Percutaneous epidural drainage through a burr hole.

Intracranial extradural collection may cause an increase in intracranial pressure, requiring rapid emergency treatment to reduce morbidity and mortality. We described an alternative CT-guided percutaneous access for extradural collection drainage. We report a case of a patient with previous craniectomy for meningioma ressection who presented to the Emergency Department with symptoms of intracranial hypertension. Brains CT showed a extradural collection with subfalcine herniation. After multidisciplinary discussion a CT-guided percutaneous drainage through previous burr hole was performed. The patient was discharged after 36 hours of admission, without further symptoms. We describe a safe and effective alternative percutaneous access for extradural collection drainage in patients with previous burr hole.

Introduction

Intracranial extradural collection are often due to trauma or surgery,[1] and may cause an increase in intracranial pressure, requiring rapid emergency treatment to reduce morbidity and mortality.[2] Conventional treatment is decompressive craniectomy performed by neurosurgeons.[1] The increased use of computed tomography (CT) scans has changed the diagnosis and management of intracranial extradural collection, allowing its early approach.[3] We described an alternative CT-guided percutaneous access for extradural collection drainage.

Case Report

A 65-year-old male presented to the Emergency Department with headache, dizziness, and a slowly diminishing level of consciousness. Neurological examination showed mental confusion without motor weakness. The patient had a past medical history of craniectomy for meningioma resection in the left anterior frontal region 6months ago and development of an extradural collection in the postoperative period, which was already treated with two surgical drainage procedures in the last 2months [Figure 1].

Figure 1

Computed tomography of the brain: Three-dimensional reformation showing previous craniectomy and burr holes

Brain CT was immediately performed and showed recurrence of extradural collection (22HU) with subfalcine herniation [Figure 2]. After discussion with neurology and neurosurgery on call team, we decided to perform a percutaneous drainage of epidural collection in the scan room using the prior burr hole, for immediate reduction of the hypertensive patient's symptoms. Therefore, a CT-guided percutaneous drainage was performed under sedation though a previous burr hole. A coaxial bone biopsy system and 13 G × 10 cm (Cook, Inc, Bloomington, IN, USA) needle were introduced into the collection [Figure 3]. Approximately50 ml of yellowish liquid was slowly aspirated to avoid vascular disruption and increase in blood cerebral flow. Control CT scan showed reduction of epidural collection and midline shift [Figure 4]. The patient was discharged after 36 hours of admission, without further symptoms. Three months later, a magnetic resonance imaging (MRI) scan demonstrated complete resolution of the collection. After an 18-month follow-up, the patient remains in attendance without any further symptoms.

Figure 2

Computed tomography scan of the brain demonstrating recurrence of extradural collection causing subfalcine herniation

Figure 3

A 13G coaxial bone biopsy system needle was introduced into the collection through a burr hole

Figure 4

Control computed tomography scan showed small fluid accumulation and pneumocephalus

Discussion

Intracranial extradural collection are often due to trauma or surgery,[1] and may cause an increase in intracranial pressure, requiring rapid emergency treatment to reduce morbidity and mortality.[2] The management of extradural collection has changed dramatically in the last decade and the most frequent adoption of nonoperative therapies in the treatment of Intracranial hypertension have reduced the craniotomy rates.[34] The guidelines recommend transfer to neurosurgical centers for patients with extradural collection and compressive symptoms.[34] However, before the transfer, surgical decompression should be performed for deteriorating patients due the risk of additional compromise caused by delays during transport. Xianlin et al.,[5] who analyzed 33 cases of patients undergoing percutaneous intracranial CT-guided collection drainage, observed among others the following advantages: Possibility of performing the procedure under local anesthesia in the CT room in primary hospitals, minimally invasive trauma, short operation trauma, low cost, and short hospital stay. We describe a safe and effective alternative percutaneous access for extradural collection drainage in patients with a previous burr hole. Emergency doctors in hospitals without neurosurgical facilities could easily perform this procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.