Neurosurgery notes/Burr holes and points

Burr holes and points

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General cranial procedures

Burr holes

  • Frontal; in the mid pupillary line 1” behind the hairline
  • Temporal; 1” in front and 1” above the external auditory meatus.
  • Parietal; directly over the parietal eminence.
  • MacCarty‘s keyhole: Tubbs 2010
    • 7mm superior and 5mm posterior to frontozygomatic suture
    • Give access to both orbitozygomatic and supraorbital craniotomies
        • 1 FIGURE 3. Left cranial view noting the frontozygomatic suture (arrow) and the exit site of drill holes that have been placed from the upper outer aspect of the orbit (single lower hole) and from the floor of the anterior cranialfossa (4 horizontal holes).
        Left cranial view noting the frontozygomatic suture (arrow) and the exit site of drill holes that have been placed from the upper outer aspect of the orbit (single lower hole) and from the floor of the anterior cranial fossa (4 horizontal holes).
        A person's face with text and lines AI-generated content may be incorrect.

Kocher’s (coronal) point

  • Position
    • Located 1–2 cm anterior to the coronal suture in the midpapillary line OR
    • 11 cm posterior from the nasion and 3cm lateral from midline
  • Relations
    • Lateral to the superior sagittal sinus
    • Anterior to the primary motor cortex
  • In patients with midline shift, drain placement tends to be more accurate if the surgical side was ipsilateral toward the midline shift
  • Catheter insertion
    • Location
      • Right: non dominant
        • The right side is still preferred even in cases of left-sided haemorrhages
    • Direction: intersection between two imaginary lines
      • A line that runs backward from the ipsilateral medial canthus
      • A line extending coronally from the ipsilateral tragus
    • Depth: 5 to 6 cm (into frontal horn of lateral ventricle
      • Tip should be near the foramen of Monro decreases the risk of obstruction by the choroid plexus
    • Success rate
      • Relatively inaccurate with miss rates ranging from 4 to 40%
  • Used for
    • VP shunt catheter insertion
    • ETV
    • Endoscopic removal of colloid cysts
    • Endoscopic removal of intraventricular haemorrhage
écth Foramen of Monro Catheter tra-ectol FIGURE l. Ventricular access via Koc-her's point. The bum hole should be placed I I cm superior and posterior m rhe nasion and3 cm lateral to the midline, Next. the ventricular catheter should be aimed at an angle that is perpendicular to the intersection Of the medial the (EAM). The catheter be passed ro a dept/' of apprm-imarely 6 cm or until rhefrontal horn of rhe ipsilareral lateral ventricle i' reached. @2015 Elizabeth N. Weissbrod. Used with permission.
Ventricular access via Kocher’s point. The burr hole should be placed 11 cm superior and posterior to the nasion and 3 cm lateral to the midline. Next, the ventricular catheter should be aimed at an angle that is perpendicular to the intersection of lines drawn from the ipsilateral medial canthus and the ipsilateral external auditory meatus (EAM). The catheter should be passed to a depth of approximately 6 cm or until the frontal horn of the ipsilateral lateral ventricle is reached. ©2015 Elizabeth N. Weissbrod. Used with permission.

Kaufman’s point

  • Catheter insertion
    • Location
      • 5 cm superior to the nasion and 3 cm lateral to the midline.
    • Direction
      • Towards midline, 3 cm superior to inion.
    • Depth
      • 7 cm
  • Use for
    • Rapid access to the ventricular system for emergent drainage of CSF.
  • Pros
    • The accuracy rate (90%) of forehead access exceeded that of Kocher access.
      • This is mainly due to use of a more proximal landmark, CT guidance, and reserving a place for a future potential shunt
    • Can be cleaned quickly because the patient’s hair does not need to be clipped.
  • Cons
    • Cosmetic concerns, although minimal, have decreased the use of this technique.
, Catheter trajectory to midline FIGURE 2. Ventricular access Kaufman's point. The burr should be 5 cm superior to the nasion and 3 em midline. Next, toward 'o a point is 3 cm superior m the inion. The catheter should be passed ro a depth of approximately 7 cm or until the frontal horn of 'be ipsilateral lateral ventricle is reached 02015 Elizabeth N. Weissbrod. Used with permission.
Ventricular access via Kaufman’s point. The burr should be placed 5 cm superior to the nasion and 3 cm lateral to midline. Next, the ventricular catheter should be aimed toward the midline and inferiorly to a point that is 3 cm superior to the inion. The catheter should be passed to a depth of approximately 7 cm or until the frontal horn of the ipsilateral lateral ventricle is reached. ©2015 Elizabeth N. Weissbrod. Used with permission.
 

Paine’s Point

  • For CSF drainage via direct ventricular puncture and was first used in patients undergoing a frontotemporal craniotomy for aneurysm clipping after aneurysmal subarachnoid haemorrhage.
  • Indication
    • Severe brain oedema after completing a frontotemporal craniotomy → needing to remove some CSF → lessens the need for brain retraction
  • Catheter insertion
    • Location: Paine's triangle
      • After the dura is opened, a point that is 2.5 cm above the floor of the anterior cranial fossa and 2.5 cm anterior to the sylvian fissure (marked by the superficial sylvian vein) is identified.
      • The intersection of these lines forms the anterior and posterior limbs of Paine’s triangle, respectively.
    • Direction
      • Next, the surface of the pia is cauterized and a ventricular catheter is passed at a trajectory that is perpendicular to the convexity of the brain surface.
    • Deep
      • 4 to 5 cm to reach lateral ventricular is reached
  • Cons
    • Theoretical risk of damaging Broca’s area, the head of the caudate nucleus, and the thalamus
  • 2 Modifications to Paine’s Point
    • Indication same as above
    • Hyun
      • Catheter insertion
        • Entry point
          • Extended 2 cm from the anterior limb of Paine’s triangle (4.5cm from the floor of anterior cranial fossa).
        • Direction
          • Perpendicular to the convexity of the brain
        • Depth
          • 5 to 6.5 cm reaching the frontal horn of the ipsilateral lateral ventricle
      • Accuracy
        • In 10 patients, 100% with neuronavigation.
    • Park and Hamm
      • Catheter insertion
        • Entry point
          • Extended 2 cm from the posterior limb of Paine’s triangle (4.5cm from sylvian fissure)
        • Direction
          • Perpendicular to the convexity of the brain
        • Depth
          • 5 to 6 cm or until reaching the frontal horn of the ipsilateral lateral ventricle
      • Pros
        • Less risk of injury to the head of the caudate nucleus,
          • 2.5% chance of injury vs 90% with Paine’s point.
      • Accuracy
        • In 32 patients, 94%
Park's Point Sylvian fissure 2.5cm •2.Grn- - - Floor of Ant. cranial fossa 5-6cm 01 FIGURE3. Ventricularaccess via Paine's, Hyun's, andPark'spoints. Ventricularaccessshouldonlybeattemptedafiercompletion of a frontotemporal craniotomy. For Paine's point, the ventricular catheter should enter the brain at a location that is 2.5 cm above thefloor of the anterior cranial fossa and 2.5 cm anterior to the sylvianfissure. The catheter should be passedperpendicular to the convexity of the brain surface and advanced to a depth ofapproximately 4 to 5 cm or until the frontal horn of the ipsilateral lateral ventricle is reached. For Hyun's point, the ventricular catheter should enter the brain at a location that extends 2 cm from the anterior limb of Paine's triangle (4.5 cm above the floor of the anterior cranial fossa). The catheter should be passed perpendicular to the convexity of the brain surface and advanced go a depth of approximately 5 to 6.5 cm or until the frontal horn of rhe ipsilateral lateral ventricle is reached. For Park's point, the ventricular catheter should enter rhe brain at a location that extends 2 cm from the posterior limb of Pain/s triangle (4.5 cm anterior to the sylvian fissure). The catheter should be passed perpendicular to the convexity of the brain surface and advanced to a depth of approximately 5 to 6 cm or until the frontal horn of the ipsilareral lateral ventricle is reached. 02015 Elizabeth N. Weissbrod. Used with permission.
Ventricular access via Paine’s, Hyun’s, and Park’s points. Ventricular access should only be attempted after completion of a frontotemporal craniotomy. For Paine’s point, the ventricular catheter should enter the brain at a location that is 2.5 cm above the floor of the anterior cranial fossa and 2.5 cm anterior to the sylvian fissure. The catheter should be passed perpendicular to the convexity of the brain surface and advanced to a depth of approximately 4 to 5 cm or until the frontal horn of the ipsilateral lateral ventricle is reached. For Hyun’s point, the ventricular catheter should enter the brain at a location that extends 2 cm from the anterior limb of Paine’s triangle (4.5 cm above the floor of the anterior cranial fossa). The catheter should be passed perpendicular to the convexity of the brain surface and advanced to a depth of approximately 5 to 5.5 cm or until the frontal horn of the ipsilateral lateral ventricle is reached. For Park’s point, the ventricular catheter should enter the brain at a location that extends 2 cm from the posterior limb of Paine’s triangle (4.5 cm anterior to the sylvian fissure). The catheter should be passed perpendicular to the convexity of the brain surface and advanced to a depth of approximately 5 to 6 cm or until the frontal horn of the ipsilateral lateral ventricle is reached. ©2015 Elizabeth N. Weissbrod. Used with permission.

Menovsky’s Point

  • Indication
    • During supraorbital craniotomy through an eyebrow incision. When presence of brain edema → for CSF drainage and brain relaxation prior to complete bone removal.
  • Catheter insertion
    • Location
      • Keyhole burr hole → excise dura
    • Direction
      • 45◦ toward the midline and 20◦ superior to the orbitomeatal line.
    • Depth:
      • 5 to 6.5 cm until the frontal horn of the ipsilateral lateral ventricle is reached (Figure 4).
  • Accuracy
    • 10 patients and 5 cadaveric specimens, 87% first-pass ventricular cannulation rate.
 
450 _ FIGURE 4. Ventricularaccess via Menovskys point. Afterdrillingthekeyhole burrhole through the bone duringa supraorbital craniotomy and incising the dura, the ventricular catheter should be passed at an angle that is 450 toward the midline and 203 superior to the orbitomeatal line. The catheter should be passed to a depth of approximately 5 to 6.5 cm or until the frontal horn of the ipsilateral lateral ventricle is reached. 02016 Elizabeth N. Weissbrod. Used with permission.
Ventricular access via Menovsky’s point. After drilling the keyhole burr hole through the bone during a supraorbital craniotomy and incising the dura, the ventricular catheter should be passed at an angle that is 45° toward the midline and 20° superior to the orbitomeatal line. The catheter should be passed to a depth of approximately 5 to 6.5 cm or until the frontal horn of the ipsilateral lateral ventricle is reached. ©2016 Elizabeth N. Weissbrod. Used with permission.

Tubb’s point

  • Indication
    • Emergent ventricular decompression via a transorbital route and is completed with a spinal needle.
  • Catheter insertion
    • Position
      • The needle tip is placed under the upper left or right eyelid just medial to the mid pupillary line
    • Direction
      • 45◦ superior to the orbitomeatal line and 20◦ toward the midline.
    • Depth
      • 8 cm to the frontal horn of the ipsilateral lateral ventricle
  • Pros
    • A burr hole does not need to be drilled, making this procedure more time efficient.
  • Cons
    • Increase risk of a globe injury and requires blind puncture of the orbital roof.
  • Accuracy
    • Unknown
450 8cm , 200 Enters ven a 02016 FIGURE 5. Ventricular access via Tubbs' point. The spinal needle should be placed under the upper eyelid medial to the midpupillary line and advanced at a trajectory that is 450 superior to the orbitomeatal line and' 2m toward the midline. As the needle is advanced, the orbital roof should be encountered and penetrated. The needle should be passed to a depth of approximately 8 cm or until the frontal horn of the ipsilateral lateral ventricle is reached. (02016 Elizabeth N. Weissbrod. Used with permission.
Ventricular access via Tubbs’ point. The spinal needle should be placed under the upper eyelid medial to the midpupillary line and advanced at a trajectory that is 45° superior to the orbitomeatal line and 20° toward the midline. As the needle is advanced, the orbital roof should be encountered and penetrated. The needle should be passed to a depth of approximately 8 cm or until the frontal horn of the ipsilateral lateral ventricle is reached. ©2016 Elizabeth N. Weissbrod. Used with permission.

Keen’s (posterior parietal) point

  • Aka: posterior parietal point
  • Indication:
    • Emergent CSF diversion during posterior fossa surgery
    • Elective placement of a proximal VP shunt catheter.
  • Catheter insertion
    • Location
      • Burr hole should be placed approximately 2.5 to 3 cm superior and posterior to the pinna of the ear
      • R>L dominant
    • Direction
      • Slight cephalic direction and positioned perpendicular to the temporal lobe cortex.
    • Depth
      • 4 to 5 cm until reaching the trigone (atria) of ipsilateral lateral ventricle
  • Accuracy: unknown
 
FIGURE 6. Ventricular access via Keen's point. After a burr hole is placed 25 cm superior and posterior to the pinna Of the ear, the catheter should be placed perpendicular to the cortex and aimed in a slight cephalic direction. The catheter should be advanced 4 to 5 cm or until the trigone of the ipsilateral lateral ventricle is reached. (02016 Elizabeth IV. Weissbrod. Used' with permission.
Ventricular access via Keen’s point. After a burr hole is placed 2.5 cm superior and posterior to the pinna of the ear, the catheter should be placed perpendicular to the cortex and aimed in a slight cephalic direction. The catheter should be advanced 4 to 5 cm or until the trigone of the ipsilateral lateral ventricle is reached. ©2016 Elizabeth N. Weissbrod. Used with permission.

Dandy’s point

  • Indication
    • CSF diversion is needed for a patient already positioned for an occipital or retromastoid craniotomy.
      • During emergent procedure
      • During planned procedure
  • Catheter insertion
    • Location
      • The burr hole is placed 3 cm above the inion and 2 cm left or right to the midline, corresponding to a region of the occipital bone that is below the lambdoid suture.
      • In paeds: lamboid suture at midpapillary line
    • Direction
      • The catheter tip is directed toward a point 2 cm above the glabella
    • Depth
      • 4 to 5 cm or until CSF is encountered → body of the ipsilateral lateral ventricle
  • Accuracy
    • Real life clinical: unknown
    • Simulation: 100%
  • Cons
    • Catheter’s trajectory near or through the optic radiations, damage to the visual fields
2r-1JJ 3cm Inion Catheter target 5cm , 2cm Glåbella Inion FIGURE 8. Ventricular access via Dandy's point. From an occipital approach, a burr hole is created 3 cm above the inion and 2 cm lateral to the midline. The catheter is directed toward a point 2 cm above the glabella and passed 4 to 5 cm or until the body of the ipsilateral lateral ventricle is reached.
Ventricular access via Dandy’s point. From an occipital approach, a burr hole is created 3 cm above the inion and 2 cm lateral to the midline. The catheter is directed toward a point 2 cm above the glabella and passed 4 to 5 cm or until the body of the ipsilateral lateral ventricle is reached. ©2016 Elizabeth N. Weissbrod. Used with permission.

Frazier’s (parieto-occipital)

  • Indication
    • Used during posterior fossa surgery when there is a need for rapid CSF diversion to decrease elevated intracranial pressure.
  • Catheter insertion
    • Location
      • 6 cm superior to the inion and 3 to 4 cm left or right to the midline, corresponding to a region of the parietal bone that is above the lambdoid suture.
    • Direction
      • Medially and superiorly to a point that lies 4 cm above the contralateral medial canthus and
    • Depth
      • Initially 5 cm
      • After CSF is encountered, the catheter stylet is removed, and the catheter is soft-passed an additional 5 cm (total 10 cm), positioning the catheter entirely within the body of the ipsilateral lateral ventricle
  • Accuracy
    • No real life clinical data
    • Simulation data is 100%
¯ ¯6cm Catheter target ninth' Inion Inion FIGURE 7. Ventricular access via Frazier's point. From a parietal approach, the burr hole should be above and lateral to the lambdoid suture at a location that is 6 cm superior to the inion and 3 to 4 cm lateral to the midline. The catheter is directed to a point that lies 4 cm above the contralateral medial canthus and passed 5 cm or until CSF is encountered. The catheter stylet is then removed, and the catheter is soft-passed an additional 5 cm, placing it within the body of the ipsilateral lateral ventricle. 02016 Elizabeth N. Weissbrod. Used with permission.
Ventricular access via Frazier’s point. From a parietal approach, the burr hole should be positioned slightly above and lateral to the lambdoid suture at a location that is 6 cm superior to the inion and 3 to 4 cm lateral to the midline. The catheter is directed to a point that lies 4 cm above the contralateral medial canthus and passed 5 cm or until CSF is encountered. The catheter stylet is then removed, and the catheter is soft-passed an additional 5 cm, placing it within the body of the ipsilateral lateral ventricle. ©2016 Elizabeth N. Weissbrod. Used with permission.

Sanchez’s Point

  • Used to catheterize the temporal horn and can be employed to divert CSF in the setting of a trapped ventricle or to endoscopically access mesial temporal structures.
  • Catheter insertion
    • Location
      • 5.6 cm above the inion and 2.7 cm left or right to the midline.
    • Direction
      • The catheter is directed 5◦ lateral from a parasagittal plane (which is parallel to midline) and 30◦ inferior toward the orbitomeatal plane.
    • Depth
      • 5 cm, and passage of the catheter an additional 4 to 5 cm (total 9-10 cm) should place the tip within the temporal horn of the ipsilateral lateral ventricle
  • Accuracy
    • Real life clinical: None
    • 9 cadaveric specimens (bilaterally done = 18 procedure) 100% ventricular cannulation success rate.
5 .öca 2.7cm—7 FIGURE 9. Ventricular access via Sanchez's point. A burr hole is placed 5.6 cm above the inion and 2.7 cm lateral to midline. The catheter is angled 50 lateral to the parasagittal plane and 300 inferior toward the orbitomeatal plane. The catheter is then advanced 9 to 10 cm to be positioned within the temporal horn of the ipsilateral lateral ventricle. (02016 Elizabeth N. Weissbrod. Used with permission.
Ventricular access via Sanchez’s point. A burr hole is placed 5.6 cm above the inion and 2.7 cm lateral to midline. The catheter is angled 5° lateral to the parasagittal plane and 30° inferior toward the orbitomeatal plane. The catheter is then advanced 9 to 10 cm to be positioned within the temporal horn of the ipsilateral lateral ventricle. ©2016 Elizabeth N. Weissbrod. Used with permission.

Images

Fig. 3 Schematic illustration of all the extra-calvarial ventricular access points: I Keen, 2 Kocher, 3 Dandy, 4 Frazier, 5 Kaufinan, and 6 Tubbs
Schematic illustration of all the extra-calvarial ventricular access points: 1 Keen; 2 Kocher; 3 Dandy; 4 Frazier; 5 Kaufman; 6 Tubbs