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J Biomed Clin Res Volume 11 Number 2, 2018

DOI: 10.2478/jbcr-2018-0020 Original Articles

BASIC NEURONAVIGATION OPTIONS FOR CORTICAL AND


SUBCORTICAL BRAIN LESIONS SURGERY

0LODQ10ODGHQRYVNL Summary
Nikolay V. Vasilev,
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Iliya V. Valkov points help to manage any pathological lesion located on
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Department of Neurology and J\UL VKRXOG EH LGHQWL¿HG EHIRUH FUDQLRWRP\ ,W LV GLI¿FXOW
Neurosurgery, WR LGHQWLI\ WKHVH DQDWRPLFDO VWUXFWXUHV LQWUDRSHUDWLYHO\
Medical University – Pleven, DIWHUFUDQLRWRP\ ZLWKSUHFLVLRQ7KHPDLQSXUSRVHRIWKLV
Bulgaria VWXG\ZDVWRFROOHFWDVPXFKLQIRUPDWLRQDVSRVVLEOHIURP
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the second method mentioned above (118 patients), while
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Introduction
&RUUHVSRQGLQJ$XWKRU Craniometric points DUHFUDQLDOODQGPDUNVIURPZKLFK
Milan N. Mladenovski
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Neurosurgery, /DQGPDUNVDUHDQDWRPLFDOVWUXFWXUHVXVHGDVSRLQWV
Medical University – Pleven RI RULJLQ LQ ORFDWLQJ RWKHU DQDWRPLFDO VWUXFWXUHV
Bulgaria Craniometric points are essential cranial points that
1, St. Kl. Ochridski Str. RULHQWDWH QHXURVXUJHRQV LQ SUDFWLFH 7KH EUDLQ VXOFL
Pleven, 5800 DQGJ\ULFRXOGEHLGHQWL¿HGEHIRUHFUDQLRWRP\DQGWKLV
Bulgaria PDNHVLWSRVVLEOHWRapproach any pathological lesion
e-mail: milanmladenovski@gmail.com ORFDWHG RQ WKH FRUWLFDO VXUIDFH RU GHHS LQ WKH EUDLQ
3UHFLVH LGHQWL¿FDWLRQ RI WKHVH DQDWRPLFDO VWUXFWXUHV
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5HYLVLRQUHFHLYHGNovember 07, 2018
PDLQ REMHFWLYH RI WKLV VWXG\ ZDV WR FROOHFW  DV PXFK
$FFHSWHGJanuary 17, 2019

© Medical University Pleven
J Biomed Clin Res Volume 11 Number 2, 2018

LQIRUPDWLRQ DV SRVVLEOH IURP WKH OLWHUDWXUH DQG Basic anthropological (craniometric)
RXU FOLQLFDO SUDFWLFH WR IDFLOLWDWH WKH SODFHPHQW points
RI FUDQLRWRPLHV ZLWKRXW XVLQJ PRGHUQ 6RPHRIWKHHVVHQWLDODQWKURSRORJLFDOSRLQWVDUH
QHXURQDYLJDWLRQV\VWHPV YHU\ XVHIXO UHIHUHQFHV IRU SUHFLVH GHVFULSWLRQ
,Q WKH VWXG\ WKH WHUP ³QHXURQDYLJDWLRQ´ LV RI WKH DSSURDFK SODQQHG 7DEOH   7KH PDMRU
QRWDV\QRQ\PIRULPDJHJXLGHGVXUJHU\ ,*6  DGYDQWDJH FRPHV IURP WKHLU IHDWXUH ± WKH\ FDQ
DQG FRPSXWHUDVVLVWHGFRPSXWHUDLGHG VXUJHU\ EHVHHQERWKRQWKHKHDGDQGWKHLPDJLQJVWXGLHV
&$6 WKHODWWHUWZREHLQJV\QRQ\PVIRUPRGHUQ VKRZLQJWKHLQWUDFUDQLDOSDWKRORJ\IRXQG>@
QHXURQDYLJDWLRQ V\VWHPV 1HXURQDYLJDWLRQ LV
D WHFKQLTXH GHVLJQHG WR KHOS QHXURVXUJHRQV Topography of the main cerebral
SUHFLVHO\ GHWHUPLQH WKH ORFDWLRQ RI YDULRXV sulci
FRUWLFDO DQG VXEFRUWLFDO OHVLRQV E\ XVLQJ 7KH ODWHUDO DQG FHQWUDO ¿VVXUHV DUH WKH WZR
PHWKRGVVXFKDVFUDQLRPHWULFSRLQWVFRPSXWHG PRVW LPSRUWDQW VXOFL RQ WKH FRQYH[ VXUIDFH RI
tomography (CT), magnetic resonance imaging WKH FHUHEUDO KHPLVSKHUH VHUYLQJ DV UHIHUHQFHV
05, XOWUDVRQRJUDSK\ 86* LPDJHVHWF IRU ORFDOL]LQJ WKH RWKHU VXOFL DQG FRQYROXWLRQV
RI WKH KHPLVSKHUHV +RZHYHU ZKHQ SODQQLQJ
0DWHULDOVDQG0HWKRGV FUDQLRWRPLHV GLVSODFHPHQW SURGXFHG E\ PDVV
OHVLRQV VKRXOG EH DOVR FRQVLGHUHG VLQFH DIWHU
2SHUDWLYH UHSRUWV IURP  WR  ZHUH WKH SODQQHG FRUWLFDO H[SRVXUH J\UL DQG VXOFL
UHYLHZHG RQ VXUJHULHV SHUIRUPHG DW WKH FDQEHIRXQGWREHQRWH[DFWO\DWWKHLUH[SHFWHG
1HXURVXUJHU\ &OLQLF 8QLYHUVLW\ 0XOWLSUR¿OH locations.
+RVSLWDOIRU$FWLYH7UHDWPHQW³'U*6WUDQVNL´ $FFRUGLQJWRWKHVLPSOL¿HG.URQOHLQPHWKRG
LQ 3OHYHQ 7ZR KXQGUHG QLQHW\¿YH FUDQLDO DKRUL]RQWDOOLQHLVGUDZQDWWKHOHYHORIWKHXSSHU
RSHUDWLRQV IRU FRUWLFDO DQG VXEFRUWLFDO WXPRU RUELWDOHGJH )LJXUH 
lesions were reviewed. All craniotomies 7KHQWZRYHUWLFDOOLQHVDUHVXSHULPSRVHGWKH
KDG EHHQ SODQQHG E\ XVLQJ IRXU PHWKRGV ¿UVWRQHWKURXJKWKHPLGSRLQWRIWKH]\JRPDWLF
FUDQLRPHWULF SRLQWV &7 VFDQVWRSRJUDPV 05, DUFK DQG WKH VHFRQG WKURXJK WKH SRVWHULRU
VFDQVWRSRJUDPV DQG LQWUDRSHUDWLYH UHDOWLPH ERUGHU RI WKH DXULFOH 7KH OLQH FRQQHFWLQJ WKH
XOWUDVRQRJUDSK\ LQWHUVHFWLRQSRLQWEHWZHHQWKHKRUL]RQWDODQGWKH
$OOLPDJHVZHUHSUHYLHZHGE\XVLQJ5DGL$QW ¿UVWYHUWLFDOOLQHZLWKWKHSRLQWZKHUHWKHVHFRQG
',&20 9LHZHU GHVLJQHG WR XVH UHVRXUFHV vertical line crosses the midline, corresponds to
DV HI¿FLHQWO\ DV SRVVLEOH LQ YLHZLQJ PHGLFDO WKHSURMHFWLRQRIWKHFHQWUDOVXOFXV,IWKHDQJOH
images. IRUPHG E\ WKH SURMHFWLRQ RI WKH FHQWUDO VXOFXV

Table 1. Basic anthropological (craniometric) points and their characteristics

Craniometric Characteristics
points
1DVLRQ $SRLQWVLWXDWHGRIWKHEDVHRIWKHQRVHLQWKHPLGGOHRIWKHQDVRIURQWDOVXWXUH
Bregma $SRLQWZKHUHWKHFRURQDODQGVDJLWWDOVXWXUHVMRLQRQWKHLQWDFWVNLQLWFDQEHGHWHUPLQHG
DVWKHLQWHUVHFWLRQRIWKHWZRSHUSHQGLFXODUOLQHVGUDZQXSIURPWKHPLGSRLQWVRIERWK
]\JRPDWLFDUFKHV
Lambda 7KHSRLQWZKHUHWKHODPEGRLGDQGVDJLWWDOVXWXUHVMRLQ
,QLRQ 7KLVSRLQWFRUUHVSRQGVWRWKHH[WHUQDORFFLSLWDOSURWXEHUDQFH
Estephanon 6\PPHWULFDOSRLQWVRQERWKVLGHVRIWKHVNXOODWWKHSODFHZKHUHWKHFRURQDOVXWXUHFURVVHV
WKHVXSHULRUWHPSRUDOOLQH
Pterion $SSUR[LPDWHO\V\PPHWULFDOSRLQWVRQERWKVLGHVRIWKHVNXOOORFDWHGZKHUHWKHIURQWDO
SDULHWDODQGWHPSRUDOERQHVMRLQWKHODUJHZLQJRIWKHVSKHQRLGERQH
Asterion 6LPLODUWRWKHSUHYLRXVELODWHUDOSRLQWVDWWKHSODFHZKHUHWKHRFFLSLWDODQGSDULHWDOERQHV
MRLQZLWKWKHPDVWRLGSDUWRIWKHWHPSRUDOERQH
Glabella (g) ,WLVDFHSKDORPHWULFODQGPDUNWKDWLVMXVWVXSHULRUWRWKHQDVLRQ

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FRQQHFWLQJWKH]\JRPDWLFSURFHVVRIWKHIURQWDO
ERQH ZLWK D SRLQW DW  RI WKH OHQJWK RI WKH
QDVLRQLQLRQ GLVWDQFH VWDUWLQJ IURP WKH QDVLRQ
7KHFHQWUDOVXOFXVFRUUHVSRQGVWRWKHXSSHUKDOI
RIWKHOLQHFRQQHFWLQJWKHPLGOLQH FPEHKLQG
it is the nasion-inion midpoint) and reaches the
PLGGOHRIWKH]\JRPDWLFDUFK>@
Correlations between anthropological
FUDQLRPHWULF SRLQWVDUHNQRZQDVFUDQLRPHWULF
NH\ SRLQWV >@ 7KHVH DUH SRLQWV RI FUXFLDO
LPSRUWDQFHWKDWKHOSWRLGHQWLI\WKHFRUWLFDOEUDLQ
VXOFLDQGJ\UL 7DEOH 

CT brain scans/topograms
Figure 1. Kronlein method CT head (brain) scan is the most common cranial
$%KRUL]RQWDOOLQHDWWKHOHYHORIVXSHULRURUELWDOHGJH
&' ¿UVW YHUWLFDO OLQH () VHFRQG YHUWLFDO OLQH +( LQYHVWLJDWLRQ LQ QHXURVXUJHU\ $ KHDG &7 LV DV
SURMHFWLRQ RI WKH FHQWUDO VXOFXV +* SURMHFWLRQ RI WKH important as a chest x-ray is in internal medicine.
ODWHUDOFHUHEUDOVXOFXV VXOFXVRI6\OYLL  $ V\VWHPDWLF UHYLHZ RI &7 VFDQV FDQ SUHYHQW
FRPPRQ HUURUV HJ VHHLQJ DQ REYLRXV ODUJH
parietal metastasis, and missing a smaller one at
DQGWKHKRUL]RQWDOOLQHLVELVHFWHGWKLVODWWHUOLQH
WKHSRVWHULRUFUDQLDOIRVVDLQWKHFHUHEHOOXP
ZLOOFRUUHVSRQGWRWKHODWHUDOVXOFXV>@
:H VKRXOG SRLQW RXW WKDW LW LV HVVHQWLDO
$FFRUGLQJ WR (JRURY¶PHWKRG IRU
to approach this cranial investigation in a
LGHQWL¿FDWLRQ WKH FHQWUDO VXOFXV SURMHFWLRQ
V\VWHPDWLFIDVKLRQLQRUGHUWRE\SDVVDQ\PLVVWHS
corresponds to the line, which begins 2 cm
LQGLDJQRVLVDQGQHXURQDYLJDWLRQ
EHKLQGWKHPLGSRLQWRIWKHQDVLRQLQLRQGLVWDQFH
&7 VFDQWRSRJUDP LV RQH RI WKH RSWLRQV IRU
RQWKHVDJLWWDOOLQHDQGIRUPVGHJUHHVRIWKH
QHXURQDYLJDWLRQ ,W LV DEVROXWHO\ QHFHVVDU\ IRU
angle with it, open in an anterobasal direction.
FUDQLRWRPLHV 1HXURUDGLRORJLVWV VKRXOG LQFOXGH
7KXV WRSRJUDSK\ RI WKH WZR EDVLF ¿VVXUHV RI
CT topograms in every CT head scan )LJXUHV
the cerebral hemisphere (the lateral and central
DEDE 
VXOFL FDQEHGHWHUPLQHGLQWKHIROORZLQJVLPSOH
ZD\ WKH ODWHUDO VXOFXV OLHV DOO DORQJ WKH OLQH

Figure 2. CT topogram
7KHWXPRU PHQLQJLRPD LVORFDWHGLQWKHOHIWSDULHWRWHPSRUDOUHJLRQ-XVWDQWHULRUWR,53

© Medical University Pleven
J Biomed Clin Res Volume 11 Number 2, 2018

Table 2.&UDQLRPHWULFNH\SRLQWV

Craniometric key points Abbreviation


AQWHULRUV\OYLDQSRLQW H[WHUQDOFUDQLDOVXUIDFHDWWKHDQWHULRUVTXDPRVXV ASP
6\OYLDQ)LVVXUH SyF
,QIHULRU5RODQGLFSRLQW DSSUR[LPDWHO\FPDERYHWKHWUDJXV ,53
'LVWDQFHEHWZHHQWKH$63DQGWKH,53DORQJWKH6\)LVRIDURXQGFP FP $63,53GLVWDQFH
,QIHULRUIURQWDOVXOFXVDQGSUHFHQWUDOVXOFXVPHHWLQJSRLQW OLHVDURXQGFPSRVWHULRUWR ,)63UH&6
the estephanion
(VWHSKDQLRQSRLQWLVDFUDQLRPHWULFSRLQWDWWKHOHYHORIWKHLQWHUVHFWLRQEHWZHHQWKH Es
FRURQDOVXWXUHDQGWKHVXSHULRUWHPSRUDOOLQH
$QHDV\ZD\WRGHWHUPLQH%URFDDUHDRQWKHGRPLQDQWKHPLVSKHUHLVE\ORFDOL]LQJWKHIRXU Broca area
FUDQLRPHWULFDOSRLQWVWKH(VWHSKDQLRQFPSRVWHULRUWRWKH(VWHSKDQLRQWKHDQWHULRU
6\OYLDQSRLQWDQGWKH,53
SXSHULRUIURQWDOVXOFXVDQGSUHFHQWUDOVXOFXVPHHWLQJSRLQW 6)63&6
PRVWHULRUFRURQDOSRLQW±is aFUDQLRPHWULFDOSRLQWORFDWHGFPODWHUDOWRWKHVDJLWWDOVXWXUH PCop
DQGFPSRVWHULRUWRWKHFRURQDOVXWXUH this PCop locates the hand motor cortex
SXSHULRUURODQGLFSRLQW FPSRVWHULRUWRWKH%UHJPD 653
,QWUDSDULHWDODQGSRVWFHQWUDOVXOFXVPHHWLQJSRLQW,33±LQWUDSDULHWDOSRLQW FRUUHVSRQGV ,363&6
,363&6 /RFDWHGFPDQWHULRUWR/DPEGDDQGFPODWHUDOO\WRWKHVDJLWWDOVXWXUH
E[WHUQDORFFLSLWDO¿VVXUH (2)
E[WHUQDORFFLSLWDO¿VVXUHDQGSDULHWRRFFLSLWDOVXOFXVPHHWLQJSRLQW FPVXSHULRUWRWKH (2)326
2SLVWKRFUDQLRQ QRWWREHFRQIXVHGZLWKWKH,QLRQ
(XULRQ MXQFWLRQRIWKHVXSHULRUWHPSRUDOOLQH 67/ DQGDYHUWLFDOOLQHGUDZQRYHUWKH (X
PRVWSRVWHULRUSDUWRIWKHPDVWRLG
7KH(XU\RQZDVIRXQGWREHRYHUWKHVXSHULRUDVSHFWRIWKHVXSUDPDUJLQDOLVJ\UXV 60*  60*$*
7KH60*DQG$QJXODU*\UXV $* EHORQJWRWKHLQIHULRUSDULHWDOOREXOHDQGDUHVHSDUDWHG
IURPWKHVXSHULRUSDULHWDOOREHE\WKHLQWUDSDUHWDOVXOFXV6XSUDPDUJLQDOJ\UXV 60* 
LVIRXQGWREHDVWKHPRVWSRVWHULRUSRLQWRI6\OYLDQ¿VVXUH 6) ZKLOHDQJXODUJ\UXVLV
IRXQGWREHDVWKHPRVWSRVWHULRUSDUWRIVXSHULRUWHPSRUDOVXOFXV 676 7KHVXOFXVWKDW
GLYLGHV60*IURP$*LVFDOOHGWKHVXOFXVRI-DQVHQ
2pisthocranon (the most prominent occipital cranial point) 2S
LDPEGD VXWXUDODPEGRLGHD±VXWXUDVDJLWDOLVPHHWLQJSRLQW±EHWZHHQFPDERYH La
opisthocranon)
,QLRQ±SURWXEHUDQWLDRFFLSLWDOLVH[WHUQDDSSUR[LPDWHO\FPEHOORZWKHRSLVWRFUDQRQ ,Q

Figure 3. CT angiogram
6KRZLQJWKHWXPRU¶VYDVFXODUL]DWLRQLWLVRIKXJHLPSRUWDQFHIRUWKHVXUJLFDOSODQQLQJ

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Figure 4.,53DQG%UHJPDDVDFUDQLRPHWULFSRLQWV
&7WRSRJUDPKHOSVIRUSUHFLVHFUDQLRWRP\

Figure 5a.%RQHÀDSLVHOHYDWHG Figure 5b. 'XUDORSHQLQJDQGPHQLQJLRPDLVLQWKH


FHQWHURIWKHWUHSDQDWLRQ

Figure 6a.7KHWXPRULVEHLQJPRELOL]HG Figure 6b.(QEORFNWXPRUUHVHFWLRQ

MRI scans/topograms IRU FRPSOH[ FRUWLFDO RU GHHS SDWKRORJLFDO


05, KDV UHFHQWO\ EHFRPH D YLWDOO\ LPSRUWDQW OHVLRQVDQGUHODWLYHO\OHVVRIWHQIRUGLDJQRVWLF
GLDJQRVWLF WHFKQLTXH 1HXURVXUJHRQV RIWHQ SXUSRVHV VLQFH GLDJQRVLQJ XVLQJ &7 VFDQV
UHO\ RQ 05, LPDJHV ZKLOH SODQQLQJ VXUJHU\ LV OHVV H[SHQVLYH $ UHODWLYHO\ ODUJH JURXS

© Medical University Pleven
J Biomed Clin Res Volume 11 Number 2, 2018

RI QHXURVXUJHRQV UHOLHV RQ DGYDQFHG LPDJH Results


JXLGDQFHWHFKQRORJ\LQWKHLUSUDFWLFH$GHWDLOHG
KLJKTXDOLW\ QHXURUDGLRORJLFDO LQYHVWLJDWLRQ 5HWURVSHFWLYHO\ ZH DQDO\]HG  FUDQLDO
SURYLGLQJUHOLDEOHLQIRUPDWLRQDQGLQWHUSUHWDWLRQ RSHUDWLRQVIRUWXPRUOHVLRQV 7DEOH 
RQ WKH H[DFW UHODWLRQV RI D WXPRU WR DGMDFHQW 2QH KXQGUHG VL[W\VHYHQ SDWLHQWV KDG EHHQ
VWUXFWXUHV DQG LWV YDVFXODUL]DWLRQ LV RI FUXFLDO GLDJQRVHG YLD KHDG &7 2QH KXQGUHG WZHQW\
LPSRUWDQFH$Q05,VFDQWRSRJUDPDVDPHDQV HLJKWSDWLHQWVKDGEHHQGLDJQRVHGE\KHDG05,
RI RULHQWDWLRQ LV RQH RI WKRVH PRVW FRPPRQO\ Forty-six patients had had CT prior to admission,
XVHGLQFDVHVRIFRUWLFDODQGVXEFRUWLFDOOHVLRQV DQG 05, LQYHVWLJDWLRQV ZHUH FDUULHG RXW IRU
)LJXUH  PRUHSUHFLVHHYDOXDWLRQ7KHVXFFHVVUDWHRIWKH
SURMHFWLRQVXVHGZDVJUDGHG RQDVFDOHIURPRQH
Intraoperative real-time WRWKUHH 7DEOH 
ultrasonography Grade 1: Projections exactly matched the
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VXUJHU\WLPH )LJXUH  EXWLQWKHVXUJLFDO¿HOG

Figure 7.05,VFDQWRSRJUDPVKRZLQJRFFLSLWDOPHWD

Table 3. 'LDJQRVWLF PHWKRGV XVHG WR LGHQWLI\ WKH


EUDLQWXPRU

Patients Number
CT scan* 
05,VFDQ 128
Total 295

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1RWHWKHRYRLGOHVLRQ

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Table 4. *UDGLQJWKHVXFFHVVRIWKHSURMHFWLRQVLQWKHRSHUDWHGSDWLHQWV

Grades Cortical Tu (n=118) Subcortical Tu (177)


Grade 1*    
Grade 2*    
*UDGH    

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ZDV QRW LQ WKH VXUJLFDO ¿HOG DQG DGGLWLRQDO The pterion is the most commonly
craniotomy was done). XVHG H[WHUQDO ODQGPDUN LQ WKH PDMRULW\ RI
We considered Grade 1 and Grade 2 as QHXURVXUJLFDOSURFHGXUHV>@.7KHUHIRUHLWV
VXFFHVVIXO *UDGH  SURMHFWLRQV LQ D RI WRWDO SUHFLVHORFDWLRQLQUHODWLRQWRRWKHUVXUURXQGLQJ
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GLIIHUHQFHVLQFUDQLRPHWULFSRLQWVDQGGLVWDQFHV IURQWR]\JRPDWLF VXWXUH DQG H[WHUQDO DFRXVWLF
QRWXVLQJUHDOWLPH86*DQGDVXUJHRQ¶VHPRWLRQ PHDWXVFDQEHYHU\XVHIXOIRUNH\KROHVXUJHULHV
DQG SK\VLFDO IDWLJXH 2XU UHVXOWV DUH EDVHG RQ in these areas.
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PHWKRGVRIQHXURQDYLJDWLRQLQSDWLHQWVZLWK 7KH PDLQ JRDO LQ QHXURVXUJHU\ LV WR WUHDW
D VXFFHVV UDWH RI  &UDQLRPHWULF SRLQWV QHXURVXUJLFDO SDWKRORJLHV WKURXJK D PLQLPXP
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