hematoma (patient is facing the observer). The hematoma causes the shift of the medial portion
of the temporal lobe (uncus) against the brainstem, impinging on the left third cranial nerve and left cerebral peduncle. This causes dilation of the left pupil and a right
hemiparesis (shaded area in illustration). These clinical findings localize the hematoma to the side ipsilateral to the dilated pupil in approximately 85% of cases. (C and
D) Same hematoma causing the shift of both the uncus and the brainstem, resulting in impingement of the right third cranial nerve against the dural edge of the tentorium
cerebelli and dilation of the right pupil. The right cerebral peduncle may also be compressed, producing the phenomenon of “Kernohan’s notch” and left (ipsilateral)
hemiparesis. These phenomena may produce such “false” localizing signs in up to 15% of patients.

more extensive shave (i.e., the entire head) is recommended for
patients with penetrating injuries or scalp lacerations, but a
prolonged period of time should not be wasted on this task.
In the absence of CT or other localization as described above,
burr holes are initially placed on the side ipsilateral to the larger
pupil. If the pupils are equal or there is no hemiparesis, the side
of obvious external trauma should be chosen and the burr hole
should be placed next to, not within, a skull fracture. This
allows exposure of uninjured dura so that bone fragments can
be removed from the area of normal anatomy toward the injured
area with a rongeur. Except in cases with obvious localization,
the temporal burr hole should be performed first, since temporal
lobe decompression is usually the most urgent priority in acute
cerebral herniation. This site is also the most common location
of EDH and allows access to the area of the middle meningeal
vessels. The skin incision should begin just above the root of the
zygoma, coursing 1 cm anterior to the tragus and about 5 cm in
length, continuing just over the top of the ear. This avoids
injuring the superficial temporal artery posteriorly and the tem-
poral branch of the facial nerve anteriorly (Fig. 3B). If present, a
scalp laceration overlying the injured skull may be used to
create an incision. The temporalis fascia is sharply incised and
monopolar cautery is used to divide the temporalis muscle.
Significant bleeding may occur here, but can often be controlled
by distracting the tissue with a self-retaining retractor. Persis-
tent bleeding can be controlled with electrocautery or hemo-
stats, and even severe bleeding can be tamponaded temporarily
with digital pressure and a sponge until controlled. The perios-
teum is then dissected away using a periosteal elevator or the
handle of the scalpel. The self-retaining retractor should be left
in place, but should not interfere with making the burr hole.
A high-speed pneumatic drill will rapidly create a burr hole if
available and even a dental drill has been improvised to perform
this procedure.44 A handheld drill such as a Hudson brace was
used extensively before the invention of motorized drills and
remains extremely useful. It is attached to a perforating bit (Fig.
2B), which is held perpendicular to the skull and turned rapidly
(Fig. 4). Initially it may be difficult to turn the drill until the outer
cortex is penetrated, but the cancellous bone is softer and more
easily penetrated, producing more bleeding. As the inner cortex
is engaged, there is initially a feeling of cogwheel-type resis-
tance, and then the drill feels almost as if it is being pulled into
the skull with every turn. The burr hole should be visually
inspected frequently to assess whether the inner cortex has
been breached, otherwise the drill may penetrate all the way
through the inner cortex and plunge into the brain. When 5 to
10 mm of dura are seen, the drill is removed and a sharp bone
curette is used to remove the remaining lip of bone. If the
Hudson brace is used, the perforating bit can be exchanged for
a rounded burr at this point, which will more safely enlarge the
hole without penetrating as deeply toward the brain (Fig. 2B).
There may be bleeding from the bone which obscures the dura,
and bone wax is applied to the edges of the burr hole. It is
important to differentiate this normal liquid bleeding from the
coagulum of an epidural hematoma.
If there is EDH present, it will be encountered now, and the
hole should be enlarged with a rongeur to allow removal of
additional clot, but great care should be taken not to tear the
dura. As the clot is removed with irrigation and suction, vigor-
ous bleeding from the middle meningeal artery can occur, which
may be very difficult to control and requires persistent effort
with bipolar cautery or suture ligation through the dura. The
hemorrhage may be especially difficult if it arises in the proximal
portion of the artery near the foramen spinosum of the skull,

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Cranial Burr Holes and Emergency Craniotomy
Fig. 2. (A) Instrument set for emergency cranial surgery. 1, Bone curette; 2,
narrow and wide bone rongeurs; 3, Cohn brain needles; 4, Kerrison bone rongeur (5
mm); 5, suction tips; 6, Heiss retractor; 7, small Weitlaner retractor; 8, Hudson
brace with perforating bit attached; 9, bayonet forceps; 10, Penfield 3 dissector; 11,
Penfield 1 dissector; 12, Large and small needle holders; 13, Adson (scalp) forceps;
14, Gerald (dural) forceps; 15, Woodson 3 dissector; 16, periosteal elevator; 17,
round burr for Hudson brace; 18, scalpel handle; 19, scalpel blades (size 10 and 11);
20, hemostat; 21, malleable brain retractor; 22, silastic ventricular catheter with
stylet and adaptor; 23, scalp retractors, Sachs (above) and Cushing subtemporal
(below); 24, hemostatic clip appliers for scalp; 25, dural scissors; 26, bipolar cau-
tery forceps; 27, Gigli wire saw and handles; 28, Gigli wire guide. (B) Close-up view
of Hudson brace and bits, including revolving handle (A); perforating bits, wide (B)
and narrow (C); burr attachment (D); and extension piece (E).
and cautery may be useless if the artery retracts into the fora-
men. Placing the wooden end of a cotton tip applicator into the
foramen and breaking it off is a desperate measure that may
staunch the bleeding.
If there is no EDH encountered, the blue-white dura is seen.
Since the temporal area is the most likely area to contain ICH,
the burr hole can be widened when exploration is initially neg-
ative. ICH may be located anywhere, including immediately ad-
jacent to a burr hole that appears to be negative for ICH; there-
fore, enlarging the hole improves diagnostic accuracy. If dural
pulsations are not visualized after EDH evacuation, consider-
ation should be given to opening the dura to look for coexisting
SDH, and the decision to proceed should be weighed against the
risk of causing brain injury. The surface of the dura should be
cauterized first under low power with bipolar cautery. The dura
is then grasped with small-toothed forceps and opened with two
15
perpendicular incisions, using a no. 11 blade. Great care is
required because the incision may cause injury to the cortical
brain vessels. The edges of the dura are carefully cauterized and
will shrink to expose the underlying brain. SDH can now be
removed if present using saline irrigation to lift the clot and
gentle suction to aspirate it.
If the temporal burr hole is negative, a sponge soaked in
antibacterial solution should be placed in the wound and then a
frontal burr hole placed. The incision should be placed imme-
diately anterior to the coronal suture. This suture is palpable in
most patients and should lie approximately 13 cm posterior to
the root of the nose in the average adult. It is imperative that the
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incision be at least 3 cm lateral to the midline of the skull, at
approximately the mid-pupillary line (Fig. 3C). If the skull is
penetrated near the midline, there is risk of injury to the under-
lying superior sagittal sinus, which may result in exsanguina-
tion of the patient. If the burr hole is made more posterior than
the coronal suture, there is risk of injury to the motor cortex of
the brain and resulting paralysis. The technique for the skull
and dural opening are the same as that described for the tem-
poral approach. If the frontal burr hole is also negative for ICH,
then a parietal one should be performed in the same fashion.
The incision is 3 cm posterior to the external auditory meatus
and 5 cm lateral to the midline, made in a vertical fashion (Fig.
3, B and C).
Removal of a small amount of acute blood clot through a burr
hole may provide enough temporary decompression to allow
evacuation of the patient to a neurosurgeon. Acute clot is thick
and tenacious however and usually extends beyond the exposed
area, such that ⬍10% of acute ICH can be adequately removed
57
through burr holes alone. The options would then include
either enlarging the craniectomy with bone rongeurs or remov-
ing a free bone flap (formal craniotomy). The latter is a more
extensive procedure and the risk of complications is higher. If a
large ICH is encountered and a formal craniotomy is performed,
the skin incisions described will allow a smooth connecting
incision in the shape of a question mark to be made, preserving
vascularization of the scalp flap based anteriorly and inferiorly
(Fig. 3). In this case, hemostats or hemostatic clips are applied
to the scalp, the temporalis muscle is divided with monopolar
cautery and detached from the skull with a periosteal elevator
(Fig. 5A). A dissector is used to separate the dura from the
overlying bone for SDH (Fig. 5B), but not for EDH, since the
bleeding has already dissected the dura away from the bone.
Connecting cuts through the skull are made between each burr
hole using a specialized power drill with a foot plate attachment,
a Gigli saw with a dural guide device to introduce the wire safely
under the bone, or a bone punch such as a Kerrison rongeur.
If all three burr holes are negative, then the same procedure is
performed on the contralateral side, proceeding in order from
temporal to frontal to parietal burr holes. This sequence pro-
vides the most efficient method of finding and treating ICH, and
a complete exploration on both sides reduces the chance of a
falsely negative exploration. Even if ICH was present on the
initial side, the surgeon must decide whether the clinical situ-
ation warrants exploring the contralateral side, depending on
the patient’s response to initial decompression as well as clinical
and radiographic indicators that bilateral hemorrhage may be
present.
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Fig. 3. (A) Photograph of patient prepared for burr hole procedure. The patient is intubated and the head is shaved. A padded head holder supports the head so that the
side with the suspected hematoma is facing upward, and a gel pad has been placed under the ipsilateral shoulder (large arrows). (B) The incision for the temporal burr hole
(T) is started at the root of the zygoma (Z), 1 cm anterior to the tragus so it is anterior to the superficial temporal artery (A) and posterior to the hairline (H). The parietal
incision (P) is located more superiorly and can be connected to the temporal incision if necessary to turn a bone flap (dashed line). (C) Close-up view of the frontal incision
(F) as it crosses the hairline (H) in this patient. The frontal incision is just anterior to the coronal suture of the skull, which is palpable at the posterior edge of the incision.
The incision lies at least 3 cm lateral to the midline (ML) to avoid entering the superior sagittal sinus.

If all six burr holes are negative despite strong suspicion of
ICH, a posterior cranial fossa burr hole may be considered. ICH
is rare here, comprising only 4 to 13% of acute EDH58,59,60 and
⬍1% of acute SDH.60,61 The risk of surgical complications is even
higher in this area; therefore, it should be pursued only as a last
resort or if there is obvious injury only to this area. The patient
is placed in the prone position with the head supported by a
headrest, and the skin incision is vertical, 3 cm medial to the
easily palpated mastoid eminence (Fig. 6). Posterior fossa EDH
usually results from a laceration of the transverse venous sinus
and decompression will then result in vigorous bleeding from
the sinus. Pressure applied to hemostatic agents may be suffi-
cient to control it, but a wider craniectomy and definitive repair
of the dura may become necessary. Removing bone on top of the
sinus risks tearing it further, so the surgeon should persevere
with simple application of local pressure unless it is clearly
failing to provide hemostasis. A piece of muscle is placed over
the sinus, reinforced with pressure, and sutured to the dura on
either side of the sinus. Simultaneously, the head of the oper-
ating table is raised to reduce venous pressure. This maneuver
risks air embolism through the venous sinus, which may man-
ifest itself as an increase in end tidal CO2 or systemic hypoten-
sion, in which case the head must be lowered again. Copious
saline irrigation and liberal application of bone wax will also
reduce the amount of air entrained.
At wound closure, a drain should be left in the epidural space
if EDH was evacuated. A 10-mm Jackson-Pratt drain is ideal,
since it was originally designed for use in the subdural space.62
However, if SDH is encountered, the inexperienced surgeon
placing a drain into the subdural space may disrupt the cerebral
cortical vessels and cause further bleeding.63 It should be em-
phasized that meticulous hemostasis, especially of scalp bleed-
ing, is essential before drain placement and closure, or else ICH
can recur postoperatively.64 When decompression is complete,
all scalp incisions should be closed in two layers, with absorb-
able suture in the galeal layer and staples or monofilament
suture for the skin, unless the patient has a penetrating injury
with gross contamination or regions of poorly vascularized
scalp. For these patients, closure of the temporalis muscle or
galea should be performed to cover the exposed brain and the
wound is dressed with the skin open. Scalp flaps will be rotated
to provide appropriate coverage later.
Postoperatively, the patient should remain intubated to en-
sure proper ventilation and careful attention to the vital signs
and to supportive care should continue. Worsening brain edema
may occur for several days after the injury and may cause

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Fig. 4. Photograph of the surgeon creating a burr hole. The perforating bit is
attached to a handheld trephine such as a Hudson brace and placed against the
skull. The trephine is held perpendicular to the skull and rotated in clockwise
fashion as the bit penetrates the skull. Drilling is frequently stopped to determine
the depth of the hole. When the dura is encountered, the bit is changed to a burr to
widen the hole more safely. A curette may also be used to clear the remaining thin
layer of bone, and a rongeur is used to enlarge the hole.

increased ICP, but recurrent hemorrhage is always possible and

should be considered when increasing ICP or clinical deteriora-
tion occurs. Transfer to a neurosurgical facility should be ac-
complished as rapidly as possible to provide the best possible
care for these and other complications of head injury.

Results
In the most modern series, Andrews et al.65 in 1986 investi-
gated 100 consecutive patients with acute cerebral herniation
after blunt trauma. They were taken immediately to the operat-
ing room for burr holes without prior CT, and if ICH was found Fig. 5. (A) Photograph of the skull and three burr holes in a patient who requires
a craniotomy flap was turned to allow complete evacuation. All formal craniotomy for evacuation of ICH. The scalp incision has been completed,
patients underwent postoperative CT. ICH was found in 56 pa- and the scalp and temporalis muscle have been elevated from the skull. (B) A
Penfield 3 dissector (P) is used to gently strip the dura away from the overlying skull
tients and 86% of ICH was detected on the initial side of explo-
between each burr hole. (C) The burr holes have been connected by cutting through
ration. The need for bilateral exploration was apparent, since the intervening bone with a Gigli wire saw, the bone flap was elevated with a Penfield
14% required bilateral burr holes to find the clot. ICH was 3 dissector, and the dura was grasped with dural forceps and opened widely with a
missed in six patients because an incomplete procedure was pair of dural scissors. A thick acute subdural hematoma is seen.
performed, including four who had ICH located very close to a

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18
Fig. 6. For the posterior fossa burr hole, a suboccipital incision (I) is made. The
patient is lying prone, with the head flexed as much as possible and supported by
the head holder. The incision is made vertically 3 cm medial to the mastoid emi-
nence (M, with marker placed on the skin for location), which is easily palpated. The
midline (ML) is also indicated for reference. The musculature here is thick and
requires a deeper retractor, and the cerebellar extension piece is added to the
trephine to penetrate the skull at the depth of the wound. The transverse sinus (TS)
lies at a variable distance above the incision and is at risk for injury if the incision
is too high. If there is ICH in this area, however, the sinus is usually the source of
bleeding. Thus, the incision and bone removal may need to extend up to it to allow
complete evacuation and/or repair of the sinus.
single negative burr hole. No extra-axial hematoma was missed
in any patient who underwent a complete bilateral procedure.
No posterior fossa burr holes were performed, and no ICH for
any patient was visualized there on CT.
All patients who presented with bilaterally enlarged, unreac-
tive pupils and flaccid extremities died, whether or not ICH was
present. The poor outcome for these most severely injured pa-
tients has been corroborated by numerous other clinical
series.66–69 Patients with a Glasgow Coma Scale of 3, 4, or 5
and/or bilaterally dilated pupils after resuscitation are thus
unlikely to benefit from burr holes, especially if they have been
dilated for several hours or if the patient has sustained a
through and through gunshot wound.
The results cited above show the outcomes for patients
treated by experienced neurosurgeons under the best of condi-
tions. Procedures performed by inexperienced surgeons may be
expected to have worse outcomes and, in some cases, only delay
transfer to an appropriate neurosurgical facility.70 It should also
be noted that some authors have reported excellent success
with a simple twist drill rather than using burr holes.71–73 The
supposed advantage over burr holes is speed and simplicity of
use. However, the twist drill hole is quite small and therefore
less likely to allow sufficient evacuation of an acute clot.74
Discussion
Posttraumatic ICH is associated with great morbidity and
mortality. It is best treated by experienced neurosurgeons in a
medical facility equipped with a CT scanner. In the rare instance
that CT is not available, burr holes may be performed to diag-
nose and treat this condition. If CT is available and confirms the
diagnosis, even the non-neurosurgeon may be required to per-
form decompressive burr holes or craniotomy in dire circum-
Military Medicine, Vol. 171, January 2006
Cranial Burr Holes and Emergency Craniotomy
stances. It cannot be condoned as a routine practice by inexpe-
rienced surgeons however, since even in the hands of an
experienced neurosurgeon burr holes are a substantially sub-
optimal method of diagnosis compared with CT imaging. The
decision itself whether to perform this procedure or not is at
least as important as the technique, since nonsurgical interven-
tions alone may mitigate the need for burr holes, and burr holes
placed by the inexperienced surgeon may exacerbate the injury.
Consultation with a neurosurgeon is recommended in all cases,
if possible, to determine whether the patient may be transferred
to a neurosurgeon for the procedure. If the patient is rapidly
deteriorating and cannot await transfer, careful attention to
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detail by the non-neurosurgeon is required to prevent a difficult
situation from becoming even worse. The patient must be trans-
ferred rapidly to the neurosurgeon when stabilized after the
procedure, since worsening brain edema and/or recurrent hem-
orrhage will exacerbate the clinical condition and require long-
term follow-up care at an appropriate facility.
Acknowledgment
We thank Ms. Teri Thomson for technical assistance in preparing the
photographs and illustrations and Mr. Dalton Nouchi for his original
illustrations.
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