Posterior Burr Hole Research Articles

Effectiveness of Burr Hole Sizes on Midline Shift and Hematoma Thickness in the Treatment of Chronic Subdural Hematoma

The aim of our study was to investigate the effect of the burr hole width on the postoperative chronic subdural hematoma (CSH) thickness and midline shift radiologically. The medical records of 92 patients who had undergone surgery after a diagnosis of CSH between April 1, 2015 and July 1, 2021 were reviewed retrospectively. Preoperative and postoperative computed tomography (CT) scans were reviewed, and the thickness of the hematoma and midline shift and the diameters of 2 burr holes opened were measured and recorded. The correlation between the burr hole diameter width and CSH thickness on postoperative CT scans and the improvement in midline shift were investigated statistically. When the CT scans performed on the first postoperative day and first postoperative month were examined, we found that the preoperative hematoma thickness and midline shift were significantly reduced postoperatively (P < 0.001). A positive significant correlation was found between the improvement in the midline shift, posterior burr hole diameter, and anteroposterior burr hole arithmetic mean (P < 0.001 and P= 0.029, respectively). Having examined the current surgical techniques in the treatment of CSH, we found that an increase in the burr hole craniostomy width, especially the posterior burr hole craniostomy width, contributed to the improvement in the midline shift.

Value of Burr‐Hole Surgery as an Adjunct to Encephaloduroarteriosynangiosis in Treatment of Adult Moyamoya Disease: A Case Series

Background Using a single indirect revascularization technique in adult patients with moyamoya disease has been associated with inconsistent outcomes. Herein, we aimed to describe treatment outcomes following combined encephaloduroarteriosynangiosis plus burr‐hole surgery (BHS) in adult moyamoya disease. Methods Encephaloduroarteriosynangiosis combined with 1 anterior and 1 posterior burr hole per hemisphere was performed in 16 adults with moyamoya disease who presented to our center between 2013 and 2019. Patients were followed with clinical reassessments and cerebral angiograms to evaluate for neovascularization. Results Combined encephaloduroarteriosynangiosis and BHS procedures were performed on 24 hemispheres in 16 patients. Follow‐up ranged from 9 to 57 months, during which no new ischemic or hemorrhagic events, perioperative or long‐term complications, or deterioration of symptoms was observed. Follow‐up angiography showed evidence of additional neovascularization provided by the burr holes in 18 of the 24 hemispheres. Of 9 hemispheres with poor revascularization response to encephaloduroarteriosynangiosis, 5 achieved neovascularization at the burr‐hole sites. Older age, smoking, and cerebral infarction or hemorrhage on preoperative magnetic resonance imaging tended to correlate with absence of neovascularization following BHS. Conclusions BHS is a simple and safe procedure that can be done simultaneously with other indirect or direct revascularization procedures. It can provide additional neovascularization even in patients unresponsive to encephaloduroarteriosynangiosis (EDAS) and can be tailored to improve the blood flow in any vascular territory that may not be properly covered by standard revascularization procedures. We find value in adding BHS as an adjunct to other indirect or direct revascularization techniques such as encephaloduroarteriosynangiosis for treatment of adult moyamoya disease.

Reevaluation of Classic Posterior Ventricular Puncture Sites Using a 3-Dimensional Brain Simulation Model.

To revalidate the craniometric dimensions of classic posterior burr holes for ventricular catheter insertion in hydrocephalic patients, based on ideal catheter position on a 3-dimensional simulated computed tomography (CT) reconstruction model of the ventricles. Fifteen patients with hydrocephaly underwent multislice, thin-cut CT to geometrically determine the Cartesian coordinates of a new point for optimal posterior ventricular catheterization. The success rate for ventricular puncture and the thickness of brain traversed by the catheter with 3 approaches (Frazier, Keen, and the suggested point) were compared. The suggested burr hole point for posterior ventricular catheterization is 51 and 57 mm posterior and 58 and 60 mm above the external auditory meatus parallel to the orbitomeatal plane on the right and left sides, respectively, significantly different from the classical Frazier and Keen points. The success rate was 100% for approaches using the suggested point and the Frazier point, compared with 83% using the Keen point. This 17% difference was marginally significant (P= 0.052). The parenchymal mantle for the Frazier point was thicker than that of the suggested point on both sides, although the difference was statistically significant only on the right side (P= 0.006). The parenchymal mantle was thinner in the Keen approach compared with the suggested approach, but the difference was not statistically significant. The use of a suggested burr hole point for posterior ventricular catheterization may decrease the amount of parenchymal mantle of the brain transgressed by the catheter, and may marginally improve the chance of successful posterior ventricular catheterization.

Factors related to shunt survival in paediatric hydrocephalus. Could failure be avoided?

BackgroundImproved shunt survival and a better understanding of factors related to failure in paediatric hydrocephalus still pose a challenge for neurosurgeons, in order to avoid morbidity and mortality, as well as the economic impact of repeated revision surgeries. For these reasons, an analysis is performed on the factors related to the first shunt failure in the long-term follow-up of a series in a single centre. MethodsA retrospective review was conducted on 166 hydrocephalic paediatric patients shunted for the first time between 2000 and 2014. An analysis was made of the statistical relationships between first shunt failure and the demographic, aetiological, surgical and clinical variables. ResultsOf the 166 shunts implanted in our centre during the study period, 111 required revision over a mean follow-up period of 93 months. Factors significantly related to failure were post-haemorrhagic and post-infectious hydrocephalus, meningitis episode, posterior burr hole, differential pressure valve, standard catheter in first surgery, and symptomatic over-drainage. Multivariable analysis showed that previous meningitis and symptomatic over-drainage were risk factors for shunt failure, whereas frontal burr hole location and antibiotic-impregnated catheters were protective factors. Cox regression determined that independent factors significantly related to a worse shunt survival, were shunt infection and symptomatic over-drainage. ConclusionsMeningitis, symptomatic over-drainage, frontal burr hole, and antibiotic impregnated catheters are significant prognostic factors for shunt survival. Shunt infection and symptomatic over-drainage are independent factors significantly related to a shorter shunt survival. Prospective, randomised, controlled trials are required to validate these results.

Factors related to shunt survival in paediatric hydrocephalus. Could failure be avoided?

Improved shunt survival and a better understanding of factors related to failure in paediatric hydrocephalus still pose a challenge for neurosurgeons, in order to avoid morbidity and mortality, as well as the economic impact of repeated revision surgeries. For these reasons, an analysis is performed on the factors related to the first shunt failure in the long-term follow-up of a series in a single centre. A retrospective review was conducted on 166 hydrocephalic paediatric patients shunted for the first time between 2000 and 2014. An analysis was made of the statistical relationships between first shunt failure and the demographic, aetiological, surgical and clinical variables. Of the 166 shunts implanted in our centre during the study period, 111 required revision over a mean follow-up period of 93 months. Factors significantly related to failure were post-haemorrhagic and post-infectious hydrocephalus, meningitis episode, posterior burr hole, differential pressure valve, standard catheter in first surgery, and symptomatic over-drainage. Multivariable analysis showed that previous meningitis and symptomatic over-drainage were risk factors for shunt failure, whereas frontal burr hole location and antibiotic-impregnated catheters were protective factors. Cox regression determined that independent factors significantly related to a worse shunt survival, were shunt infection and symptomatic over-drainage. Meningitis, symptomatic over-drainage, frontal burr hole, and antibiotic impregnated catheters are significant prognostic factors for shunt survival. Shunt infection and symptomatic over-drainage are independent factors significantly related to a shorter shunt survival. Prospective, randomised, controlled trials are required to validate these results.

Two-Part Parasagittal Craniotomy: Technical Note.

Introduction: Craniotomy along the midline can be done in a variety of ways. Methods include single piece craniotomy with burr holes on the midline, crossing the midline with footplates of drills using drilled troughs or bilateral burr holes, and craniotomies in multiple pieces. The authors describe a two-part parasagittal craniotomy useful for safely exposing the midline for parasagittal and inter-hemispheric lesions. Methods: The two-part parasagittal craniotomy begins with anterior and posterior burr holes 1.5 cm lateral to the midline. Once the first bone flap is removed, the dura is dissected under direct vision from the inner table of the skull crossing the midline over to the contralateral side for the second part bone flap. In this way, the superior sagittal sinus (SSS) is dissected and protected. Bony reconstruction and closure is straightforward using recessed screws and plates as well as hydroxyapatite for filling in gaps in the bone. Results: The two-part parasagittal craniotomy has been used in more than 200 patients in the last 24 years. During this time, no direct significant laceration of the SSS has occurred due to a dural tear in the anterior, middle, or posterior thirds while completing the craniotomy. The authors recommend this technique as an option for craniotomy around the midline of the supratentorial cranial vault. Conclusions: The two-part parasagittal craniotomy is an option for opening the skull around the midline of the cranial vault for pathologies along the midline and inter-hemispheric fissure. Surgeons can consider this as an option to a one piece bone flap crossing midline.

Tension Pneumocephalus - The Mount Fuji Sign

A 69-year-old female presented to the emergency department after becoming unresponsive at home following a progressive decrease in her level of consciousness (LOC) (See Figure 1). An urgent computerized tomography (CT) scan of the head demonstrated large bilateral chronic subdural hematomas (SDH’s). Due to the resulting mass effect she was brought urgently to the operating room where the SDH’s were evacuated via anterior and posterior burr holes placed bilaterally. No complications were encountered during the procedure. Prior to skin closure bilateral subdural catheters were placed in the posterior burr hole sites and left under closed suction.

Temporal Epileptogenesis: Localizing Value of Scalp and Subdural Interictal and Ictal EEG Data

To determine the value of scalp epileptiform EEG data and subdural interictal spikes in localizing temporal epileptogenesis among patients requiring invasive recordings. For this delineation, we related such factors to site of subdural seizure origin in 27 consecutive patients. Patients with temporal lobe epilepsy whose non-invasive lateralizing data were inconclusive and therefore required subdural electroencephalography were studied. All patients had (a) 24-h scalp telemetered EEGs, (b) adequate bitemporal subdural placements with an inferomesial line extending from a posterior burr hole anteriorly to <2.5 cm from anterior uncus and a lateral line reaching within 2.5 cm of the temporal tip, and (c) > or =2 subdurally recorded seizures. Three hundred one (96%) of 314 subdurally recorded clinical seizures involving all 27 patients arose from a discrete focus; 266 (85%) arose from mesial temporal regions, which was the origin of the majority of seizures in 24 (89%) patients. The majority of subdural seizures arose ipsilateral to the majority of scalp EEG spikes in 22 (81%) of 27, and most subdural seizures of 15 (75%) of 20 arose ipsilateral to scalp seizures. Lateralization of interictal subdural spikes correlated with that of subdural seizures in 74-92% of patients, depending on the method of spike compilation: for example, most subdural seizures arose from the same lobe of most consistent principal temporal spikes in 92% of patients. These indices of epileptogenesis also appeared more commonly on the side of effective (> or =90% improvement) temporal lobectomy than contralaterally in the following proportions: most consistent principal subdural spikes, 86% of patients ipsilateral vs. 9% contralateral; scalp-recorded clinical seizures, 55% vs. 18%; scalp EEG spikes, 45% vs. 9%. Even among patients whose scalp data are sufficiently complex to require invasive recording for clarification, lateralization of temporal scalp interictal and ictal epileptiform activity and subdural interictal spikes should be included when assessing the side of temporal epileptogenesis.

A guide to placement of parietooccipital ventricular catheters. Technical note.

Accurate placement of parietooccipital ventricular catheters can be difficult and frustrating. To minimize the morbidity of the procedure and lengthen the duration of shunt function, the catheter tip should lie in the ipsilateral frontal horn. The authors describe a posterior ventricular guide (PVG) for placement of parietooccipital catheters that operates by mechanically coupling the posterior burr hole to the anterior target point. In a series of 38 patients who underwent ventriculoperitoneal shunting with the assistance of the guide, postoperative computerized tomography (CT) scanning revealed that 35 (92.0%) had accurate catheter placement. In comparison, a retrospective review of free-hand posterior catheter placement revealed good catheter position in only 22 of 43 patients (51.1%). The use of the guide added less than 5 minutes to the entire procedure, and there were no complications related to its use. The PVG is a simple and useful tool that aids in the placement of parietooccipital ventricular catheters.

Dural liposarcoma associated with subdural hematoma. Case report.

On September 1, 1966, a 4-month-old baby girl was admitted to the hospital because of increasing head circumference and intermittent vomiting. No history of birth trauma or head injury could be obtained. First Admission. Head circumference was 18 inches, the fontanel full, and the scalp veins prominent. Radiographs showed marked separation of the sutures. The hemoglobin was 85 %. Fontanel aspiration yielded 40 cc of blood-stained fluid from the subdural cavity of each side, and thereafter 25 cc from each side on four successive days. Operation. On September 5, bitemporal burr holes drained further amounts of subdural hematoma and revealed a thin subdural membrane on the right side; there was no membrane on the left side. A 4F rubber tube placed in the right subdural cavity was removed the following day. The fontanel remained concave until the 10th postoperative day when it became tense; subdural tap released 30 cc of blood-stained fluid from the right side and 5 to 10 cc from the left side. Eleven days after the burr hole operation, unhealthy-looking skin over the right temporal burr hole was excised, and an additional burr hole was made more posteriorly on the right side, through which further subdural hematoma escaped. The right subdural space was drained with a 4F rubber catheter for 3 days. When the baby went home on September 23, 1966, the head circumference was 17.5 inches and the fontanel concave. Second Admission. On December 31, 1968, the child now 2 years 7 months was readmitted to the hospital because of headaches, vomiting, and increasing drowsiness of 4 weeks' duration. She was thin and pale, with slight neck rigidity. There was bilateral papilledema with retinal hemorrhages. The temperature was 36.2~ the head circumference 20 inches, and the fontanel fused. The right posterior burr hole was bulging but not tense. Power in the limbs was normal, reflexes uniformly brisk, and plantar responses both extensor. The hemoglobin was 79%, white blood cell count 84,000 cu mm with predominant polymorphs, and the sedimentation rate 50 mm in the first hour. X-ray films of the skull showed marked separation of sutures. The serum electrolytes were normal and the blood urea 37 mg%. Bilateral carotid angiograms showed a lens-shaped filling defect on the right anteroposterior venogram, and the left lateral venogram showed a filling defect in the posterior parietal region. Operation. On January 1, 1969, a burr hole placed just above and behind the left

Anterior fossa extradural haematoma following ventriculography through posterior Burr-holes.

A case is reported of a woman of 32 with external hydrocephalus, presumably due to sinus thrombosis. One hour after ventriculography, carried out under local anaesthesia through posterior burr-holes, signs of an extradural haematoma developed. The Patient was re-x-rayed and a marked shift to the right of the anterior ventricular system was displayed. Through a left frontal flap a large extradural haematoma was evacuated. The patient made a full recovery.