
Burr Hole
Rapid Review
- Background
- Also known as “trepanning”. Involves drilling or scraping a hole into the skull to provide drainage for expanding intracranial hematoma
- Indications
- Epidural or subdural hematoma w/ midline shift on imaging.
- Contraindications
- Lack of imaging, reasonable access to neurosurgery, GCS > 8
- Complications
- Damage to brain parenchyma, infection, bleeding.
Pearls
- The optimal location for this procedure will be based on the location of the hemorrhage on CT scan. When in doubt though, utilize the temporal site.
- If a trephination tool is not available, there are case studies supporting the use of a 25-mm EZ-IO needle with an electric driver.

HINTS Exam
Rapid Review
- Background
- Physical exam technique utilized as a screening tool to distinguish central causes of vertigo (ex. Posterior stroke) from peripheral causes (ex. Vestibular neuritis)
- Indications
- Patients with acute onset, continuous vertigo.
- Contraindications
- Chronic or episodic vertigo, C-spine injury
- Complications
- Cervical injury from head impulse test.
Pearls
- The patient’s neck must be fully relaxed in order to perform the test correctly. Avoid being too gentle withe the head impulse, as this may cause a false negative.
- Any positive finding from one of the 3 components (Head Impulse, Nystagmus, or Test of Skew) warrants further diagnostic imaging for posterior circulation stroke.

Lumbar Puncture
Rapid Review
- Background
- Insertion of a needle into the lumbar subarachnoid space for the purposes of measuring CSF pressure, administering therapeutic agents, or collecting CSF for laboratory testing
- Indications
- Suspected subarachnoid hemorrhage, meningitis, or GBS. May also provide relief for pseudotumor cerebri.
- Contraindications
- Trauma or overlying skin infection at insertion site. Suspected spinal epidural abscess.
- Complications
- Post-lumbar puncture headache, spinal epidural hematoma
Pearls
- Ultrasound can be useful for identifying the intervetebral spaces, especially in obese patients.
- There are no differences in complications or success rates between the sitting position and the lateral decubitus, so do whatever works best for you!
Deep Dive

Ventricular Shunt Aspiration
Rapid Review
- Background
- Aspirating fluid from a ventriculoperitoneal (VP) shunt may be diagnostic (evaluate for infection or blockage), as well as therapeutic (alleviates symptoms of blocked shunt).
- Indications
- Suspected VP shunt infection, meningitis, or blockage
- Contraindications
- Infection over entry site. Relative contraindications include coagulopathy, lack of shunt imaging/information.
- Complications
- Infection (low risk), bleeding, CSF leak, ventricular collapse, or misplaced tap.
Pearls
- It is always best to consult neurosurgery prior to attempting any ventricular shunt taps.
- No fluid return or abrupt stop in flow = proximal obstruction. Opening pressure > 20 = distal obstruction