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INTRODUCTION

Skulls with burr holes have been found dating back 10,000 years.1 One of the oldest written records of a burr hole placement was between 2000 and 1700 BC.2 The ancient history of burr holes is well described.1-4 A surgical algorithm included the placement of burr holes in the Continental Army.4

Patients with a closed head injury and expanding intracranial hematomas require urgent decompression and control of hemorrhage. Burr hole drainage of epidural and subdural hematomas is uncommonly performed in the Emergency Department but can be lifesaving when timely neurosurgical intervention is not possible. Burr hole drainage is indicated in patients with suspected increased intracranial pressure and evidence of tentorial herniation or upper brainstem dysfunction.5 There has been less need to make exploratory burr holes in head-injured patients since computed tomography (CT) scanning is widely available.

Burr holes can be lifesaving on rare occasions when the patient is worsening neurologically or has blown a pupil and CT scan is unavailable. Suspect a space-occupying lesion when there is clinical evidence of tentorial herniation or upper brainstem dysfunction. This includes progressive deterioration in the patient’s level of consciousness, a fixed and dilated pupil, hemiparesis, posturing (i.e., decerebrate or decorticate), or flaccidity.

The placement of a temporal burr hole on the side of the fixed and dilated pupil to decompress an epidural or subdural hematoma can be lifesaving.6 Up to 70% of patients with evidence of brainstem dysfunction soon after head trauma have significant intracranial mass lesions, most of which are extra-axial blood collections.7 With adequate training, burr hole drainage of acute intracranial hematomas can be successfully performed in the Emergency Department by Emergency Physicians.8-12

ANATOMY AND PATHOPHYSIOLOGY

A significant proportion of patients with fatal head injuries die before reaching the hospital. Death is usually secondary to an expanding intracranial hemorrhage, basilar skull fractures with associated injury to the venous sinuses, intracranial carotid artery lacerations, or major cortical blood vessel lacerations. Skull fractures are present in up to 90% of adults who develop a traumatic intracranial hematoma. Children are less likely to suffer a skull fracture after head trauma than adults due to the relative plasticity and malleability of their skulls.

Injury to the middle meningeal artery, or its branches, is a frequent cause of severe intracranial hemorrhage following head trauma. This artery is a branch of the maxillary artery and enters the cranium via the foramen spinosum. It is usually located between the periosteal and meningeal layers of the dura mater. It divides into anterior and posterior branches after entering the skull. The larger branches of the middle meningeal artery lie within the dura and are accompanied by veins. Their superficial location in the dura produces grooves on the interior of the cranium and makes them vulnerable to injury, especially from temporal bone fractures. The bony vault of the ...

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