Open Access Technical

Report DOI: 10.7759/cureus.8643

Immersive Surgical Anatomy of the

Craniometric Points
Vera Vigo 1 , Kimberly Cornejo 1 , Lizbeth Nunez 1 , Adib Abla 1 , Roberto Rodriguez Rubio 1

1. Neurological Surgery, University of California, San Francisco, USA

Corresponding author: Roberto Rodriguez Rubio, [email protected]

Abstract
Craniometric points (CPs) have been used in neurosciences since the 1800s. Localization of the
CPs allows for the identification of crucial intracranial structures. Despite the contribution of
advanced technology to surgery, the knowledge of these points remains crucial for surgical
planning and intraoperative orientation. The understanding of these crucial points can be
facilitated with the use of three-dimensional technology combined with anatomical dissections.
The present study is part of a stereoscopic collection of volumetric models (VMs) obtained from
cadaveric dissections that depict the relevant anatomy of the CPs. Five embalmed heads and
two dry skulls have been used to depict these points. After the anatomical dissection,
stereoscopic images and VMs were generated to show the correlation between external and
internal landmarks. The CPs identified were divided into sutures, suture junctions,
prominences and depressions, and cortical surface landmarks. The VMs represent an
interactive way to define these points easily and their correlation with different intracranial
structures (vascular structure, ventricle cavity, and Brodmann’s areas).

Categories: Neurosurgery
Keywords: craniometric points, cerebral cortex, vascular landmarks, ventricular access, keyholes,
motor cortex, speech area, volumetric models, cranial sutures

Introduction
Craniometry is a science that utilizes measurements of the skull and facial structures with the
aim of analysing specific osseous features in different populations. Therefore, craniometric
points (CPs) were described as the landmarks from which these measurements could be taken.
The CPs have been used for several purposes in anthropology, forensic sciences, and
neurosciences. In 1876, Broca published the “Sur la topographie crânio-cé ré brale” and, for the
first time, correlated the CPs to intracranial structures such as sulci and gyri of interest [1]. In
the following years, anatomists, surgeons, and radiologists have studied the craniocerebral
topography and measured lines from different CPs to identify them easily. In the late 19th
Received 04/19/2020
Review began 04/27/2020
century, the application of the CPs in surgery established the foundation of modern
Review ended 06/03/2020 neurosurgery, with the possibility to tailor craniotomies in specific areas of interest [1].
Published 06/15/2020 Recently, Ribas and others have focused most of their anatomical research around the surgical
© Copyright 2020
applications of CPs, underlying their importance in modern neurosurgery [1-4].
Vigo et al. This is an open access
article distributed under the terms of Nowadays, preoperative and intraoperative surgical planning is based on neuroimaging
the Creative Commons Attribution
information. With the advent of neuronavigation systems, the recognition of critical
License CC-BY 4.0., which permits
unrestricted use, distribution, and intracranial structures has been simplified. Nevertheless, such a sophisticated technology
reproduction in any medium, provided cannot fully replace the three-dimensional (3D) understanding of the craniocerebral
the original author and source are relationships that can be utilized for the intraoperative assessment of anatomy. The knowledge
credited.
of these anatomical landmarks should be the starting point of each cranial neurosurgical

How to cite this article

Vigo V, Cornejo K, Nunez L, et al. (June 15, 2020) Immersive Surgical Anatomy of the Craniometric Points.
Cureus 12(6): e8643. DOI 10.7759/cureus.8643
 procedure.

In this study, we will review the available literature related to CPs with the aim of describing
their location, relation to critical structures (i.e., cortical areas, vasculature, and ventricles),
and their implication for neurosurgical procedures. Moreover, with the use of anatomical
volumetric models (VMs) and online 3D platforms, we aimed to facilitate the visuospatial
understanding of the CPs and their correlation with intracranial structures.

Technical Report
Materials and methods
Five embalmed and latex-injected cadaveric heads were prepared for anatomical dissections
and two dry skulls were utilized to identify the CPs. Dissections were performed under a
surgical simulation setting. After removing the scalp and reflecting the temporalis muscles, the
cranial sutures and relevant prominences were identified and isolated. After removing the
surrounding bone with a high-speed drill (Midas Rex; Medtronic, Minneapolis, MN, USA), the
following windows were created: superior frontal, inferior frontal, sphenoid, superior parietal,
inferior parietal, temporal, and occipital. The relationship between the CPs and intracranial
structures at different layers (i.e., dura, arachnoid, brain surface, white matter, and ventricular)
were analysed. Dissections were photo-documented using a professional camera (D810; Nikon,
Tokyo, Japan), and selected specimens were reconstructed using 3D data obtained via surface
scanning techniques (i.e., photogrammetry and structured light scanning). Our laboratory had
previously documented the comprehensive workflow of 3D scanning using the aforementioned
techniques [5]. Additionally, the 3D reconstruction of the left brain hemisphere of a healthy
male obtained from magnetic resonance was included. The VMs were post-processed using a
computer graphics software (Blender 2.82; Blender Foundation, Amsterdam, Holland), and the
corresponding texture maps were generated with a 3D texturing program (Substance Painter;
Adobe, San Jose, CA, USA).

No IRB/ethics committee approval was required for this study.

Virtual platform
The anatomical VMs were uploaded to a web-based 3D model viewer (Sketchfab; Sketchfab Inc,
New York, NY, USA), a platform that belongs to a series of new modalities meant to enhance the
immersive and functional capacities of VMs. Once the VMs were uploaded, the virtual scene
was prepared for its real-time rendering. Position, lighting, materials, and filters were set to
highlight regions of anatomical interest. Strategic points were labeled and annotated for an
interactive experience. Views of the models were set for both two-dimensional (2D) and 3D
experiences. The stereoscopic version of the virtual scene was set up and tested using a virtual
reality headset (HTC Vive; HTC Co., Taiwan, China) and a browser compatible with WebVR
technology (Firefox Nightly; Mozilla Co., Mountain View, CA, USA).

Anatomical description
In the following section, we will review the main osteometric features of the skull including
sutures, suture junctions, prominences, and depressions. Afterward, essential cortical points
and their relationship with CPs will be reviewed. A clear understanding of the topology of sulci
and gyri is fundamental to correlate the intracranial structures with the corresponding
superficial landmarks properly (Figure 1, Interactive Model 1).

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 FIGURE 1: Overview of the main cortical gyri: (A) lateral
surface and (B) medial surface of the brain.
AG: angular gyrus; CC: corpus callosum; Cing. G: cingular gyrus, Cu: cuneus; FP: frontal pole; GR:
gyrus rectus; IFG: inferior frontal gyrus; ITG: inferior temporal gyrus; IOG: inferior occipital gyrus;
LG: lingual gyrus; MFG: middle frontal gyrus; MOG: middle occipital gyrus; MTG: middle temporal
gyrus; OG: orbital gyrus; Op: pars opercularis of the IFG; Orb: pars orbitalis of the IFG; PCu:
precuneus; PoCG: post-central gyrus; PPG: posterior parietal gyrus; PreCG: pre-central gyrus;
SFG: superior frontal gyrus; SMG: supramarginal gyrus; SOG: superior occipital gyrus; SPL:
superior parietal lobule; STG: superior temporal gyrus; Th: thalamus; TP: temporal pole; Tr: pars
triangularis of the IFG.

INTERACTIVE MODEL 1: Volumetric model of the left

hemisphere, with labels of the gyri and annotations of the
lateral sulci.
Knowledge of the gyri of the brain is critical when performing any brain surgery. This 3D model

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 shows an overview of half of the brain, annotations of the gyri of the lateral, basal, and medial
surface. The following instructions can be used to manipulate all models: to move, left click and
drag; to zoom in and out, use the mouse scroll. For smartphones and virtual reality (VR)-ready
computers, click "view in VR" (glasses icon); to view annotations, click on the numbers, to move
around the object, tap or press trigger on the floor using the blinking yellow circle as a pointer. For
mobile augmented reality (AR), click on the AR icon (cube) in the top right corner and aim at a
horizontal flat surface; once the surface is detected, tap on it to place the model. To view the video
in VR mode, Google Cardboard and YouTube mobile app are necessary. First, open the video on
the YouTube mobile app and tap the Cardboard icon. Next, place the mobile device inside the
Google Cardboard. Finally, look around to view the video in 360°. Quality of the textures and
navigation style can be modified by clicking the Settings icon.

View Interactive Model here: https://vimeo.com/409584025

Sutures
The sutures of the neurocranium are a type of fibrous joint (i.e., synarthroses) that allows the
development and expansion of the cranial vault. Around the age of seven years, the ossification
of these sutures leads to the formation of the adult skull. Ossification occurs from anterior to
posterior and from lateral to medial. These sutures are located between the frontal, parietal,
temporal, sphenoid, and occipital bones. The metopic suture is positioned between the two
portions of the frontal bone. It is not usually visible in the skull of an adult since its closure
occurs in around 9th and 11th months of age [6]. The coronal suture detaches the frontal and
parietal bones. This suture forms a subtle depression in the skull that can be commonly located
by touch under the scalp (Figure 2A). Over the anterolateral portion of the skull, three main
sutures can be found: frontozygomatic, frontosphenoid, and sphenozygomatic (Figure 2B). The
frontozygomatic and frontosphenoid sutures merge the frontal bone with the zygomatic and
the sphenoid bones, respectively. The sphenozygomatic suture marks the junction of the
sphenoid and zygomatic bones on the anterior side of the skull. The sagittal suture is located
down the midline of the calvaria convexity connecting the coronal suture and the lambdoidal
sutures, thereby, separating the parietal bones (Figure 2C). Laterally, the squamosal suture joins
the squamous portion of the temporal bone with the parietal bones and extends horizontally.
Towards the inferior posterolateral portion of the skull, three sutures can be found:
parietomastoid, occipitomastoid, and lambdoid. The parietomastoid suture separates the
parietal bones and the mastoid process of the temporal bone, whereas the occipitomastoid lies
at the connection of the inferolateral occipital bone with the posterior portion of the mastoid
process. Superior and medial, the lambdoid suture is located at the posterior end of the skull
and separates the parietal and the superior portion of the occipital bone (Figure 2D, Interactive
Model 2).

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 FIGURE 2: Overview of main sutures, suture junction points,
and prominences of the human skull: (A) anterior view, (B)
lateral view, (C) superior view, and (D) posterior view.
Ast: asterion; Br: bregma; Eu: euryon; In: inion; Lm: lambda; Na: nasion; Oph: ppisthocranium; Pt:
pterion; STL: superior temporal line; St: stephanion; V: vertex.

INTERACTIVE MODEL 2: Volumetric model of the skull, with

labels of the sutures and the craniometric points of the
exocranial and endocranial surfaces.
View Interactive Model here: https://vimeo.com/409584049

Suture junctions

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 Located at the mid-sagittal plane, bregma (Br) is the point where the coronal suture intersects
the sagittal suture (Figures 2A, 3A). This CP corresponds to the anterior fontanelle, which is a
diamond-shape membrane-filled space between the frontal and the parietal bones. It is the
largest fontanelle and persists until 12-18 months after birth [6]. It is commonly palpated
during the neurological examination of newborns to assess intracranial hypertension and to
perform ultrasound examination. Its position on the skull makes it a reference point for lateral
and anteroposterior coordinates. In adults, the pre-central gyrus is located approximately 4.5
cm posterior to the Br [7]. The point known as the superior Rolandic point (SRP) is found 5
cm posterior to the Br, along the sagittal suture, between the central sulcus (CS) and the
interhemispheric fissure (IHF) [8].

FIGURE 3: Depiction of the principal craniometric points on the

skin: (A) superior view and (B) posterior view of the head.
Br: bregma; Eu: euryon; In: inion; IPP: intraparietal point; Lm: lambda; Oph: opisthocranium; PCoP:
posterior coronal point; SSagP: superior sagittal point; St: stephanion.

Lambda (Lm) is located at the junction of the lambdoid and sagittal sutures (Figures 2D, 3B).
The distance from Br to Lm is about 13 cm, and this measurement runs along the sagittal suture
(Interactive Model 3). The distance from nasion to Lm is about 24-26 cm, and it is 2-4 cm
superior to the opisthocranion (Figure 4A) [1]. Inferior and lateral to Lm lies the parieto-
occipital fissure, which corresponds to the emergence of the parieto-occipital sulcus inside the
IHF. The Lm is found 3-5 cm posterior to the obelion; this indicates the intersection of the
sagittal suture with the foramina of the parietal emissary veins [9].

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 INTERACTIVE MODEL 3: Volumetric model of the skull, with
labels of the main craniometric points and their respective
lengths.
View Interactive Model here: https://vimeo.com/409584062

FIGURE 4: Osteometric points and prominences of the human

skull. (A) Lateral view of the skull with the representation of
the mean distance of the main craniometric points; (B)
posterior view of the skull with an underline of the principal
points and prominences.
Br: bregma; Eu: euryon; In: inion; Lm: lambda; Na: nasion; Oph: opisthocranium; St: stephanion.

The pterion (Pt) is an H-shaped sutural junction located between the frontal, parietal,
temporal, and sphenoid bones (Figure 2B). The Pt has been classified into four different types

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 depending on how the sutures intersect: sphenoparietal, frontotemporal, stellate, and epipteric
(more common in childhood) [10]. The most common is the sphenoparietal type. Pt is an
essential landmark for most anterolateral cranial procedures and the pterional craniotomy is
centered over this point. Indeed, the Pt stands above the anterior branch of the middle
meningeal artery and the Sylvian fissure (SF) (Interactive Model 4). The anterior Sylvian point
(ASyP), described below, is located underneath the most posterior portion of the Pt, where the
squamous suture intersects the sphenoparietal suture. This point is also known as the anterior
squamous point (ASP) [8]. The most anterior and inferior region of the inferior frontal gyrus
(IGF) can be located below the Pt (Brodmann's area 44-45, Broca’s area - motor speech
programming).

INTERACTIVE MODEL 4: Volumetric model of a specimen with

monolateral cranial windows exposing the dura and
annotations of the main craniometric points.
View Interactive Model here: https://vimeo.com/409584073

The asterion (Ast), is located laterally and posteriorly at the junction of the lambdoid,
parietomastoid, and occipitomastoid sutures (Figure 2B). Two types of Ast have been described
based upon the presence of a sutural bone at Ast (Type I) or not (Type II). The second type is the
most common [10]. The Ast is a crucial landmark in lateral approaches to the posterior fossa,
being the most commonly used in the retrosigmoid approach. In fact, the Ast defines the
superior limit of the craniotomy since it serves as a landmark for the junction between the
transverse and sigmoid sinuses and, therefore, the transition between supratentorial space and
posterior fossa. Moreover, beginning at the Ast and descending along the occipitomastoid
suture, the occipital artery can be identified within the occipital groove. These landmarks can
be utilized during the harvesting of the occipital artery for bypass surgery or simply to facilitate
vascular control of the regional extracranial circulation.

Prominences and depressions

The nasion (Na) is located at the midpoint of the frontonasal suture, at its intersection with the
nasal suture. Na is visible as a midline depression area superior to the nose bridge and between
the two eyes. The distance from Na to Br is about 12-14 cm, and Lm is 24-26 cm posterior to the
Na (Figure 4A, Interactive Model 3) [1]. The Na is also positioned at the same axial level of the

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 corpus callosum (CC), precisely 12.6 ± 0.44 cm anterior to the genu and 19.8 ± 0.82 cm anterior
to the splenium [7].

The glabella (Gl) is the most anterior midline point of the frontal bone. The Gl is located just
superior to the Na, over the smooth surface between the orbital rims (Figure 2A). The
anteroposterior length of the skull is equal to the distance from the Gl to opisthocranion, which
is around 17 cm in adults (Figure 4A) [11]. The Gl is also a landmark for the frontal sinus.

The vertex is the most superior point of the skull and is located in the midline above the
superior sagittal sinus (SSS) and between the the Br and Lm.

The superior temporal line (STL) is a subtle ridge of bone that extends from the posterior edge
of the zygomatic process to the lateral surface of the parietal bone (Figure 2B, Interactive Model
4). At the level of the coronal suture, it splits into a superior and an inferior temporal line,
which serves as an attachment site for the temporalis fascia and muscle, respectively [9]. The
STL has a close relationship with speech areas: it demarks the superior limit of the IFG and is
an important landmark for the supramarginal and angular gyrus [7].

The stephanion (St) corresponds to the intersection between the STL and the coronal suture
(Figures 2B, 3A). It lies around 8 cm lateral to Br (Interactive Model 3) [2]. The inferior frontal
sulcus (IFS) and pre-central sulcus (PreCS) meeting point is located about 0.5 cm posterior to
the St [8]. Along with the STL, St is found 6.4 cm anterior to the euryon (Eu), and hence, the
supramarginal gyrus (Figure 4A). The St is located on the same coronal plane as Broca’s area
(Brodmann's area 44-45).

The Eu is a palpable prominence, localized in the middle of the parietal tuberosity (Figures 2B,
2D, 3). It is positioned at the junction between the STL and a vertical line that ascends from the
posterior aspect of the mastoid process passing through the meeting point of the squamous and
parietomastoid sutures. The Eu is always posterior to the post-central sulcus (PoCS) and
corresponds to the posterior aspect of the supramarginal gyrus (Brodmann’s area 40). The Eu is
located 1-2 cm anterior to the sulcus of Jensen and 1-3 cm lateral to the intraparietal sulcus
(IPS) (Interactive Model 5) [2].

INTERACTIVE MODEL 5: Volumetric model of a specimen with

bilateral windows dissections, opening of the dura and

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 annotations of the principal cortical points, and their
representation on the skull surface.
View Interactive Model here: https://vimeo.com/409584089

The obelion is located on the sagittal suture 2.5 cm anterior to Lm. The obelion sits between the
two foramina parietalia (Figure 2C) [9].

Opisthocranion (Oph) is the most posterior prominent point along the midline (Figure 2D,
Interactive Model 2). This point is located on the occipital bone, and is identified 3-4 cm
superior the In, 2-4 cm inferior Lm, and 12-14 cm posterior to Br (Figure 4A) [2,8]. The Oph is
one of the main landmarks for posterior craniotomy focused on the occipital lobe since the
calcarine fissure and the cuneus base (Brodmann’s area 17 - primary visual cortex area) are
located at the same axial plane of this prominence.

The inion (In) is a palpable midline prominence given by the external occipital protuberance
(Figures 2D, 3B, 4B). The In is situated above the torcular Herophili, which corresponds to the
confluence of the sinuses. The In provides attachment to the medial portion of the trapezius
muscle and the superior segment of the nuchal ligament. This CP indicates the location of the
tentorium and, therefore, the beginning of the posterior fossa. The line between the In and the
Ast corresponds to the transverse sinus position and can be used as an inferior landmark for
supratentorial exposures [3].

The nuchal lines are four curved crests of the external surface of the occipital bone (Figure 4B).
The highest nuchal line begins at the posterior curvature of the skull, extends from midline to
the lambdoid sutures bilaterally, and is where the occipital muscles join the galea. The medial
nuchal line is a vertical crest that runs from the In to the foramen magnum and gives
attachment to the nuchal ligament and the medial portion of trapezius, semispinalis capitis,
and rectus capitis posterior minor muscles. This nuchal line overlies the occipital sinus. The
superior nuchal line extends from the In to the lambdoid sutures and is the external landmark
for the transverse sinus. This line gives attachment to the occipitalis, splenius capitis, and
sternocleidomastoid muscles. The inferior nuchal line is a prominence that begins at the
midpoint of the medial nuchal line and curves laterally and downward. The muscles attached to
this line are the rectus capitis posterior major, rectus capitis posterior minor, and obliquus
capitis superior [9].

The opisthion is a midline point for the posterior edge of the foramen magnum (Figure 4B) [2].
The basion is the midpoint of the anterior edge of the foramen magnum (Figure 4B) [9]. The
distance from the Br to the basion is the height of the skull (approximately 13.2 cm). These
points are used in spinal surgery as landmarks of the foramen magnum and to measure the
distance with the atlas.

Cortical surface
The ASyP marks the division between the proximal and distal portions of the SF. The ASyP can
be identified on the cranial surface medial to the ASP (Figure 5A) [2]. This point is 2-2.5 cm
anterior from the inferior Rolandic point (IRP).

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 FIGURE 5: Relationship of relevant craniometric points and
cortical surface structures. After performing the dissection of
the superficial layer, seven bony windows were created
outlining the main cranial landmarks. The correlation between
the craniometric points and the brain surface is visible. (A)
Lateral view of the head - superior frontal, inferior frontal,
sphenoidal, superior parietal, inferior parietal, and temporal
windows are shown; (B) superior-posterolateral view of the
head - superior parietal, inferior parietal, and temporal
windows are shown; (C) inferior-posterolateral view of the
head - superior parietal, inferior parietal, temporal, and
occipital windows are shown; (D) posterior view of the head -
superior parietal and occipital windows are visible.
AG: angular gyrus; ASP: anterior squamous point; Ast: asterion; Br: bregma; dECaS: distal
extremity of the calcarine sulcus; Eu: euryon; IFS/PreCS point: inferior frontal sulcus/pre-central
sulcus meeting point; In: inion; IOG: inferior occipital gyrus; IPS: intraparietal sulcus; IRP: inferior
Rolandic point; ITG: inferior temporal gyrus; Lm: lambda; MFG: middle frontal gyrus; MOG: middle
occipital gyrus; MTG: middle temporal gyrus; Op: pars opercularis of the IFG; Oph: ophistocranium;
Orb: pars orbitalis of the inferior frontal gyrus (IFG); PoCG: post-central gyrus; POinc: parieto-
occipital incisure point; PPG: posterior parietal gyrus; PreCG: pre-central gyrus; PTP: posterior
temporal point; SFG: superior frontal gyrus; SFS/PreCS point: superior frontal sulcus/pre-central
sulcus meeting point; SMG: supramarginal gyrus; SPL: superior parietal lobule; SSP: superior
squamous point; SRP: superior Rolandic point; STG: superior temporal gyrus; STL: superior
temporal line; St: stephanion; TP: temporal pole; Tr: pars triangularis of the IFG.

The SF is the most prominent landmark of the lateral surface of the brain and can be divided
into anterior and lateral segments [1]. The anterior portion of the SF starts at the anterior
clinoid process extending laterally along the sphenoid ridge to reach the lateral convexity [12].
The ASyP corresponds to the anterior enlargement of the SF, where its anterior and lateral
segments are divided. The lateral portion of the SF is formed by two anterior rami, horizontal
and ascending, and a posterior ramus. The squamosal suture represents the direction of the

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 lateral portion of the SF. The anterior horizontal ramus separates the pars orbitalis and
triangularis of the IFG, whereas the anterior ascending ramus splits the pars triangularis and
opercularis of the IFG. The posterior ramus divides the frontal and temporal lobe and runs
obliquely, backward and upward to reach the inferior parietal lobule. Near the posterior ramus
it is possible to identify a second enlargement of the SF, the posterior Sylvian point (PSyP),
where two other rami arise. The posterior ascending branch ends inside the supramarginal
gyrus and a distal descending branch which enters in the superior temporal gyrus [1]. During
surgery, the ASyP and the PSyP are key landmarks for the splitting of the SF. Further medial
dissection of the SF can lead to the operculoinsular, sphenoidal, and anterior basal
compartments.

The IRP is the junction between the SF and the CS (Figures 5A, 5B). The superficial landmark to
the IRP can be localized on the cranial surface at the intersection of the highest portion of the
squamous suture with a vertical line that ascends from the preauricular depression, also known
as the superior squamous point (SSP) [8]. The distance between the ASyP and the IRP is 2-2.5
cm. The IRP is also a landmark for the Heschl’s gyrus that is positioned in the superior temporal
gyrus and, therefore, signals the beginning of Wernicke’s area (Interactive Model 5).

The IFS/PreCS point corresponds to the meeting of the IFS and the PreCS (Figure 5A). This
point is commonly found underneath St. Specifically, the IFS is located an average distance of
0.17±0.5 cm superior to St and the preCS around 0.34±0.71 cm posterior to St [2]. The IFS/PreCS
point is important to identify the pre-central gyrus (Brodmann’s area 4 - primary motor cortex)
and delimitates the superior and posterior margin of the IFG.

The SRP is located at the intersection of the IHF and the CS (Figures 5A, 5B). The CP, which lies
above the SRP, is about 5 cm posterior to the Br along the sagittal suture, and it is known as the
superior sagittal point (SSagP) (Interactive Model 5) [8]. The SRP lies at the same coronal plane
as the splenium of the corpus callosum and the quadrigeminal cistern [2].

The SFS/PreCS point marks the junction between the superior frontal sulcus (SFS) and PreCS
(Figure 5B). This point can be localized in the skull 1.5 cm posterior to Br and 3 cm lateral to the
sagittal suture, and it is called posterior coronal point (PCoP) (Interactive Model 5). The
SFS/PreCS point is also an important landmark to identify the omega region (hand motor
activation area, Brodmann’s area 6) in the pre-central gyrus. Moreover, it is coronally
correlated to the thalamus and, hence, with the floor of the lateral ventricle (posterior to the
foramen of Monro). The SFS/PreCS point is a crucial reference for superior frontal transulcal
and interhemispheric transcallosal approaches to the ventricular cavity [1].

The IPS/PoCS point represents the connection between the IPS and the PoCS. This point can be
identified on the skull as the intraparietal point (IPP) and is located 6 cm anterior to Lm and 5
cm lateral to the sagittal suture (Figure 5B, Interactive Model 3). The coronal projection of the
IPS/PCS point corresponds to the atrium and trigone of the lateral ventricle. In surgery, it is a
central landmark to confine the PoCS and as a starting point for a parietal transulcal approach
to the atrium [1].

The parieto-occipital incisure (POinc) corresponds to the meeting point of the most superior
point of the parieto-occipital sulcus and the external occipital fissure (EOF) into the medial
aspect of each hemisphere (also called EOF medial point) [1,8]. The POinc lies underneath the
lateral aspect of Lm (Figures 5C, 5D). This point is a surgical landmark for the posterior face of
the precuneus along the IHF (Interactive Model 5).

The postSTS point is the most posterior portion of the superior temporal sulcus (STS), just
before its trifurcation, where its middle and most horizontal branch penetrates into the angular

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 gyrus [1]. This point lies underneath the posterior temporal point (PTP), which is positioned 3
cm above the ascending line from the meeting point between the parietomastoid and the
squamosal sutures (Figure 5C, Interactive Model 3). The PSyP is approximately 2-3 cm anterior
and superior to the postSTS. The PTP is useful in temporal posterior and inferior parietal
craniotomies, and its axial projection corresponds to the atrium of the lateral ventricle.

Discussion
Craniometric landmarks based on surgical applications
Craniometric Points for Ventricular Access

Access to the ventricular cavities is one of the most performed procedures in neurosurgery,
both in elective and emergency cases. The ventricles are localized in the center of the brain
and, hence, reaching these cavities requires crossing through grey and white matter structures
(Figure 6, Interactive Model 6). For these reasons, the cranial surface landmarks have been used
to identify and describe burr hole locations to obtain safe pathways to reach different parts of
the ventricles. Knowledge of the entry points is crucial to achieving an effective and secure
ventriculostomy.

FIGURE 6: Subcortical structures and craniometric points. (A)

Superior view of the head with windows craniotomies
including white matter dissection showing the correlation of
the anterior segment of the perisylvian network and the
craniometric points; (B) superior view of the head with
windows craniotomies with further with matter dissection
showing the correlation of the body of the lateral ventricle and
the craniometric points.
Ant. segm.: anterior segment; Br: bregma; ChP: choroid plexus; FM: foramen of Monro; MFG:
middle frontal gyrus; PSN: perisylvian network; SFG: superior frontal gyrus; STL: superior temporal
line; St: stephanion; Th: thalamus.

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 INTERACTIVE MODEL 6: Volumetric model of a specimen with
bilateral windows dissections; on the left half head, the
ventricular system is shown.
View Interactive Model here: https://vimeo.com/409584108

Kocher's point is the most utilized point for anterior access to the lateral ventricles. This point
can be localized 11 cm posterior and superior to Na or 1-2 cm anterior to the coronal suture and
2-3 cm from the midline (Interactive Model 7). Kocher’s point is situated along the midpupillary
line to avoid any disruption to the superficial venous system. The catheter should be inserted 6
cm below the skin surface, with a direction perpendicular to the meeting point between the
ipsilateral medial canthus and external auditory meatus. Kocher’s point provides access to the
frontal horn of the lateral ventricle. This precoronal point is so located to be lateral to the SSS
and always anterior to the primary motor area [13].

INTERACTIVE MODEL 7: Composed volumetric model of a

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 semitransparent skull depicting inner structures (i.e., left
hemisphere and ventricular system) highlighting strategic burr
holes based on craniometric points.
View Interactive Model here: https://vimeo.com/409584178

Keen’s point is located in the posterior parietal surface, 2-3 cm superior and posterior to the
ear’s pinna. The catheter is direct cephalic and perpendicular to the temporal cortex
(Interactive Model 7). The trigone of the ipsilateral ventricle is located 4-5 cm below [13].

Frazier’s point is another posterior parietal point. This point is positioned 6 cm superior to the
In, and 3-4 cm lateral to the midline, above the lambdoid suture (Interactive Model 7). The
catheter follows a medial and superior trajectory and is directed to a point placed 4 cm above
the contralateral medial canthus. After 5 cm, the occipital horn and the body of the lateral
ventricle should be reached [13].

Dandy’s point serves as an access point to the lateral ventricles from the posterior occipital
region. The burr hole is placed 3 cm over the In and 2 cm laterally under the lambdoid suture
(Interactive Model 7). The catheter is directed superiorly towards a point 2 cm above the Gl and
inserted 4-5 cm to reach the occipital horn and body of the lateral ventricle [13].

Craniometric Points for the Identification of Cortical Areas

The primary motor cortex area is located at the pre-central gyrus on the dorsolateral surface of
the brain (Interactive Model 1). Distance from the coronal suture to the CS measures around 5
cm. Localization of the CS and the motor cortex is a crucial aspect during frontoparietal
craniotomies. Despite the common use of neuronavigation systems, a comprehensive
understanding of the 3D topography of the primary motor cortex is commonly needed during
cranial cases. Therefore, different surface topographic localization methods have been
described to identify this critical area (Interactive Model 8) [14].

INTERACTIVE MODEL 8: Volumetric model of a specimen with

bilateral windows dissections; on the left half head, the white

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 matter dissection has been performed to show the segments
of the perisylvian network.
View Interactive Model here: https://vimeo.com/409584138

The Taylor-Haughton method uses different lines and their intersection to identify the CS: the
Frankfurt plane (i.e., a line that extends from the inferior margin of the orbit to the upper
margin of the external auditory canal), the distance from Na to In along the calvarium (Na-In)
divided in quarters (25%-50%-75%), the posterior ear line (i.e., a perpendicular line from the
mastoid directed upward), condylar line (i.e., a perpendicular line from the mandibular condyle
headed upward), the line from the middle of the orbit to the 75% mark along the Na-In, which
corresponds to the SF from the orbit to the posterior ear line. The CS is situated 2 cm posterior
to the 50% mark between Na-In (or the intersection between the Na-In and the posterior ear
line), corresponding to the SRP, to the connection of the SF and condyle line, corresponding to
the IRP (Figure 7A) [14].

FIGURE 7: Representation of the main craniometric methods

used to identify the central sulcus: (A) Taylor-Haughton
method, (B) Broca’s method, and (C) Rhoton’s method.
Red points and dashed lines represent the superior Rolandic point, inferior Rolandic point, and
central sulcus.

ABL: auriculobregmatic line; In: inion; Na: nasion.

Broca’s method uses as a reference Broca’s plane (BP), a horizontal line that extends from the
base of the upper teeth through the bottom edge of the mastoid process. Two horizontal lines
are then drawn parallel to BP: a superior line, intersecting with the Br, and a medial line from
the external angular process of the frontal bone to just below the lambda suture. Then two
vertical lines, perpendicular to BP, are drawn: the vertical auriculobregmatic line (ABL) and a
second line 45 mm posterior to the ABL. The SRP can be located from the most superior point of
the second vertical line at its intersection with the horizontal line intersecting Br. The IRP is
situated at the intersection of the horizontal line from the external angular process of the
frontal bone to the lambda suture and the ABL. The CS can be identified as the oblique line
from the SRP and the IRP (Figure 7B) [14].

With Rothon’s method, the CS is detected with the use of three lines. The first is the Na-In line
marked at the halfway point and at the three-fourths point (50% and 75%). The second one,
which represents the SF, is an oblique line extending from external angular process of the
frontal bone (i.e., anatomic keyhole) to the 75% mark of the Na-In line. The third line is an

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 oblique line going from the midpoint of the zygomatic arch to the 50% mark of the Na-In line.
The intersection of this last line with the 50% mark on the Na-In line corresponds to the SRP.
The IRP is recognized at the junction of the midpoint of the third line with the second line (SF)
(Figure 7C) [14].

Craniometric Points for the Identification of Vascular Structure

Awareness and identification of venous vascular structures of the brain surface are crucial
during surgery to avoid early bleeding complications and to localize specific areas of interest.
Therefore, some CPs have been detected to properly tailor the craniotomies (Interactive Model
9).

INTERACTIVE MODEL 9: Volumetric model of a hemisected

skull with annotations showing the relationship between
exocranial structures and critical venous structures.
View Interactive Model here: https://vimeo.com/409584158

The SSS lies at the midline and runs from behind the frontal sinuses posteriorly in the shallow
groove on the inner table of the cranium, below the sagittal suture, until the In, where it merges
with the two transverse sinuses (Figure 8). The arachnoid granulations are commonly located
2.6 cm lateral to the SSS and can be found from 3.9 cm anterior to 7.3 cm posterior to the Br [7].
These granulations are important for the drainage of the superficial veins of the brain and the
cerebral spinal fluid reabsorption into the venous system (Figures 8A, 8C, 8D) [7]. The bridging
veins are the connection between the superficial venous system and the SSS. The connection
between the superficial veins of the different lobes with the SSS can have different orientations,
and they commonly run near the lateral wall of the SSS before draining into it. Accumulations
of these veins are found conventionally between Br and L, predominantly in the right
hemisphere: posteriorly to the frontal region above the genu of the CC and 4-6 cm from the
torcular Herophili (Figures 8C, 8D). In this region also, the lacunae, enlarged venous spaces, can
be found (Figure 8D). The lacunae are contained in the dura mater adjacent to the SSS and
receive drainage of the meningeal veins. The cortical veins are known to pass beneath the
lacunae to reach the sinus and, less frequently, to open into the lacunae. In the posterior frontal
and parietal regions, the lacunae are the biggest and most consistent.

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 FIGURE 8: Overview of the major dural sinuses and veins of
the brain. (A) Superior view of the head after removal of the
superior sagittal suture and visualization of the SSS; (B)
posterior view of the head after removal along the superior
sagittal suture and opening of the posterior fossa, visualization
of the SSS, torcula Herophili, transverse sinus, and sigmoid
sinus; (C) visualization of the anterior portion of the brain
underlying the venous structures (SSS, arachnoid
granulations, and bridging veins); (D) visualization of the
posterior portion of the brain underlying the venous structures
(SSS, arachnoid granulations, bridging veins, torcula Herophili,
transverse sinus).
SSS: superior sagittal sinus; TSSJ: transverse-sigmoid sinus junction.

The vein of Trolard, also known as the superior anastomotic vein, is the largest anastomotic
vein that crosses the cortical surface of the frontal and parietal lobes just between the SF and
the SSS. The vein of Trolard is most frequently found in the PoCS lying 1.2 cm posterior to CS
[15].

The vein of Labbé, also known as the inferior anastomotic vein, arises from the middle portion
of the SF and descends to the transverse sinus (Figure 9). This drainage is located 0.8-1.5 cm
superior to the zygomatic arch and 2-5 cm posterior to the external auditory meatus opening.
The vein of Labbé drains into the tentorial venous group, sigmoid or transverse sinus about 7
mm away from the superior petrosal sinus [15,16].

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 FIGURE 9: Overview of the SF and the vein of Labbé. (A)
Lateral view of the head with exposure of the SF after selective
drilling was performed over the central portion of the
squamosal suture; (B) lateral view of the head with focus bone
removal above the SF and the course of the vein of Labbé.
ASyP: anterior Sylvian point; PSyp: posterior Sylvian point; SF: Sylvian fissure; St: stephanion.

The transverse sinuses extend from the torcular Herophili to the sigmoid sinus bilaterally
(Figures 8B, 8D, Interactive Model 9). They run laterally into a groove along the interior surface
of the occipital bone, which can be identified externally by the line from In to Ast [1].

The transverse-sigmoid junction is important for the placement of the strategic burr hole in
posterolateral craniotomies. Traditionally, it has been associated with the Ast superficially,
though it has been shown that the Ast overlays the transverse sinus more frequently [17,18].
Several methods to identify the transverse-sigmoid sinus junction have been described. The
techniques that rely on local bony anatomy, observable in the surgical field, are the most
accurate (Figure 10). Among these, the most accurate methods are the Ribas method, which
recognizes the junction 1 cm anterior to Ast, with the superior edge of the burr hole adjacent to
the petromastoid line, and the Teranishi method, which places the burr hole 0.65 cm inferior
and 0.65 cm lateral to the Ast [17].

FIGURE 10: Overview of the Asterion and the transverse-

sigmoid sinus junction. (A) Postero-lateral view of the skull;
(B) interior view of the postero-lateral aspect of the skull; (C)
inferior view of the postero-lateral aspect of the skull.
Ast: asterion; TSSJ: transverse-sigmoid sinus junction.

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 Craniometric Points for the Strategic Burr Hole Position

Sutures, cranial protuberances, and the CPs have been extensively used to locate critical
structures while placing the burr holes of craniotomies. In this section, we will describe the
main landmarks used in anterolateral cranial approaches (Interactive Model 7).

The MacCarthy keyhole is found in the frontal orbito-zygomatic region, most specifically on the
frontosphenoidal suture. It is located approximately 6.8 mm superior and 4.5 mm posterior to
the frontozygomatic suture [19]. This burr hole reveals frontal dura and the lower half’s area
around the orbit, and it is used in the fronto-orbit-zygomatic craniotomies. In the pterional
approach, the keyhole should be positioned along the frontosphenoid suture approximately 5-6
mm posterior to the junction of the frontosphenoid, frontozygomatic, and sphenozygomatic
sutures: a landmark also referred to as the three-suture junction (Figure 11).

FIGURE 11: Representation of the strategic burr hole position

(green spheres) on the lateral aspect of the skull.
Ast: asterion; Pt: pterion; PmSqJ: parietomastoid-squamosal suture junction.

The sphenoparietal point corresponds to the projection of the most lateral and anterior aspects
of the sphenoid ridge and the SF (Figure 11). This point constitutes an osseous transition
between the anterior and middle fossae, which are the compartments that need to be exposed
in frontotemporal approaches. The sphenoparietal point can be identified 21.72 mm posterior
and 4.76 mm superior to the frontozygomatic suture [20].

The preauricular depression (PreAD) keypoint represents the most anterolateral position of the
petrous bone, and thus the transition of the temporal fossa and the ascending petrous bone
surface. This point is located above the PreAD, which is described as the ascendant portion of
the superior margin of the posterior part of the zygomatic process, just anterior to the tragus
and external acoustic meatus (Interactive Model 3). The burr hole performed on the PreAD
keypoint exposes the posterior portion of the middle fossa. This point is related to the inferior
temporal sulcus and in the coronal plane to the upper third of the clivus. The 1 cm above the

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 external junction of the parietomastoid and squamous sutures (PMSQj) keyhole is a surgical
landmark for the most posterolateral part of the intracranial petrous surface, which borders the
petrous surface and the superior surface of the tentorium (Interactive Model 3). A burr hole
placed at this point underlies the inferior temporal sulcus and, in the coronal plane, the
posterior aspect of the midbrain. The preauricular point and the 1 cm above the PMSQj
delimitate the external projection of the petrous bone; the middle fossa floor lies anterior to the
first bur hole, and the superior surface of the tentorium lies posterior to the second bur hole.
These two burr holes define the lateral aspect of the superior surface of the petrous bone and,
therefore, the lateral aspect of the brainstem. The 1 cm above the Ast keyhole corresponds to
the occipital notch, and it is related to the superior aspect of the transverse sinus and the
superior tentorial surface (Figure 11, Interactive Model 7) [4].

Conclusions
In this study, we review and describe all the crucial CPs that should be utilized in everyday
practice. We aimed to facilitate the 3D comprehension of this critical landmark using VMs.

A thorough understanding of the relationship between the cranial surface and intracranial
structures is paramount to avoid unnecessary exposure or damage to critical anatomical
structures. Due to its superficiality, the correct interpretation of the neurovascular architecture
underneath the craniotomy site is a primary and critical step in successful surgery. Although
the average morphometrics found in the literature are not generally applied due to individual
anatomical variations, the study of CPs still serves as a practical preoperative and
intraoperative tool for the operator aiming to navigate the intricate neurosurgical anatomy. The
knowledge of anatomical landmarks and a constant 3D visuospatial orientation of the relevant
surgical topography remains an essential component to perform safe and efficient surgeries
with successful outcomes.

Additional Information
Disclosures
Human subjects: All authors have confirmed that this study did not involve human
participants or tissue. Animal subjects: All authors have confirmed that this study did not
involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform
disclosure form, all authors declare the following: Payment/services info: All authors have
declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at
present or within the previous three years with any organizations that might have an interest in
the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.

Acknowledgements
We would like to express our gratitude to the body donors and their families, who, through
their altruism, contributed to making this project possible. We would also like to thank the
Neuroscape Laboratory at the University of California, San Francisco, for sharing their publicly
available 3D dataset (3DPX-000757) for anatomical concepts used in Models 1 and 9.

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