Bone Perforation Only
Immediate neurosurgery consult is advisable to carefully investigate whether there is any violation of the dura or CSF leak (open surgery). A baseline CT without contrast to exclude an intracranial bleed is warranted. A robust neurosurgical monitoring protocol to monitor neurological status may be needed. Consider a repeat CT without contrast after 6 h if there are neurological changes during monitoring. Postoperative antibiotics are usually not needed if there is no dural tear.
Bleeding and Extradural/Subdural Hematoma
This mandates an immediate neurosurgery consult, baseline CT scan, and neurological monitoring in a dedicated neurosurgery ICU setting. Neurosurgical intervention or repeat CT without contrast may be required. Antibiotics may also be indicated.
Dural Tear and CSF Leak
If the dural tear is small, it may be possible to seal the leak with fibrin glue and local hemostatic agents. Neurosurgical consultation is recommended as an IVC or lumbar drain may be needed. A baseline noncontrast CT to exclude intracranial bleeding, dedicated neurosurgical monitoring in an ICU setting, and antibiotics are also needed.