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Summary

A burr hole surgery is done to remove accumulated fluid/blood inside meninges (protective layers of tissues around the brain). Burr holes are small holes made in the skull. The fluid can accumulate below the dura layer, which is the outermost layer of meninges (subdural haematoma) or above the layer (epidural haematoma). This fluid accumulation causes compression of the brain tissues and puts pressure on the skull. Burr holes help to relieve this pressure on the brain. 

You will need general anaesthesia before the procedure. During the procedure, a neurosurgeon will drill small holes in your skull using a special instrument to drain out the fluid. After the procedure, care needs to be taken to keep the wound clean and dry. You will be asked to avoid activities that can cause injury to your head. 

Burr hole surgery can help in relieving the symptoms caused by the accumulation of blood in the skull. 

  1. What is burr hole surgery?
  2. Why is burr hole surgery recommended?
  3. Who can and cannot get burr hole surgery?
  4. What preparations are needed before burr hole surgery?
  5. How is burr hole surgery done?
  6. How to care for yourself after burr hole surgery?
  7. What are the possible complications/risks of burr hole surgery?
  8. When to follow up with your doctor after a burr hole surgery?

Our brain sits inside the skull and is protected by a layer of thin tissues called meninges. The meninges are rich in blood vessels that carry blood to and from the brain. A tear to the blood vessels due to a head injury can cause bleeding and build-up of blood inside the meninges just below the dura mater (outer layer of meninges). This type of blood build-up is called a subdural haematoma. Generally, a haematoma is the accumulation of blood that causes swelling. If the tear is too big, the blood accumulation would be quick and sudden (acute hematoma) while small cuts may cause slow and gradual accumulation of blood (chronic haematoma). If the blood accumulates above the dura layer, it is called an epidural haematoma. The build-up of blood can push up against the skull or cause compression of the brain. 

Burr hole surgery is done to remove this fluid build-up inside the meninges to relieve pressure on the brain. During the surgery, small holes are made in the skull to drain the excess fluids. 

Your healthcare practitioner may recommend this surgery if you show the following symptoms of subdural haematoma:

  • Headache that worsens over time 
  • Fits (seizures)
  • Confusion 
  • Vision problems (double vision)
  • Loss of consciousness 
  • Feeling and being sick 
  • Feeling drowsy and difficulty in keeping your eyes open 
  • Problems in walking and frequent falls 
  • Personality changes, such as rapid mood swings or being unusually aggressive 
  • Paralysis (loss of movement) of one side of your body 
  • Slurred speech

Burr hole surgery is commonly performed in case of both sudden (acute) and ongoing (chronic) subdural haematoma.

Other indications where a burr hole surgery may be performed are as follows:

  • Epidural haematoma 
  • Build-up of pus in meninges 
  • Bleeding from the brain itself (rarely)
  • Certain types of brain cancer
  • Hydrocephalus (widening of spaces in the brain due to excessive accumulation of fluids in the brain cavities)

An emergency burr hole surgery should be avoided in the following conditions:

  • Unavailability of imaging scan (e.g. computed tomography (CT) scan) of the brain
  • Neurosurgical intervention available in a reasonable time frame 
  • Glasgow coma scale >8 - this scale is a scoring method to check for the level of consciousness in a person after a traumatic brain injury.

Burr hole surgery may be an emergency procedure or it may be planned. Following preparations are required before this surgery:

  • The healthcare practitioner will order certain tests like a CT scan to get information about the fluid around the brain. 
  • Inform your healthcare practitioner about all the medicines that you are taking, including non-prescribed medicines like aspirin. 
  • You will be asked to stop the use of blood-thinning medicines. 
  • Smoking can delay the healing process after the surgery. Hence, you will be asked to stop smoking. 
  • You need to undergo fasting from the midnight before the procedure. 
  • Tell your doctor if you recently had any health issues like a fever.

The procedure involved in the burr hole surgery is as follows:

  • The healthcare provider will place an intravenous line in your arm or hand to give you a relaxation medicine or general anaesthesia (medicines that make you sleep fully). 
  • They will monitor your blood pressure and heart rate throughout the surgery. 
  • The hair on your scalp may be trimmed. 
  • Numbing medicine will be injected into your scalp. 
  • The surgeon will make an incision in your scalp and drill one or two small holes using a special drill instrument. 
  • He/she will open the dura layer of your meninges, and remove the excess fluid to reduce pressure on the skull. 
  • The surgeon will then cover the burr holes with a small metal plate. 
  • They may place a temporary drain to continue removing the fluid or close your scalp and dura immediately. 

After the surgery, you will have to remain in the hospital for a few days. You may experience slight pain at the incision site on your scalp. Over-the-counter medicines may help to reduce this pain.

After the surgery, you should take care of the wound in the following manner:

  • Keep the area of the incision clean and dry. 
  • Wear a shower cap while bathing until the stitches on the incision are removed. 
  • Wear a loose hat or turban. 
  • Avoid wearing a wig (if you otherwise do) for three to four weeks.
  • Do not use cream, lotion or any hair products for a few weeks after the surgery. 
  • To reduce the swelling or pain, you may be asked to place an ice-wrapped towel on the incision site.

You can resume your regular diet after the surgery. Consult your healthcare provider when you can have sex or begin driving again. Avoid performing any activities that may cause a blow to your head.

When to See the Doctor?

Inform your healthcare provider immediately if you observe any of these symptoms after the surgery:

The risks associated with burr hole surgery are as follows:

You may need a follow-up meeting with your doctor to remove stitches or drain. A CT scan or magnetic resonance imaging scan will also be repeated. The healthcare practitioner will monitor your progress and check if you need further treatment for your condition.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.

References

  1. Johns Hopkins Medicine [Internet]. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System; Burr Holes
  2. Saint Luke's Health System [Internet]. Kansas city. US; Understanding a Burr Hole Procedure
  3. National Health Service [internet]. UK; Subdural haematoma
  4. National Institute of Neurological Disorders and Stroke [internet]: US Department of Health and Human Services; Hydrocephalus Fact Sheet
  5. Wilson MH, Wise D, Davies G, Lockey D. Emergency burr holes: "How to do it". Scand J Trauma Resusc Emerg Med. 2012;20:24. PMID: 22469190.
  6. University of Rochester Medical Center [Internet]. Rochester (NY): University of Rochester Medical Center; Burr Holes
  7. Sawyer MM. Postanesthetic care. In: Duke JC, Keech BM, eds. Duke's Anesthesia Secrets. 5th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 28.
  8. Ortega-Barnett J, Mohanty A, Desai SK, Patterson JT. Neurosurgery. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 67.

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