Procedure: Craniostomy

Procedure, instructions and discussion

Emergency department Burr holes (Craniostomy)

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Instructions

Indications

• Extradural or subdural haematoma With, midline shift on CT, or High clinical suspicion if CT unavailable (head trauma, rapidly deteriorating course)

AND

• GCS <8 with unequal pupils on examination

AND

• Inability to access neurosurgical assistance within two hours

THIS PROCEDURE IS RARELY PERFORMED BY EMERGENCY PHYSICIANS

DISCUSSS THE CASE AND POCEDURE WITH A NEUROSURGEON PRIOR TO THE INTERVENTION

USE VIDEO LINK FOR LIVE ADVICE IF AVAILABLE

Contraindications (ABSOLUTE and relative)

• Lack of CT confirmation of haematoma

Alternatives

• Rapid transport to a neurosurgical centre
• Bringing a neurosurgeon to the patient

Consent

CONSENT IS NOT REQUIRED

• This is an emergency procedure to save a life

Potential complications

• Failure (clotted blood, absence of blood at site)
• Bleeding (scalp and superficial temporal artery)
• Damage to brain parenchyma
• Infection

Infection control

• Standard precautions
• PPE: sterile gloves and gown, surgical mask, eye protection

Area

• Resuscitation bay

Staff

• Procedural clinician
• Airway clinician
• Two assistants

Equipment

• Razor
• Scalpel
• Retractor
• Manual (Hudson brace) drill or powered neurosurgical drill
• Clutched penetrator drill bit (preferred) or
• Non-clutch penetrator (sharp) and burr (blunt) drill bits
• Suction and saline
• Sharp hook or artery forceps (to grasp dura)
• Additional artery forceps (to control potential superficial temporal artery bleeding)

A clutched penetrator drill bit can be used to drill through the skull in one motion. It is designed to disengage on penetrating the inner table of the skull (reducing ‘plunging’ and brain injury). Without a clutch, a penetrator bit must be changed to a blunt burr drill bit after initiating the craniotomy to reduce the chance of plunging into brain tissue.

Positioning

• Intubated, anaesthetised, paralysed
• C-spine immobilisation
• Supine with head supported by assistant
• Injured side tilted up if possible

Three sites are available for craniotomy:

• TEMPORAL – two finger-widths anterior and superior to the auditory canal (avoiding temporal artery)
• FRONTAL – 10cm above the eye in the mid-pupillary line
• PARIETAL – four finger-widths posterior and superior to external auditory canal

WITH CT SCAN:

• PERFORM AT SITE WITH GREATEST HAEMATOMA DEPTH

WITHOUT CT SCAN:

• PERFORM TEMORAL CRANIOTOMY ON SIDE WITH PUPILLARY DILATION

Medication

• 10ml lignocaine 1% with adrenaline (1:100,000)
• 2g cephazolin IV

Sequence

• Shave scalp widely over selected site
• Infiltrate local anaesthetic with adrenaline at chosen site
• Use scalpel to make a 4cm incision down to bone
• Apply retractor to expose skull
• Scrape periosteum with scalpel (improves contact drill bit)
• Use the drill and clutched penetrator drill bit to penetrate through entire skull (if available), or
• Use the drill and non-clutched penetrator drill bit to penetrate through outer table of skull, then
• Use the drill and burr drill bit to cautiously penetrate through inner table
• Apply drill perpendicular to skull and begin drilling while applying firm pressure
• Have assistant apply gentle saline wash to drilling site
• With a clutched drill bit continue drilling until loss of resistance felt or drill bit stops spinning
• With a burr drill bit regularly pause and assess progress and cease drilling when the inner skull has been penetrated
• Blood and clot can now escape from extradural space through opening
• Allow blood to drain freely (gentle suction may be used, but do not suction brain tissue)
• Flush gently with normal saline and suction gently if required
• If subdural haematoma suspected, elevate dura with sharp hook and make careful incision with scalpel
• If no clot evacuated, proceed with same technique at the frontal and parietal two sites on the affected side
• If no clot evacuated from all three burr holes, repeat technique on the other side
• Once blood flow slows or stops, apply loose dressing

Post-procedure care

Rapid transport to a neurosurgical centre applying standard neuroprotective measures:

• SUPINE POSITION 30 DEGREES HEAD UP
• AVOID RESTRICTING NECK WITH TIES
• DEEP SEDATION WITH PARALYSIS
• OXYGEN TO AVOID HYPOXIA
• MAINTAIN PaCO2 AT 35-40 mmHg
• MAINTAIN MEAN ARTERIAL PRESSURE >90mmHg
• ISOTONIC CRYSTALLOIDS TO MAINTAIN EUVOLAEMIA

Apply active neuroprotective measures for pupillary deterioration (asymmetry, dilation or non-reactive):

HYPERVENTILATION

• 30 mmHg PaCO2 FOR 5-10 MINS
• CEASING IF SIGNS RESOLVE

INTRAVENOUS 20% MANNITOL: 0.5-1 gram/kg body weight

Or

HYPERTONIC SALINE: 6-8 ml/kg OF 3% OR 4 ml/kg OF 7.5% SOLUTION

Tips

• Expanding intracranial haematoma is rapidly fatal and requires early therapeutic intervention
• Non-neurosurgical drills have been successfully used when no dedicated drill is available
• The standard IO drill is preferred in ED if no neurosurgical drill is available
• Temporal burr holes are performed first as 75% of extradural haematomas are temporal
• The scalp and superficial temporal artery (if incised) will bleed profusely

Discussion

Increased time to evacuation of extra axial haemorrhage is associated with worse outcomes in patients who have evidence of cerebral herniation and increased ICP, such as altered mental status, GCS <8, or anisocoria. In this patient group emergency decompressive burr hole in the ED is associated with better outcomes compared to transfer to a neurosurgical centre (>2hrs).

This procedure is rarely performed by emergency physicians, the case should be discussed with a neurosurgeon prior to the intervention and ideally performed with video conferencing and real time support from a specialist.  Medical interventions to lower the ICP should occur simultaneously, such as with the administration of mannitol or hypertonic saline.

If a neurosurgical drill is not available, a reasonable alternative in the emergency department is to use a standard intraosseous drill with 25 mm (blue) needle applied directly to the periosteum. After insertion, the stylet is removed, extension tubing is connected, and aspiration is attempted with a large syringe. This has been described in case reports and may be effective if no alternative is available.  

Our expert neurosurgical reviewers in rural Queensland note that removing “jelly-like” clot with a burr hold is challenging and may require telehealth advice to extend the burr hole with a bone nibbler. Another problem encountered with small burr holes for extradural haematomas is that the culprit middle meningeal artery bleeder can’t be properly visualised, so temporary haemostasis prior to transfer is difficult.

Drs C Juni Jobson, Dr Masee Naidoo, Dr David Kealy and the team in Gladstone hospital in regional Queensland contacted us having performed this procedure successfully with an IO drill. It was necessary to make multiple holes in the same area to facilitate drainage. The team in Gladstone emergency department removed a piece of bone from between these holes which facilitated drainage during hospital transport to Brisbane 600 km away. Ongoing blood transfusions were needed in transport for ongoing bleeding.

Andrew Hebdon, a provider in Plymouth, USA notes that this procedure can be performed with a trephine instead of an IO drill.

References

• Neurosurgical Society of Australasia. The management of acute neurotrauma in rural and remote locations. 3^rd ed. Melbourne: Neurosurgical Society of Australasia; 2009.
• Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.
• Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.
• Smith SW, Clark M, Nelson J, Heegaard W, Lufkin KC, Ruiz E. Emergency department skull trephination for epidural hematoma in patients who are awake but deteriorate rapidly. J Emerg Med. 2010;39(3):377-383. doi:10.1016/j.jemermed.2009.04.062
• Wilson MH, Wise D, Davies G, Lockey D. Emergency burr holes: “How to do it”. Scand J Trauma Resusc Emerg Med. 2012;20:24. Published 2012 Apr 2. doi:10.1186/1757-7241-20-24
• Mendelow AD, Karmi MZ, Paul KS, Fuller GA, Gillingham FJ. Extradural haematoma: effect of delayed treatment. Br Med J. 1979;1(6173):1240-1242. doi:10.1136/bmj.1.6173.1240
• Gustafson ML, Edwards J, Tager A: Emergency Burr Hole utilizing the EZ-IO™ drill: A pilot cadaver study .
• Am J Emerg Med. 2021, 39:229-30. 10.1016/j.ajem.2020.05.008
• 2022
• Wu J et Al: Emergency Decompressive Craniostomy “Burr Hole” Using an Intraosseous Vascular Access System in a Resource-Limited Setting: A Technical Report on a Cadaver; 2022 Wu et al. Cureus 14(4): e24420. DOI 10.7759/cureus.24420 7 of 9
• Raman V et Al: ‘Burr holes in the bush’: Clinician preparedness for undertaking emergency intracranial haematoma evacuation surgery in rural and regional Queensland: Emerg Med Australas: 2023 Jun;35(3):406- C J Jobson: A Hole Seldom Made – Cranial Burr hole! [email protected]: Accepted for Publication and Presentation at Rural Medicine Australia Conference Perth 20-23 ,October 2021 

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