Parietal Burr Hole Research Articles

Teaching Neuro Images : Burkitt dural lymphoma mimicking a subacute subdural hematoma

A 59-year-old woman with no history of trauma presented with severe headaches and right-sided weakness. A CT scan showed a left hemispheric isodense subdural collection thought to be consistent with a subacute subdural hematoma (figure 1A). The patient underwent a single parietal burr hole for evacuation, but the neurosurgeon found subdural fleshy tissue and performed a biopsy. Immediate postoperative MRI showed a homogeneous hypercellular subdural mass (figure 1, B–F).1 Pathology was consistent with Burkitt lymphoma (figure 2). Retrospectively, the homogeneous density of the collection argued against hematoma. In nonemergent situations, an atypical radiologic appearance of a subdural hematoma may suggest the need for further radiologic investigations before surgical evacuation.2

A Rare Complication of Burr Hole Drainage of Chronic Subdural Hematoma

Chronic subdural hematoma is a common neurosurgical problem, especially in the elderly, which is frequently treated by burr hole drainage. Recurrence is the most frequent complication of chronic subdural hematoma surgery reported in literature. However, cerebrospinal fluid leak resulting subgaleal pseudomeningooele has been reported. We report a 67-year-old man who had burr hole drainage of chronic subdural hematoma and subsequently developed cerebrospinal fluid fistula which was drained by subdural drain inserted intraoperatively. A 67-year-old right-handed man who presented with nine days' history of progressive pan-cranial persistent headache following a fall from the bathroom associated with irrational behavior and weakness of the left side of the body. His Glasgow Coma Score (GCS) was 12/15, with generalized hypertonia, left-sided hemiparesis, and left-sided grade + 3 deep tendon reflexes. Brain computed tomography scan [Figure 1] showed right-sided fronto-temporoparietal chronic subdural hematoma with midline shift and effacement of the ipsilateral lateral ventricle. He had right frontal and right parietal burr holes, such as subdural hematoma and insertion of nonnegative subdural drain through the parietal burr hole. He developed cerebrospinal fluid leak, which drained into the drainage bag and subsequently managed conservatively. Cerebrospinal fluid leaks can occur following burr hole drainage of chronic subdural hematoma. Subdural drain inserted intraoperatively is helpful in preventing the sequelae of cerebrospinal fluid accumulation in the subdural and subgaleal spaces.

Does Drain Position and Duration Influence Outcomes in Patients Undergoing Burr-Hole Evacuation of Chronic Subdural Hematoma? Lessons from a UK Multicenter Prospective Cohort Study.

BackgroundDrain insertion following chronic subdural hematoma (CSDH) evacuation improves patient outcomes.ObjectiveTo examine whether this is influenced by variation in drain location, positioning or duration of placement.MethodsWe performed a subgroup analysis of a previously reported multicenter, prospective cohort study of CSDH patients performed between May 2013 and January 2014. Data were analyzed relating drain location (subdural or subgaleal), position (through a frontal or parietal burr hole), and duration of insertion, to outcomes in patients aged >16 yr undergoing burr-hole drainage of primary CSDH. Primary outcomes comprised modified Rankin scale (mRS) at discharge and symptomatic recurrence requiring redrainage within 60 d.ResultsA total of 577 patients were analyzed. The recurrence rate of 6.7% (12/160) in the frontal subdural drain group was comparable to 8.8% (30/343) in the parietal subdural drain group. Only 44/577 (7.6%) patients underwent subgaleal drain insertion. Recurrence rates were comparable between subdural (7.7%; 41/533) and subgaleal (9.1%; 4/44) groups (P = .95). We found no significant differences in discharge mRS between these groups. Recurrence rates were comparable between patients with postoperative drainage for 1 or 2 d, 6.4% and 8.4%, respectively (P = .44). There was no significant difference in mRS scores between these 2 groups (P = .56).CONCLUSIONDrain insertion after CSDH drainage is important, but position (subgaleal or subdural) and duration did not appear to influence recurrence rate or clinical outcomes. Similarly, drain location did not influence recurrence rate nor outcomes where both parietal and frontal burr holes were made. Further prospective cohort studies or randomized controlled trials could provide further clarification.

Bilateral Chronic Subdural Hematoma and Blindness: Bilateral Infarction to the Posterior Cerebral Artery following Evacuation of Bilateral Chronic Subdural Hematoma — A Rare Case Report and Review of Literature

Objective The authors report a rare scenario in which evacuation of bilateral chronic subdural hematoma (CSDH) was followed by bilateral PCA infarction and blindness. A literature review was also conducted, which revealed only four cases of blindness after CSDH evacuation. Methods A 45-year-old man was admitted with the chief complaint of holocranial headache for 2 months with past history of head trauma. Clinical examination was normal. CT and MRI scanning showed bilateral frontotemperoparietal CSDH without midline shift and parenchymal and vascular abnormality. Bilateral frontal and parietal burr holes and evacuation of CSDH was done. Results The patient developed progressive blindness in both the eyes in the postoperative period. MRI revealed bilateral PCA infarction. Discussion Bilateral PCA infarction following bilateral CSDH evacuation is an extremely rare entity. Only four case of blindness following CSDH evacuation have been reported so far, and all the patients suffered permanent visual loss. The exact etiopathogenesis and mechanism of this rare complication remain unknown. Conclusion Bilateral CSDH is a separate entity with altered pathophysiology and deranged cerebral autoregulation. The authors conclude that Bilateral CSDH may be sentinel tags for bilateral PCA infarction secondary to altered hemodynamics in the posterior circulation, and hence, needs to be evaluated and treated with greater diligence.

Fibrin glue injection into the hematoma cavity for refractory chronic subdural hematoma: A case report

Background:Repeat burr hole irrigation and drainage has been effective in most cases of recurrent chronic subdural hematoma (CSDH), however, refractory cases require further procedures or other interventions.Case Description:An 85-year-old male presented with left CSDH, which recurred five times. The hematoma was irrigated and drained through a left frontal burr hole during the first to third surgery and through a left parietal burr hole during the fourth and fifth surgery. The hematoma had no septation and was well-evacuated during each surgery. Antiplatelet therapy for preventing ischemic heart disease was stopped after the second surgery, the hematoma cavity was irrigated with artificial cerebrospinal fluid at the third surgery, and the direction of the drainage tube was changed to reduce the postoperative subdural air collection at the fourth surgery. However, none of these interventions was effective. He was successfully treated by fibrin glue injection into the hematoma cavity after the fifth surgery.Conclusion:This procedure may be effective for refractory CSDH in elderly patients.

The minimally invasive endoscopic management of septated chronic subdural hematomas: surgical technique.

Fibrin membranes and compartmentalization within the subdural space are a frequent cause of failure in the treatment of chronic subdural hematomas (CSH). This specific subtype of CSH classically requires craniotomy, which carries significant morbidity and mortality rates, particularly in elderly patients. In this work, we describe a minimally invasive endoscopic alternative. Under local scalp anesthesia, a rigid endoscope is inserted through a parietal burr hole in the subdural space to collapse fibrin septa and cut the internal membrane. It also allows cauterization of active bleedings and the placement of a drain under direct visualization. The endoscopic treatment of septated CSH represents a minimally invasive alternative to craniotomy especially for the internal membranectomy.

Teaching Neuro Images : Burkitt dural lymphoma mimicking a subacute subdural hematoma

A 59-year-old woman with no history of trauma presented with severe headaches and right-sided weakness. A CT scan showed a left hemispheric isodense subdural collection thought to be consistent with a subacute subdural hematoma (figure 1A). The patient underwent a single parietal burr hole for evacuation, but the neurosurgeon found subdural fleshy tissue and performed a biopsy. Immediate postoperative MRI showed a homogeneous hypercellular subdural mass (figure 1, B–F).1 Pathology was consistent with Burkitt lymphoma (figure 2). Retrospectively, the homogeneous density of the collection argued against hematoma. In nonemergent situations, an atypical radiologic appearance of a subdural hematoma may suggest the need for further radiologic investigations before surgical evacuation.2

Abordaje endoscópico al atrio ventricular para toma de biopsia de tumor de la región pineal: a propósito de un caso

The usual endoscopic approach in the management of pineal region tumours consists of inserting the scope into the frontal horn of the lateral ventricle and advancing it through the foramen of Monro into the third ventricle. We report the case of a patient with a pineal tumour on whom we used an endoscopic approach through the ventricular atrium to obtain a biopsy by opening the choroidal fissure. This young 25-year-old man presented with headache and double vision. Papilloedema and Parinaud's syndrome were found on physical examination. Cranial magnetic resonance revealed a pineal mass and hydrocephalus. We initially performed a third ventriculostomy and a tumour biopsy through a frontal burr hole. The tissue sample was not useful for pathological diagnosis and we decided to perform a second endoscopic biopsy. The endoscopic approach to pineal region masses, reaching the ventricular atrium through a parietal burr hole and opening the choroidal fissure, makes it possible to take a biopsy using a single endoscopic approach without needing to cross other ventricular structures.

Rapid resolution of a spontaneous large chronic subdural haematoma in the posterior fossa under conservative treatment with platelet administration to aplastic anaemia

Infratentorial chronic subdural hematomas are rare. Simultaneous supra- and infratentorial chronic subdural hematoma is extremely rare. Commonly caused by head trauma in a predisposed brain; coagulopathy, cerebral atrophy secondary to alcohol, old age, or human immunodeficiency virus infection. Only a few cases have been reported, and this is the first report from our setup.50 years old human immunodeficiency virus-positive woman presented to our hospital with headache, decreased mentation and left side body weakness of two days. Brain magnetic resonant imaging showed bilateral supra-and infratentorial chronic subdural collection. Under local anesthesia and light sedation, bilateral burr hole and evacuation of supratentorial hematoma were done and the infratentorial hematoma was managed conservatively as it is thought asymptomatic. Postoperatively consciousness and weakness improved but the patient complained of severe global headache and computed tomography scan showed significant residual right side supratentorial chronic subdural hematoma. Thus under local anesthesia and light sedation right parietal burr hole was done and the hematoma was removed. Postoperatively patient was conscious, the headache disappeared.This experience demonstrates conservative management of asymptomatic infratentorial chronic subdural hematoma is a viable treatment option in patients presenting with both supra- and infratentorial chronic subdural hematoma. We suggest burr hole evacuation, irrigation and placement of closed drainage system should be considered as a first choice surgical treatment for symptomatic infratentorial chronic subdural hematoma.

Total Agenesis of Superior Sagittal Sinus and Falx Cerebri in a Patient Who Has a Subacute Subdural Hematoma Crossing Midline

Anatomic variations of the superior sagittal sinus (SSS) and falx cerebri (FC) are uncommon in that agenesis of these structures is extremely rare. We report an extremely rare anatomic variation, total agenesis of the SSS and FC, and briefly discuss it from the anatomical, embryological, radiological, and clinical perspectives. A 49-year-old woman presented with long-standing headache, gait disturbance, and nausea. Imaging studies showed a bilateral subdural hematoma crossing the midline, dilated venous structures, and perineural cysts, but SSS and FC. Following right-sided hemiparesis and consciousness disturbances, the subdural hematoma was evacuated from a left-sided parietal burr hole because of thick hematoma in this side. After the surgical evacuation, the hemiparesis and consciousness disturbances were regressed; however, she still had severe headache. On account of ongoing headaches and related imaging findings, it was thought that she had possible spontaneous intracranial hypotension. She was treated with autologous epidural blood patch and recovered well. Agenesis of the SSS and FC are extremely rare variations. Agenesis of the SSS results in development of alternative venous pathways and may lead to misdiagnosis as dural arteriovenous fistulas. Agenesis of FC may cause diagnostic confusion, because subdural pathologies such as hematomas can cross the midline in rare occasions.

Coexistence d’un hématome sous dural chronique et un empyème sous-dural controlatéral : à propos d’un ca

Chronic sub-dural hematoma and subdural empyema are well known neurosurgical pathologies. Their coexistence is rare. The authors refered a case and discussed the various causes with a review of the literature. Comments : This is a 73 year-old woman, with a history of Alzheimer’s disease and cerebrovascular accident (CVA) treated with Salicylate acid 100 mg / day, who presented disturbance of consciousness and right hemiparesis. No notion of fever or head injury was founded. A Computed tomography (CT) scan without injection of contrast evoked the diagnosis of bilateral chronic subdural hematoma. The patient underwent surgery in emergency for neurological deterioration. After completion of two parietal burr holes from both sides and opening the dura, it was founded a chronic subdural hematoma (CSDH) on the left and a thick hard inflammatory membrane on the right, which contained a purulent material. Culture revealed Escherichia coli. Conclusion: Subdural empyema resulting from hematogenous seeding into a preexisting subdural hematoma is very rare.

Clinical and Angiographic Outcomes From Indirect Revascularization Surgery for Moyamoya Disease in Adults and Children: A Review of 63 Procedures

Several forms of indirect cerebral revascularization have been proposed to promote neovascularity to the ischemic brain. To present clinical and angiographic outcomes of indirect revascularization by encephaloduroarteriosynangiosis and burr holes for the treatment of Moyamoya disease in adults and children. Data from 63 hemispheres treated in 42 patients (average age, 30 years; 33 adults; 30 female patients; median follow-up, 14 months) were reviewed. In hemispheres with preoperative and postoperative (6- to 12-month) angiograms available, superficial temporal artery (STA) and middle meningeal artery (MMA) diameters were measured. Preoperative and postoperative corrected arterial sizes were compared. Seven patients (17%) had transient ischemic attacks that resolved within 1 month of surgery. No patients suffered moyamoya-related hemorrhage after treatment. Two patients developed additional symptoms many years after surgery. In 18 hemispheres with preoperative and postoperative angiograms, there was an average postoperative increase in STA and MMA diameters of 51% (P = .003) and 49% (P = .002), respectively. Both children and adults displayed revascularization. Two patients did not demonstrate increased vessel size. STA blush and new branches and MMA blush and new branches were identified in 12, 14, 14, and 16 hemispheres, respectively. Angiographic blush was identified in 59% of frontal and 19% of parietal burr holes (P = .03). Surgical complications included 2 subdural hemorrhages requiring evacuation and 2 new ischemic deficits (1 transient). Indirect revascularization by encephaloduroarteriosynangiosis and burr holes for moyamoya results in long-term resolution of ischemic and hemorrhagic manifestations in 95% of adults and children. The MMA appears to contribute significantly to the revascularization on follow-up angiograms with increased size and neovascularity comparable to that of the STA. Angiographically, parietal burr holes do not contribute as significantly as frontal burr holes.

Surgical Fires: 100% Preventable, Still a Problem

73-year-old man with a subdural hematoma was scheduled to receive bilateral parietal burr holes. As a result of the patient’s high risk for comorbidities, the procedure was performed with monitored anesthesia care. The anesthesia care provider placed an oxygen mask loosely on the patient’s face, with administration of oxygen at 6 L per minute. The circulating nurse shaved and prepped the patient’s head with a solution of iodoform in 74% isopropyl alcohol. After allowing the solution to dry for two minutes, the surgeon and scrub person draped the patient. The surgeon completed the burr hole procedure on the right side uneventfully. After removing the drapes and repositioning the patient’s head, the circulating nurse prepped and draped the left side in the usual manner. The surgeon then used an electrosurgical monopolar pencil after making the incision. Staff members heard a muffled “pop,” and immediately saw smoke coming from under the drapes. The surgeon quickly removed the drapes from the patient’s head, which was engulfed in flames. The anesthesia care provider turned off the oxygen flow. The fire was immediately controlled. The sequence of events lasted less than 15 seconds; however, the patient’s postoperative period was complicated with a lengthened intensive care unit (ICU) stay of two months before he was discharged to a rehabilitation center. 1

Medpor Craniotomy Gap Wedge Designed to Fill Small Bone Defects along Cranial Bone Flap

Medpor porous polyethylene was used to reconstruct small bone defects (gaps and burr holes) along a craniotomy bone flap. The feasibility and cosmetic results were evaluated. Medpor Craniotomy Gap Wedges, V and T, were designed. The V implant is a 10 cm-long wedge strip, the cross section of which is an isosceles triangle with a 4 mm-long base, making it suitable for gaps less than 4 mm after trimming. Meanwhile, the Medpor T wedge includes a 10 mm-wide thin plate on the top surface of the Medpor V Wedge, making it suitable for gaps wider than 4 mm and burr holes. Sixty-eight pterional craniotomies and 39 superciliary approaches were performed using the implants, and the operative results were evaluated with respect to the cosmetic results and pain or tenderness related to the cranial flap. The small bone defects were eliminated with less than 10 minutes additional operative time. In a physical examination, there were no considerable cosmetic problems regarding to the cranial bone defects, such as a linear depression or dimple in the forehead, anterior temporal hollow, preauricular depression, and parietal burr hole defect. Plus, no patient suffered from any infectious complications. The Medpor Craniotomy Gap Wedge is technically easy to work with for reconstructing small bone defects, such as the bone gaps and burr holes created by a craniotomy, and produces excellent cosmetic results.

Cortical osteotomy technique for mobilizing the temporal muscle in pterional craniotomies

Although many procedures have already been performed to mobilize and reconstruct the temporal muscle for pterional craniotomies, the authors described a novel cortical osteotomy technique for creating and mobilizing a cortical bone slat along the superior temporal line with the temporal muscle attached to it. Screw fixation of the cortical bone slat then provides secured temporal muscle reconstruction. As such, this new technique minimized damage to the temporal muscle and prevented the formation of an anterior temporal hollow. In addition, key hole and parietal burr hole defects were covered by the cortical bone slat.

In-vivo measurement of cytochrome using NIRS during acute focal cerebral ischaemia and reperfusion in rats.

Near-infrared spectroscopy (NIRS) based technology allows in-vivo monitoring of focal tissue cytochrome aa3 (cytochrome-c-oxidase). The aim of this study was to assess early cell alteration during acute focal cerebral ischaemia and reperfusion. Focal cerebral ischaemia was induced in 12 rats using an endovascular occlusion technique of the middle cerebral artery (MCA). Occlusion time was 60 minutes followed by reperfusion for another 60 minutes. Monitoring of oxygen saturation (SO2) and oxidized cytochrome complex (oxid. Cytaa3 ) was performed by NIRS via a parietal burr hole before (baseline), during occlusion and reperfusion. Twenty-four hours after MCA occlusion (MCAO) infarction was confirmed by TTC staining. In all animals SO2 and oxid. Cytaa 3 immediately decreased to zero during occlusion indicating complete ischaemia. According to the results of NIRS measurements during reperfusion animals were subdivided into two groups. All animals of group A demonstrated identical or even higher levels of SO2 and oxid. Cytaa3 compared to baseline. On the contrary, both parameters in group B remained at a distinct lower level compared to baseline (p < 0.05). Average reperfusion/baseline ratios for SO2 and oxid. Cytaa 3 were 0.8 (+/- 0.4) and 0.4 (+/- 0.2), respectively. The results of TTC-staining were distributed to the above mentioned two groups as follows: group A, only lesions in the basal ganglia or little cortical infarction (n = 8); group B, lesions in the basal ganglia and cortical area (n =4). After 1 hour MCAO a subgroup of animals with associated cortical infarction was identified, whose oxid. Cytaa3 values did not reach baseline values during reperfusion indicating early intracellular disturbance.

Unilateral spatial neglect associated with chronic subdural haematoma: a case report

A 69-year-old right-handed man who exhibited unilateral spatial neglect in association with a chronic subdural haematoma, presented with mild left arm and leg weakness first noted 4 weeks prior to admission. Neurologic examination on admission revealed a mild left hemiparesis, including the face. Neuropsychologic examination revealed left unilateral spatial neglect, but no language disturbance. Minimal support was necessary to maintain activities of daily living. Computed tomography revealed a large right temporoparietal, extraaxial hypodense fluid collection containing scattered hypodense foci. The haematoma was evacuated via a right parietal burr hole. Following surgery, the patient dramatically improved neurologically and neuropsychologically, as well as in independent performance of daily activities. It is suggested that the improvement in ADL provides a behavioural correlate of improvement in the latter, represented a behavioural correlate of improved cerebral function, and that either direct compression by the chronic subdural haematoma or an interhemispheric pressure difference had caused unilateral spatial neglect. Such neglect is an unusual consequence of chronic subdural haematoma.

ACUTE NEONATAL SUBDURAL HEMATOMA FOLLOWING BREECH DELIVERY

• We describe two term infants born by complicated breech deliveries, each of whom suffered an acute subdural hematoma. Both infants required repeated subdural taps; in one case a parietal burr hole was needed. Despite stormy neonatal courses, follow-up examination of the first infant at 26 months showed him to be normal, and in the other only a mild left esotropia was found at 22 months. Acute neonatal subdural hematoma is rare, but symptoms and signs are distinctive and the condition is remediable; immediate recognition and treatment is important. (Am J Dis Child131:192-194, 1977)

Roentgenologic signs of resolving subdural hematomas.

Subdural hematoma has been a recognized entity since the eighteenth century and possibly earlier (1). In spite of its long history, many questions concerning this condition remain unanswered. Among these is: Does a subdural hematoma ever undergo spontaneous resolution? Occasional reports (2–4) have appeared in the literature concerning subdural collections diagnosed by cerebral angiography or pneumography which subsequently cleared. The nature of these collections, however, whether cerebrospinal fluid or blood, has remained unknown. Cerebral atrophy may give the angiographic appearance of an acute subdural collection (5). Occlusion of several small branches of the middle cerebral artery may also simulate an acute subdural collection on the anteroposterior view. The purpose of the investigation to be reported here was to determine whether subdural hematomas ever regress spontaneously. It was not meant to offer a new mode of therapy for this condition. The patients were selected because of their good clinical condition. They were observed constantly and if, at any time, this had worsened, they would have been subjected immediately to surgery—burr holes and/or craniotomy. The clinical aspects of these cases will be included in another report. Case I: A 29-year-old man was well until two weeks prior to admission, when he first experienced frontal headaches and low back pain. He was drowsy upon entering the hospital and exhibited a left central facial palsy and slight nuchal rigidity. The left upper extremity was a little weak, the deep tendon reflexes were increased on the left, and the superficial abdominal reflexes were absent on that side. Lumbar puncture revealed xanthochromic fluid. On the seventh hospital day a left carotid angiogram (Fig. 1) demonstrated an acute subdural collection. The following day a left parietal burr hole was made. A 20-gauge needle was inserted through the dura, 0.4 c.c, of brownish-red material resembling old blood was aspirated, and the wound closed. The benzidine test of this fluid was positive. The patient was then followed with serial angiograms. He became alert, coherent, and oriented, and his neurological deficit disappeared. After eight weeks all angiographic signs of subdural hematoma had vanished. Case II: A middle-aged man was confused, disoriented, and drowsy upon admission to the hospital. No history could be obtained. Physical and neurological examinations were negative. After a bout of delirium tremens he was alert and oriented by the fourth hospital day. A lumbar puncture at that time revealed grossly bloody spinal fluid with a xanthochromic supernatant. During the following days the patient remained alert and exhibited only a “glove and stocking” sensory impairment of the limbs. Ten weeks after admission a right carotid angiogram (Fig. 2) revealed a chronic subdural fluid collection. Six days later a right parietal burr hole was made and a 20-gauge needle was inserted through the dura.