Cranial Burr Hole

Dr. Jess Mason walks you through a step-by-step process on how to perform a cranial burr hole.

Landmarks - Use CT for guidance. If no CT is available: 2 cm superior, 2 cm anterior to tragus, ipsilateral to blown pupil (temporal site). Shave the hair, prep and drape.

Reduce scalp bleeding - Inject lidocaine with epinephrine. Palpate the superficial temporal artery (STA) and remain anterior to it.

Skin incision - Make a vertical incision 3-5 cm long, down to bone. Control scalp bleeding; the frontal branch of the STA is often transected.

Insert the retractor - Insert the self-retaining scalp retractor to expose periosteum.

Expose the skull - Use the periosteal elevator to expose the skull.

Trephination - Technique varies with equipment. Have an assistant stabilize the head.

Hudson Brace:
Use the perforator bit to drill through the outer table, felt as a smooth drilling motion When the drilling motion becomes jagged, switch to the conical burr to trephinate the inner table of the skull.

Note: the non-rotating hand should provide counter-torque and resist forward motion of the drill.

Hand or Electric Drill:
Set the stopper based on the CT to prevent drilling too deeply (typically 0.5-2 cm). Use the largest drill bit in the kit. Drill through the inner table of the skull.

Epidural hematoma - Epidural blood will evacuate once through the skull. Irrigate and suction the clotted blood.

Subdural hemorrhage - For a subdural bleed, make a 3-sided (or “X”) incision in the dura. Use irrigation but do NOT suction.

Skin closure - Leave a drain in place as blood will reaccumulate. Close the skin for hemostasis.

Note: Exploratory burr holes without images can be done in the following sequence: Ipsilateral temporal, contralateral temporal, ipsilateral frontal, ipsilateral parietal.

Alexis S. -

I have read about using an IO for this procedure, any thoughts?

Jess Mason -

I read that too and if totally desperate with no other options I think I would attempt that. The problem is the IO will drill a very small hole compared to a cranial drill. If the blood is clotted I don’t think it will evacuate. The case report I read documented an attempt at this but the patient still died. We are talking about a very rare case with imminent brain herniation and no other options, so the risk benefit ratio is very slanted.

daniel C. -

Concise and excellent! Thanks! Might I suggest with the instruments to have on hand hemostats? Even doing the best anatomic planning (for my n=2), the vascular real estate as you mention is high and increases the likelihood of needing to either ligate vessels or clamp them off temporarily to get a reasonable field of view for burring. And for those who are in locations where there will be no option to transfer, the bone rongeurs and periosteal elevators have been useful to increase exposure in evacuating the clot.

Jess Mason -

Thanks for those tips!

KB -

Thank you.
Great video!
What kind of drain would you suggest leaving in place once the hematoma is evacuated?

Jess Mason -

I reached out to the neurosurgeon who helped us peer review the video and he does not recommend placing a drain. He explained that for an epidural bleed a burr hole is not definitive care and a drain may lead to considerable blood loss. For a subdural you have more time and a drain is likely not needed. When the neurosurgeons do burr holes as definitive care they leave in a Jackson Pratt drain to bulb suction.

I recommend consulting with the neurosurgeon wherever you are transferring the patient and asking their input. Hopefully you will never be put in this situation!

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