Craniometrics and ventricular access

Craniometrics and Ventricular Access:
A Review of Kocher’s, Kaufman’s, Paine’s,
Menovksy’s, Tubbs’, Keen’s, Frazier’s,
Dandy’s, and Sanchez’s Points
By Dr. Shahnawaz Alam
Mch-Neurosurgery

• The ventricular system is routinely accessed for a variety of emergency and elective
neurosurgical procedures.
• Depending upon the indications, different locations within the ventricles may need to be
accessed.
• Thus, a multitude of ventricular access points have been described over the past century.
• Each entry point requires an operative technique with different surface landmarks for
burr hole placement, trajectories for catheter passage, and ending locations within the
ventricles.
• Although ventricular access is one of the most common procedures performed, there is
a paucity of literature illustrating the operative techniques for the most common
ventricular access points.
• Additionally, the operative techniques depicted within the current literature are poor
quality and difficult to interpret.

• Because it is important that all neurosurgeons be versed in the craniometrics
associated with these techniques, there is a need for high-quality images with clear
measurements depicting the details of each access point, which remains unmet.
• In this historical review, they describe the indications and operative techniques for 9
ventricular access points. They separate them into anterior and posterior categories
based upon their starting location relative to the external auditory canal.
• Anterior access sites include Kocher’s, Kaufman’s, Paine’s, Menovksy’s, and Tubbs’
points; posterior access sites include Keen’s, Frazier’s, Dandy’s, and Sanchez’s points.
• Additionally, they include detailed, Multiview illustrations that provide the reader with
a novel understanding of the craniometrics associated with each point.

Ventricular access via Kocher's point
• MC Location for EVD
• May be used for ETV,
endoscopic removal colloid
cyst or VP-shunting
• Failure rate 4-40% (Abdoh
MG et al)

Ventricular access via Paine’s, Hyun’s, and Park's points
• In pt. undergoing FT-
craniotomy when there is
concern for severe brain
edema; lessens the need of
brain retraction
• Theoretical risk of
damaging Brocas’s area,
head of caudate nucleus,
thalamus; But no clinical
series to demonstrate its
efficacy & safety
• In series, Hyun’s point
more accurate trajectory
with 100% success rate
• Park’s point- 94% success
rate with 2.5% chance of
injury compared with 90%
with paine’s point

Ventricular access via Kaufman’spoint
• Rapid access to ventricular
system for emergent
drainage of CSF
• Rarely used d/t cosmetic
appearance
• 90% success rate

Ventricular access via Menovsky’s point
• Used while performing
supraorbital craniotomy
through eyebrow incision
• 87% success rate

Ventricular access via Tubbs’ point.
• Emergent ventricular
decompression via
transorbital route; spinal
needle
• No burr; time efficient;
Risk of globe injury; No
clinical series

Ventricular access via Keen’s point
• Used for elective
placement of proximal VP-
shunt catheter
• Emergent CSF diversion
during posterior fossa sx
• No clinical series

Ventricular access via Dandy’s point
• Initially used for
ventriculography
• In a case series 100%
success rate ( Lee,s et al)

Ventricular access via Frazier’s point
• In a case series 100%
success rate ( Lee,s et al)

Ventricular access via Sanchez’s point
• For catherization of
temporal horn in setting of
trapped ventricle or to
endoscopically access
mesial temporal structures
• 100% success rate (sanchez
et al)

CONCLUSION
• The ventricles are accessed for numerous emergent and elective neurosurgical
procedures, and all neurosurgeons should feel comfortable using craniometrics
to help cannulate the ventricles when neuronavigation is unavailable.
• This review provides detailed descriptions and illustrations of the most
common anterior and posterior ventricular access points and should serve as
an important reference for both neurosurgical trainees and experienced
neurosurgeons.

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