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 Kernohans 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

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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

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

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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