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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
Peter J. Morone, MD, MSCI∗ Intraventricular access is frequently required during neurosurgery, and when neuronavi-
Michael C. Dewan, MD, MSCI∗ gation is unavailable, the neurosurgeon must rely upon craniometrics to achieve successful
Scott L. Zuckerman, MD, ventricular cannulation. In this historical review, we summarize the most well-described
MPH∗ ventricular access points: Kocher’s, Kaufman’s, Paine’s, Menovksy’s, Tubbs’, Keen’s, Frazier’s,
R. Shane Tubbs, PhD, PA-C‡
Dandy’s, and Sanchez’s. Additionally, we provide multiview, 3-dimensional illustrations
that provide the reader with a novel understanding of the craniometrics associated with
Robert J. Singer, MD, MS§
each point.
∗
Department of Neurological Surgery, KEY WORDS: Cerebrospinal fluid diversion, Dandy’s point, External ventricular drain, Kocher’s point, Paine’s
Vanderbilt University Medical Center, point, Ventricular access
‡
Nashville, Tennessee; Department
of Neurosurgery, Seattle Science Operative Neurosurgery 0:1–9, 2019 DOI: 10.1093/ons/opz194
Foundation, Seattle, Washington;
§
Section of Neurosurgery, Dartmouth-
Hitchcock Medical Center, Lebanon, New

Hampshire
Correspondence:
Peter J. Morone, MD,
Department of Neurological Surgery,
Vanderbilt University Medical Center,
1161 21st Avenue South, T4224 MCN,
Nashville, TN 37232-2380.
Email: peter.morone@vumc.org
Received, February 27, 2019.
Accepted, April 11, 2019.
Copyright 
C 2019 by the
Congress of Neurological Surgeons
T
he ventricular system is routinely accessed
for a variety of emergent and elective
neurosurgical procedures.1-4 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.4-14 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 liter-
ature 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, we describe the
indications and operative techniques for 9
ventricular access points. We separate them into
anterior and posterior categories based upon
ABBREVIATION: CSF, cerebrospinal fluid
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, we include detailed, multiview
illustrations that provide the reader with a novel
understanding of the craniometrics associated
with each point.
ANTERIOR ACCESS SITES
Kocher’s Point
Kocher’s point is thought to be named
after the Swiss neurosurgeon Emil Theodor
Kocher (1841-1917).15 However, Cushing16
and Tillmanns6 are credited with describing
the first ventriculostomy through this point.
Kocher’s point is the most common location for
placement of an external ventricular drain for
emergent cerebrospinal fluid (CSF) diversion,
but its clinical applicability is diverse. This
location has been used for ventriculoperi-
toneal shunt catheter insertion,17 endoscopic
third ventriculostomy,18 endoscopic removal of
colloid cysts,19 and endoscopic removal of intra-
ventricular hemorrhage.20 The starting location
for Kocher’s point is a burr hole that is 11 cm
superior and posterior from the nasion
and 3 cm lateral to midline. This location
generally lies along the midpupillary line and is

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FIGURE 1. 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. 
C 2015 Elizabeth N. Weissbrod. Used with permission.

1 to 2 cm anterior to the coronal suture. Importantly, this point
is lateral to the superior sagittal sinus and anterior to the primary
motor cortex, 2 critical areas that should be avoided. For correct
placement of an external ventricular drain, the catheter should be
directed at an angle that is perpendicular to the intersection of
lines drawn from the ipsilateral medial canthus and the ipsilateral
external auditory meatus. The catheter should be passed to a
depth of approximately 6 cm below the skin surface or until the
frontal horn of the ipsilateral lateral ventricle is penetrated. For
maximal drainage of CSF, the tip of the catheter should be placed
near the foramen of Monro (Figure 1).2,21,22 In general, it is
safest to place the catheter on the patient’s right because this side
usually corresponds to the nondominant hemisphere. However,
depending upon the pathology and surgical goals, a left-sided
approach may also be used. Despite its popularity, ventricular
cannulation via Kocher’s point remains relatively inaccurate with
miss rates ranging from 4 to 40%.21,23
Kaufman’s Point
Kaufman’s point was first described by Kaufmann and Clark.8
Via a forehead approach, this point provides rapid access to the
ventricular system for emergent drainage of CSF. The starting
location for Kaufman’s point is a burr hole that is placed 5 cm
superior to the nasion and 3 cm lateral to midline. The catheter
should be aimed toward the midline and inferiorly toward a
point that is 3 cm superior to the inion. The catheter should
be passed approximately 7 cm below the surface of the skin and
placed within the frontal horn of the ipsilateral lateral ventricle
(Figure 2). When performing this technique, the skin can be
cleaned quickly because the patient’s hair does not need to be
clipped. Although this is an advantage cited by the authors,8 this
technique is rarely used in current practice secondary to cosmetic
appearance. The laterality of this approach can be right or left
depending upon the intracranial pathology and has a 90% success
rate,8 although, because of its rarity, no large series employing this
approach have been completed.
Paine’s Point
Paine’s point was initially described by Paine et al.9 It allows
for CSF drainage via direct ventricular puncture and was first
used in patients undergoing a frontotemporal craniotomy for
aneurysm clipping after aneurysmal subarachnoid hemorrhage.
This technique should be employed when there is concern for

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FIGURE 2. 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. 
C 2015 Elizabeth N. Weissbrod. Used with permission.

severe brain edema after completing a frontotemporal craniotomy.
In this setting, CSF egress lessens the need for brain retraction,
which can often be traumatic. 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.
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. The catheter should be advanced 4 to 5 cm or
until the frontal horn of the ipsilateral lateral ventricular is reached
(Figure 3). Although no clinical series have been reported demon-
strating the efficacy and safety of Paine’s point, several authors
have concluded that there is theoretical risk of damaging Broca’s
area, the head of the caudate nucleus, and the thalamus using this
approach.11,12
Modifications to Paine’s Point
Given the risk of damaging Broca’s area, the head of the caudate
nucleus, and the thalamus when passing a ventricular catheter
from Paine’s point, 2 modifications have been proposed.11,12
Similar to the indications for placement of a Paine’s point
ventricular drain, these modifications should be utilized to reduce
brain edema after completing a frontotemporal craniotomy.
Hyun et al11 suggested the entry point be extended 2 cm
from the anterior limb of Paine’s triangle. The ventricular
catheter should be aimed perpendicular to the convexity of the
brain and passed to a depth of 5 to 6.5 cm or until reaching
the frontal horn of the ipsilateral lateral ventricle (Figure 3).
In their study of 10 patients, the authors reported a 100%
success rate and concluded that their entry site resulted in a
more accurate trajectory compared with Paine’s point. However,
unlike the technique described by Paine et al,11 they used
neuronavigation.
Park and Hamm12 suggested the entry point be extended
2 cm from the posterior limb of Paine’s triangle. The ventricular
catheter should be aimed perpendicular to the convexity of the
brain and passed to a depth of 5 to 6 cm or until reaching
the frontal horn of the ipsilateral lateral ventricle (Figure 3).
The authors state that this entry site poses less risk of injury to
the head of the caudate nucleus, demonstrating only a 2.5%
chance of injury compared with a 90% chance of injury when
the catheter was passed from Paine’s point.12 Additionally, in their

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FIGURE 3. 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 6.5 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. 
C 2015 Elizabeth N. Weissbrod. Used with permission.

clinical series of 32 patients, the ipsilateral frontal horn was cannu-
lated successfully 94% of the time during first pass of the catheter.
Menovsky’s Point
Menovsky’s point was described by Menovsky et al10 and can
be employed while performing a supraorbital craniotomy through
an eyebrow incision. It is indicated in the setting of brain edema,
allowing for CSF drainage and brain relaxation prior to complete
bone removal.
After completing the initial exposure and drilling the keyhole
burr hole, the dura should be incised. The ventricular catheter
should be passed through the burr hole and directed 45◦ toward
the midline and 20◦ superior to the orbitomeatal line. It should
be passed to a depth of 5 to 6.5 cm or until the frontal horn of
the ipsilateral lateral ventricle is reached (Figure 4). In their series
of 10 patients and 5 cadaveric specimens, the authors reported an
87% first-pass ventricular cannulation rate.10
Tubbs’ Point
Tubbs’ point was given definitive landmarks by Tubbs et al,13
but this approach had been previously described in case
reports.24,25 It is used for emergent ventricular decompression
via a transorbital route and is completed with a spinal needle.
The needle tip is placed under the upper left or right eyelid and
advanced at a trajectory that is 45◦ superior to the orbitomeatal
line and 20◦ toward the midline. If done correctly, the orbital
roof should be penetrated just medial to the midpupillary line
and posterior to the superciliary arch. After advancing the spinal
needle approximately 8 cm, the frontal horn of the ipsilateral
lateral ventricle will be cannulated (Figure 5). Of note, because
ventricular access is obtained via a transorbital route, a burr hole
does not need to be drilled, making this procedure more time
efficient. Although expedient, this technique is seldom performed
because it increases the risk of a globe injury and requires blind
puncture of the orbital roof. Thus, no clinical series demon-
strating its efficacy and safety have been performed.

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FIGURE 4. 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. 
C 2016 Elizabeth N. Weissbrod. Used with permission.

POSTERIOR ACCESS SITES Frazier’s Point

Keen’s Point
Keen’s point was first described by Keen.5 It is indicated for
emergent CSF diversion during posterior fossa surgery and is
often included within the operative field. More commonly it
is used for the elective placement of a proximal ventriculoperi-
toneal shunt catheter.26 The burr hole should be placed approx-
imately 2.5 to 3 cm superior and posterior to the pinna of the
ear and can be placed on the patient’s left of right side depending
upon the intracranial pathology. The catheter should be aimed
in a slight cephalic direction and positioned perpendicular to the
temporal lobe cortex. It should then be passed to a depth of 4 to
5 cm or until reaching the trigone of ipsilateral lateral ventricle
(Figure 6).27,28 Of note, historically, Keen’s point was referred to
as the posterior parietal point.27 Even though multiple reports
have described successful ventricular cannulation using Keen’s
point,20,29 no clinical series determining its accuracy have been
completed.
Frazier’s point, described by Frazier,14,28 was initially used as a
surface landmark during extradural transection of the trigeminal
nerve in patients with trigeminal neuralgia. Today, it is used
during posterior fossa surgery when there is a need for rapid CSF
diversion to decrease elevated intracranial pressure. The burr hole
should be positioned 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. The catheter is
aimed medially and superiorly to a point that lies 4 cm above
the contralateral medial canthus and passed to an initial depth of
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 (Figure 7).30 Using these craniometrics, Lee et al30
simulated a 100% ventricular cannulation rate using magnetic
resonance imaging data in 10 patients. However, a clinical
series employing this technique in real patients has not been
completed.

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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 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. 
C 2016 Elizabeth N. Weissbrod. Used with permission.

FIGURE 6. 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. 
C 2016 Elizabeth N. Weissbrod. Used with permission.

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FIGURE 7. 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. 
C 2016 Elizabeth N. Weissbrod. Used with permission.

Dandy’s Point
Dandy’s point was described by Dandy7 as a way to perform
ventriculography via an occipital approach. Today, the utility of
this approach arises in scenarios in which CSF diversion is needed
for a patient already positioned for an occipital or retromastoid
craniotomy. This can be performed in a planned fashion just
prior to beginning the formal craniotomy, or, more commonly,
on an emergent basis wherein rapid, unplanned CSF diversion
is needed for a patient demonstrating intraoperative signs of
elevated intracranial pressure that require treatment. 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. The catheter tip is directed
toward a point 2 cm above the glabella and passed to a distance
of 4 to 5 cm or until CSF is encountered. At this point, the
tip of the catheter should be positioned within the body of the
ipsilateral lateral ventricle (Figure 8).28,30 Lee et al30 used these
craniometrics to simulate ventricular trajectories using magnetic
resonance imaging data from 10 patients and achieved a 100%
ventricular cannulation rate, but no studies involving real patients
have been completed. It is important to note that given the
catheter’s trajectory near or through the optic radiations, damage
to the visual fields is a theoretic concern when completing this
technique.
Sanchez’s Point
Sanchez’s point was described by Sanchez et al.4 This approach
is used to catheterize the temporal horn and can be employed to
divert CSF in the setting of a trapped ventricle or to endoscop-
ically access mesial temporal structures. The burr hole is made
5.6 cm above the inion and 2.7 cm left or right to the midline.
The catheter is directed 5◦ lateral from a parasagittal plane (which
is parallel to midline) and 30◦ inferior toward the orbitomeatal
plane. CSF should be encountered at 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 (Figure 9). Using 9 cadaveric specimens, Sanchez et al4
completed 18 approaches and achieved a 100% ventricular

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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.

C 2016 Elizabeth N. Weissbrod. Used with permission.

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 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. 
C 2016 Elizabeth N. Weissbrod. Used

with permission.

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cannulation success rate. To date, no studies using this approach
in real patients have been published.
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 experi-
enced neurosurgeons.
Disclosures
This study was supported by a grant from the Suzanne and Walter Scott
Foundation. The authors have no personal, financial, or institutional interest in
any of the drugs, materials, or devices described in this article.
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Acknowledgments
The authors would like to acknowledge Elizabeth N. Weissbrod, MA, CMI,
our medical illustrator, who spent countless hours creating realistic, high-quality
images for this manuscript.
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