CORRESPONDENCE
Letter: 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
To the Editor:
In their recent article, “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” Morone et al1
provide an excellent overview of the various methods of obtaining
ventricular access based on different cranial starting points and
drain trajectories. As the authors expertly illustrate, Kocher’s
point is the most common starting cranial location and is used
in the vast majority of cases, especially for emergency external
ventricular drain (EVD) placement. We agree with the authors
that the other cranial points of access are most commonly used
intraoperatively when the entry point is limited by the exposed
surgical field. The authors should be commended for their
FIGURE. The starting location and trajectory of the temporal horn EVD.
OPERATIVE NEUROSURGERY
exemplary article; they provide an excellent resource for neuro-
surgeons seeking a useful and well-illustrated reference for cranial
access.
In this letter, we wish to highlight one additional ventricular
access method not discussed by Morone et al1 : the temporal
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EVD. The temporal EVD is a useful bedside procedure when
the temporal horn requires cannulation, most commonly after
becoming trapped by a lesion more proximal in the ventricular
system (see Figure). When placing this drain, we typically use
an entry point 1 cm anterior and 1 cm superior to the superior
attachment of the pinna to the scalp. The pinna attachment is
usually just superior to the root of the zygoma. The catheter
is inserted perpendicular to the sagittal plane into the temporal
horn of the ventricle. Bohl et al2 found that this perpendicular
approach is associated with the highest likelihood of successful
cannulation of the temporal lobe, especially in the setting of
a dilated temporal horn. For both the entry point and the
depth of insertion, we always verify the desired location on
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CORRESPONDENCE

preprocedural computed tomography (CT) and confirm the Disclosures

entry point in relation to external landmarks. This is essential The authors have no personal, financial, or institutional interest in any of the
to ensure that the entry point and catheter depth is tailored drugs, materials, or devices described in this article.
to each specific patient and pathology. If there is any concern
about entry point, an external fiducial may also be placed and John F. Burke, MD, PhD
a new scan obtained to provide external orientation. Finally, it is Stephen T. Magill, MD, PhD
important to place the drain nearly to the depth of the medial Department of Neurological Surgery
wall of the temporal horn as measured from the skin on the University of California, San Francisco

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preprocedural CT, and not to stop when CSF is first encoun-
tered, because the dilated temporal horn will usually retract
after drain placement, which can leave the catheter nonfunc-
tional and sandwiched within the parenchyma after initial
drainage.
Again, we wish to congratulate and thank Morone et al1 for
a useful, illustrative, and practical guide to the various starting
locations and trajectories of ventricular access, and hope this letter
will serve to complement their work, which will be very useful to
neurosurgeons for years to come.
San Francisco, California
REFERENCES
1. Morone PJ, Dewan MC, Zuckerman SL, Tubbs RS, Singer RJ. 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. Oper Neurosurg. 2020;18(5):461-
469.
2. Bohl MA, Almefty KK, Nakaji P. Defining a standardized approach for the
bedside insertion of temporal horn external ventricular drains. Neurosurgery.
2016;79(2):296-304.
Copyright 
C 2020 by the Congress of Neurological Surgeons

Funding
10.1093/ons/opaa266
The current work was supported by the UCSF Department of Neurosurgery.

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