Skull Surface

Markings ,
Different Scalp
Incisions &
Craniotomies
Dr. Idrees Ahmed
Resident Neurosurgeon
ATH
Date: 28/8/2020
 01 SURFACE MARKINGS

contents 02 POST. FOSSA CRANIECTOMY

SUPRATENTORIAL
03
CRANIOTOMIES
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Surface anatomy of the cranium
Craniometric points:
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Surface anatomy of the cranium
Craniometric points:
Pterion: Region where the following bones are approximated: frontal, parietal, temporal and sphenoid
(greater wing). Estimated location: 2 finger-breadths above the zygomatic arch, and a thumb’s breadth
behind the frontal process of the zygomatic bone
Asterion: junction of lambdoid, occipitomastoid and parietomastoid sutures. Usually lies within a few
millimeters of the posterior-inferior edge of the junction of the transverse and sigmoid sinuses
Vertex: the topmost point of the skull.
Lambda: junction of the lambdoid and sagittal sutures.
Stephanion: junction of coronal suture and superior temporal line.
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Surface anatomy of the cranium
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Surface anatomy of the cranium
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Surface anatomy of the cranium

Relation of skull markings to cerebral anatomy :

Sylvian fissure :
On the skin surface: approximated by a line connecting the lateral canthus to the point 3/4 of the way
posterior along the arc running over convexity from nasion to inion (T-H lines).
On the skull (once it is exposed in surgery): the anterior portion of the Sylvian fissure follows the
squamosal suture and then deviates superiorly to terminate at Chater’s point, which is located 6 cm above
the EAM on a line perpendicular to the orbitomeatal line; it is also ≈ 1.5 cm above the squamosal suture
along the same perpendicular line.
SIGNIFICANCE : A 4 cm craniotomy centered at Chater’s point provides access to potential recipient
vessels in the angular gyrus for EC/IC bypass surgery
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Surface anatomy of the cranium
Relation of skull markings to cerebral anatomy :
Motor cortex:
The motor strip lie anywhere from 4 to 5.4 cm behind the coronal suture.
1. method 1: the superior aspect of the motor cortex is almost straight up from the EAM near the
midline
2. method 2: the central sulcus is approximated by connecting:
a) the point 2 cm posterior to the midposition of the arc extending from nasion to inion to
b) the point 5 cm straight up from the EAM
3. method 3: using T-H lines, the central sulcus is approximated by connecting:
a) the point where the “posterior ear line” intersects the circumference of the skull (usually about 1 cm behind the
vertex, and 3–4 cm behind the coronal suture), to
b) the point where the “condylar line” intersects the line representing the Sylvian fissure
4. method 4: a line drawn 45° to Reid’s base line starting at the pterion points in the direction of the motor strip
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POSTERIOR FOSSA CRANIECTOMIES

Indications :
To gain access to the :
cerebellum,
cerebellopontine angle (CPA),
to one vertebral artery,
posterior brainstem,
fourth ventricle,
pineal region,
using extreme lateral posterior fossa approach to the
anterolateral brainstem.
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POSTERIOR FOSSA CRANIOTOMIES
Position :
Position options include
1. sitting position
2. lateral oblique (“park bench)”:
patient three-quarters oblique (almost prone). Often
used for access to cerebellar hemisphere lesion
3. semi-sitting
4. supine with shoulder roll, head almost horizontal
5. prone
6. Concorde position
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POSTERIOR FOSSA CRANIOTOMIES
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POSTERIOR FOSSA CRANIOTOMIES
Skin incision :
Linear (paramedian) incisions:
A vertical linear paramedian incision provides adequate exposure for lesions < 2.5 cm diameter and
involves less trauma to overlying muscles, and may be easier to get watertight closure than with
midline incision.
For lesions in the cerebellar hemisphere: a linear vertical incision approximately midway
between the midline and the mastoid notch may be used.
Access to CPA (for microvascular decompressions and small CPA tumors): a slightly curved retromastoid incision placed 5 mm medial to the mastoid
notch (a palpable landmark) is used .
1. “5–6-4” incision (incision placed 5 mm medial to mastoid notch, extending from 6 cm above
notch to 4 cm below). High enough to expose transverse sinus:
a) for approach to fifth nerve: microvascular decompression for trigeminal neuralgia
2. “5–5-5” incision (5 mm medial, extending 5 cm up to 5 cm down), used for approach to seventh/
eighth nerve complex:
a) microvascular decompression for hemifacial spasm
b) small vestibular schwannoma
3. “5–4-6” incision (5 mm medial, extending 4 cm up to 6 cm down): used for approach to lower
cranial nerves:
a) glossopharyngeal neuralgia
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POSTERIOR FOSSA CRANIOTOMIES
Skin incision :
“Hockey-stick” incision:
Useful for lesions > 2.5 cm in the cerebellar hemisphere or CPA where getting the muscles out of theway
will facilitate maneuvering instruments about the posterior fossa.
Incision is made in the midline starting at ≈ C2 spinous process, proceeding superiorly to just above the
inion, and then laterally to just beyond the mastoid tip .
A short optional caudal curve may be made laterally to further remove the muscle from the operative
field.
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POSTERIOR FOSSA CRANIOTOMIES
Craniectomy:
Landmarks:
The location of the inferior margin of the transverse sinus is quite accurately estimated at two finger-breadths above the upper limit
of the mastoid notch (usually just above the superior nuchal line). This should be the upper limit of the skull opening.
For microvascular decompression:Craniectomy ≈ 2 cm diameter placed in the angle between transverse and sigmoid sinuses.
For small tumors (< 2.5 cm):Craniectomy ≈ 4 cm diameter placed in the angle between transverse and sigmoid sinuses.
For large tumors
A larger craniectomy may be needed, the size of which is limited by:
1. transverse sinus superiorly
2. foramen magnum inferiorly (which may be opened as prophylaxis against tonsillar herniation in
the event of p-fossa edema post-op)
3. sigmoid sinus laterally (opening mastoid air cells is acceptable, but to prevent CSF leak, these
must be packed with bone wax and muscle (or bone dust from craniectomy), and may be covered with reflected dura or fascia)
4. midline medially (unless the tumor extends across the midline)
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Burr hole for emergency

ventriculostomy
Location: 3–4 cm from midline. In
adults, 6–7 cm above the inion; in
pediatrics, 2–3 cm above
the transverse sinus (i.e. ≈ 3–4 cm above
the inion).
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Midline suboccipital craniectomy
Indications:
Access to the midline or both sides of the posterior fossa
1. midline posterior fossa lesions
a) cerebellar vermian and paravermian lesions, including:
vermian AVM, cerebellar astrocytoma near the midline
b) tumors of the fourth ventricle: ependymoma, medulloblastoma
c) pineal region tumors
d) brainstem lesions: brainstem vascular lesions (e.g.cavernous angioma)
2. decompressive craniectomies: e.g. for Chiari malformation
3. cerebellar hemisphere tumors: metastases, hemangioblastoma, pilocytic
astrocytoma…
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POSTERIOR FOSSA CRANIOTOMIES
Position:
For midline lesions the Concorde position is usually used.

Skin/fascia incision :
Midline incision from ≈ 6 cm above inion to ≈ C2 spinous process.
Take the incision a little higher if a Frazier burr hole is to be done (can then
utilize the same skin incision).
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POSTERIOR FOSSA CRANIOTOMIES
Craniectomy :
Craniectomy implies removal of bone (often piecemeal) with no intention of replacing it.
The advantage to not replacing the bone is that if there is post-op swelling, the inelastic bone flap may
cause more pressure to be transmitted to the brainstem.

A down-side to not replacing the bone is that local pain and/or “syndrome of the trephined” may be more
common.
The bone opening is usually taken down to foramen magnum.

C1 removal: for cerebellar hemisphere tumors, many remove the posterior arch of C1 (caution for
vertebral arteries on superior aspect of C1).

For 4th ventricular tumors, consider removing the arch if the tonsils extend below the foramen magnum.
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POSTERIOR FOSSA CRANIOTOMIES
Approach:
A “Y” shaped durotomy is often used.
If the lesion has a cystic component, aspiration through a ventricular needle is used to partially
decompress it .
Approaches to the fourth ventricle:
1. transvermian approach:
● overview: the inferior vermis is incised and the two halves are retracted to opposite sides
● split the vermis to the smallest extent possible (usually up to the fastigium, but not into the
superior medullary velum)
● the nodule, tela choroidea and inferior medullary velum also need to be incised to access the
4th ventricle
● superior exposure is limited by the superior medullary velum
● PROS: wider and slighly more rostral exposure than telovelar approach
● CONS: risk of caudal vermis syndrome (truncal ataxia, dysequilibrium, oscillation of head and
trunk, nystagmus), cerebellar mutism, injury to dentate nucleus (more severe dysequilibrium)
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POSTERIOR FOSSA CRANIOTOMIES
Approach:
2. Telovelar approach (TVA):
● overview:
exposes the 4th ventricle through the cerebello-medullary fissure without incising
the vermis or cerebellar hemisphere

● PROS:
no functioning nerve tissue is harmed in the approach - which may reduce the risk of
cerebellar dysfunction, including cerebellar mutism
improved access to the lateral recess of the 4th ventricle
● CONS:
narrower corridor than with a widely split vermis; limited access to deep or large
tumors involving the rostral third of the 4th ventricle;
limited access to contralateral floor of the 4th ventricle (TVA can be done bilaterally to
circumvent this limitation
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POSTERIOR FOSSA CRANIOTOMIES
Post-op considerations for p-fossa craniotomies :

1. Respirations: rate, pattern

2. follow closely for hypertension
3. evidence of CSF leak through wound
4.Posterior fossa edema and/or hematoma
5.Suboccipital pseudomeningocele
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Supratentorial Craniotomies
1.Pterional craniotomy
2.Temporal craniotomy
a)Small craniectomy
b) Standard craniotomy
3.Frontal craniotomy
a) Unilateral frontal craniotomy
b) Bilateral frontal craniotomy
4.Petrosal craniotomy
5.Occipital craniotomy
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Supratentorial Craniotomies
1.Pterional craniotomy :
Indications:
1. aneurysms
a) all aneurysms of anterior circulation
b) basilar tip aneurysms
2. direct surgical approach to cavernous sinus
3. suprasellar tumors
a) pituitary adenoma (when there is a large suprasellar component)
b) craniopharyngioma
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Supratentorial Craniotomies
1.Pterional craniotomy :
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Supratentorial Craniotomies
1.Pterional craniotomy :
Skin incision:
From zygomatic arch 1 cm in front of tragus (to avoid frontalis branch of facial nerve
and frontal branch of superficial temporal artery), curving slightly anteriorly, staying behind hairline to
widow’s peak, optional additional curve beyond midline to aid in skin retraction.
Over temporalis muscle, incise skin down to but not through temporalis fascia.
The temporalis muscle may be incised caudal to the skin incision (i.e., closer to zygomatic arch);
this minimizes the muscle mass that needs to be retracted inferiorly and yet keeps the scar behind the
hairline
(note: there is a greater risk of frontalis weakness with this technique than if the temporalis muscle is
incised in-line with the skin incision)
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Supratentorial Craniotomies
2.Temporal craniotomy :
Indications:
1. temporal lobe biopsy
2. temporal lobectomy: for resection of seizure focus, decompression post-trauma…
3. hematoma (epidural or subdural) overlying temporal lobe
4. tumors of the temporal lobe
5. small, laterally located vestibular schwannomas
6. access to the floor of the middle cranial fossa (including foramen ovale/Meckel’s cave, the labyrinthine
and upper tympanic portion of the facial nerve)
7. access to medial temporal lobe e.g. for amygdalo-hippocampectomy or for mesial temporal sclerosis
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Supratentorial Craniotomies
2.Temporal craniotomy :
Small craniectomy:
Incision:
Linear skin incision completely within the extent of the temporalis muscle.
To access the temporal tip: Place the incision midway between the lateral canthus and external auditory canal (EAC);
extend it from the zygomatic arch upward for ≈ 6 cm.
For small, laterally located vestibular schwannomas, the incision is made 0.5 cm anterior to the EAC, extending ≈ 7–
8 cm above the zygomatic arch.
To drain a subdural, place the incision just anterior to the tragus and start it 1–2 cm above the
zygomatic arch for ≈ 6 cm (modified based on the location of the epicenter of the subdural).
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Supratentorial Craniotomies
2.Temporal craniotomy :
Standard craniotomy :
Question-mark skin incision:
Used for access to the temporal lobe including tip (a reverse question mark incision
may be used to gain access to the middle and posterior temporal lobe).
1. the pinna is either sutured inferiorly out of the way before draping, or it can be folded under the
drapes which may be stapled to the skin
2. the lower limb extends from the zygomatic arch just anterior to the tragus (to avoid the superficial temporal artery)
3. curve as far posteriorly as ≈ 6–7 cm on the dominant side, or ≈ 8–9 cm on the non-dominant side
at the level of the top of the pinna (these dimensions allow access to the “safe” area of temporal
tip for lobectomy)
4. then superiorly to the level of the superior temporal line
5. then anteriorly towards the forehead, stopping at the hair line.
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Supratentorial Craniotomies
3 . Frontal craniotomy :
Indications:
1. access to frontal lobe: e.g. for infiltrating tumor
2. approach to third ventricle or to sellar region tumors in some situations, including
craniopharyngiomas, planum sphenoidale meningiomas
3. repair of ethmoidal CSF fistula

Two basic choices for craniotomy:

a) unilateral craniotomy
b) large bifrontal
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Supratentorial Craniotomies
Unilateral frontal craniotomy:
incision:
Skin incision starts < 1 cm anterior to the tragus, and does not need to go all the way
down to the zygomatic arch. It curves superiorly and slightly posteriorly before being taken to the
midline frontally.
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Supratentorial Craniotomies
Bilateral frontal craniotomy:
ear-to-ear” or souttar skin incision
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Supratentorial Craniotomies
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Supratentorial Craniotomies
Petrosal craniotomy:
Indications:
1. lesions of the petrous apex (e.g. petroclival meningiomas)
2. lesions of the clivus (e.g. chordomas) with both posterior fossa and supratentorial components

Spares sinus and otologic apparatuses. Minimizes cerebellar and temporal lobe retraction.
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Supratentorial Craniotomies

Skin incision:
incision starting from
zygomatic arch 1 cm
anterior to tragus, arcing
posteriorly over ear,
descending to 0.5–1 cm
medial to mastoid notch.
Temporalis muscle and
periosteum reflected
anteriorly and inferiorly
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Supratentorial Craniotomies
craniotomy:
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