3D Neuroanatomy

medical atlas
http://www.3dneuroanatomy.com

Craniometric points of the skull and the cerebral cortical

surface
Date : 25 septiembre, 2014

Fernndez-Cornejo, V (1); Gonzlez-Lpez, P (1); Abarca-Olivas, J (1); Mndez-Romn, P

(1); Moreno-Lpez, P (1); Sanchez del Campo, F (2)
(1) Department of Neurosurgery, Hospital General Universitario de Alicante, Alicante (Spain).
(2) Department of Anatomy and Histology, Universidad Miguel Hernndez. Campus de San
Juan, Alicante (Spain).

1-INTRODUCTION
The brain sulci and gyri constitutes the main cortical and neuroanatomic limits, landmarks and
operative corridors. The identification of these anatomical structures before and after performing
the craniectomy can help us delimitate the intracraneal lesions and preserve as much as
possible the neurofunctional and eloquent reas that lies around with the aid of actual and

1 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

modern technology.
Its difficult to identifying these anatomical structures intraoperatively with precision and thats
why the main purpose of this study is to establish cortical and sulcal key points of primary
microneurosurgical importance in order to facilitate the placement of the craniotomies and the
identification of the main brain sulci, thereby providing a sulcal base anatomic framework.

2-FRONTOTEMPORAL KEY POINTS

2a- The Anterior Sylvian Point (ASP)
figure 1.

The anterior Sylvian point (ASP) is a cisternal like enlargement of the Sylvian fissure (SyF).
Limits of the ASP: Superior: Pars triangularis; Inferior: superior temporal gyrus (T1); Posterior:
Pars opercularis; Anterior: Pars orbitalis. The ASP divides the SyF into an anterior and
posterior segment and has a constant location. This anatomic point is the best place to start the
opening of the SyF since is the point of maximum separation of the frontal and temporal
operculum. The suprasylvian structures (fronto-parietal operculum) should be imagine as a
series of V and U shape gyri as shown in the picture above. I- The most anterior V shape
gyrus corresponds to the Pars triangularis (color orange on figure 1). Anteriorely to this gyrus is
the Pars orbitalis (shown in color red on figure 1). II- Posteriorely to the previous gyrus we can
find a U shape gyrus, the Pars opercularis (colored brown gyrus. figure 1) . This gyrus is limited
posteriorely by the precentral sulcus. Together the pars triangularis and opercularis constitute
the motor speech area of Broca in the dominant hemisphere (Brodmann reas 44 and 45). IIIThe next U shape gyrus is called the Subcentral gyrus (Yellow colored on figure 1), also
called the "Rolandic operculum" or the classically named inferior frontoparietal plis de passage
of Broca. Just below and over the Sylvian fissure is situated the inferior Rolandic point (IRP).
This gyrus is visible in 95 % of the cases after the dura opening, the other 5 % of the cases is
hidden under the superior temporal gyrus. The subcentral gyrus contains the Rolandic central
sulcus and therfore formed by the primary motor and sensitive gyrus. Anterior limit: precentral
sulcus; Posterior limit: postcentral sulcus. IV- The third U shaped gyrus (shown on light
blue) is located posteriorely to the postcentral sulcus. Corresponds to the arm shaped
gyrus that connects the postcentral and supramarginal gyri. V- The inverted U-shaped gyrus

2 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

(Green figure 1) completes the supramarginal gyrus and it connects inferiorely to the most
posterior part of the superior temporal gyrus. figure 2.

The opening of the SyF at the level of the ASP shows very soon the insular apex on its depth.
The Insular limen wich is the point were the middle cerebral artery bifurcates
is located inferiorly and posteriorly (1-2 cm) to the ASP under the depth of T1 and corresponds
to the uncinate fasciculus wich connects parts of the limbic system. The opening of the SyF
posteriorly to the ASP exposes the insular region and the opening of the SyF anteriorly to the
ASP leads the surgeon to the suprasellar cisterns. The distance between the ASP and the IRP
along the SyF is of arround 2.3 cm (2-2.5 cm). See figure 2. figure 3.
The ASP is related with de external craneal surface at the ANTERIOR SQUAMOUS POINT
wich is defined as the point located at the uppermost portion of the junction between the
Squamous suture and the sphenoids greater wing. (see figure 3).

2b- The Inferior Rolandic Point (IRP)

figure 4.

3 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

The INFERIOR ROLANDIC POINT (IRP) is anatomically situated just below the Rolandic
central sulcus (CS) just over the SyF. This point is situated 2-2.5 cm posterior to the ASP. The
IRP also corresponds to the anterior limit of the Tranverse gyrus of Heschl or TGH (primary
auditory area), this gyrus is allways "kissing" the postcentral gyrus (primary sensory area). The
TGH on the surface of the superior temporal gyrus corresponds to Wernicke area on the
dominat hemisphere wich extends posteriorly to the Angular Gyrus. In other words, the temporal
lobectomy should never surpass the IRP in order to preserve Wernickes area. (figure 4)
figure 5.

The IRP In relation with the cranium, lies at the junction of a vertical line just anterior to the
tragus (approximately 4cm above the tragus) and the most superior part of the squamous suture
(superior squamous point). Another way to get to the same point (IRP) is to measure 2.5 cm
posterior to the Pterion over the squamous suture line as referred by Rhoton Jr. (Figure 5).

2c- The Inferior Frontal Sulcus and Precentral Sulcus Meeting

4 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

point (IFS/PCS)

figure 6

The Inferior Frontal Gyrus (IFS) can be connected or almost connected with the Precentral
Sulcus (PCS). This junction point is called The IFS/PreCS meeting point, a practical
neurosurgical key point that can help us localize the precentral gyrus, just posterior and over the
precentral gyrus of this point, correspond specifically to the face motor activation area and also
delimitates the middle frontal gyrus (F2) from the inferior frontal gyrus (F3 / frontal operculum).
See figure 6.
Figure 7.

The Stephanion point is a craniometric point at the level of the intersection between the coronal
suture and the superior temporal line. Normally, the IFS/PreCS meeting point lies around 2 cm
posterior to the Stephanions.

5 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

An easy way to delimitate Brocas area on the dominant hemisphere is by localizing the four
craniometrical points seen on figure 7. a) the Stephanion, b) 2 cm posterior to the Stephanion
C) the anterior Sylvian point and D) the IRP.

3- THE SUPERIOR FRONTAL AND CENTRAL GYRUS KEY

POINTS
3a-The superior frontal sulcus and precentral sulcus meeting point
(SFS/PCS)
figure 8.

The superior frontal sulcus (SFS) is constant and usually a continuous segment and correlates
with the underlying frontal ventricular horn. Considered an important neurosurgical
corridor. Posteriorly to the union of the SFS with the PreCS correlates to the hand motor
activation area. See figure 8 and 9.
Figure 9.

6 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

The SFS/PCS meeting point is coronally related with the superior surface of the thalamus and
with the body of the lateral ventricle just behind the foramen of Monro.
Figure 10.

The POSTERIOR CORONAL POINT (PCoP) its the craniometrical point located 3 cm lateral to
the sagittal suture and 1 cm posterior to the coronal suture, this PCop locates the hand motor
cortex underneath the bone, an important neurosurgical landmarc wich must be taken into
account in procedures around this area. (Figure 10).

3b-The superior Rolandic point (SRP).

Figure 11.

7 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

The Superior Rolandic Point (SRP) corresponds to the most superior point of the Central
Sulcus. Located 5 cm posterior to the bregma. (figure 11). This craniometrical point is used for
the exposure of the precentral and the postcentral gyri.

4- PARIETAL KEY POINTS

4a-The intraparietal and post central sulcus meeting point
(IPS/PCS)
Figure 12.

The Intraparietal Sulcus (IPS) can be a continuous or interrupted sulcus on the parietal
parenchyma, usually parallel to interhemispheric sulcus and separating the superior from the
inferior parietal lobules. The IPS is related anteriorly with the post central sulcus (PCS) and
posteriorly it usually continues with the transverse occipital sulcus. (figure 12). It is important to

8 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

locate the IPS/PCS meeting point because: 1- Anteriorly to this point we find the postcentral
gurys. 2- It can be use in a neurosurgical procedure as a safe starting point for the transulcal or
transcortical opening. 3- It is related on its depth to the ventricular trigone. Figure 13.

The IPS/PCS craniometrical point is located 6 cm anterior to Lambda and 5 cm lateraly to the
sagittal suture. (figure 13).

4b-Craniometrical Key Point of The External Occipital Fissure

(EOF)
figure 14.

The external occipital fissure (EOF) corresponds to the extension of the Parieto-Occipital Sulcus
(POS) into the brain convexity. It is usually a deep transversal sulcus on the medial side of each
hemisphere. Figure 14.

9 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

Figure 15.

The EOF/POS meeting point is a useful surgical landmark because it defines the parietooccipital sulcus wich divide de precuneus (parietal) fron the cuneus (occipital) . Figure 15.
Figure 16.

This sulcal key point (EOS/POS) lies underneath each paramedian area corresponding to the
angle between the sagittal and lambdoid suture. The craniometrical position of Lambda in adults
is around 25 cm posterior to the Nasion, 13 cm posterior to the Bregma and 3 cm superior to the
Opisthocranion (not to be confused with the Inion). Figure 16.
figure 17.

10 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

In this picture we can appreciate the POS and Calcarine sulcus wich divide the posterior medial
brain surface in to the Cingularis gyrus (on the precuneus depth), the Precuneus, the Cuneus
and Lingualis Giri.

4c-The Euryon (Eu)

Figure 18.

The Euryon or maximal raised point of the parietal tuberosity is located on the junction of the
superior temporal line (STL) and a vertical line drawn over the most posterior part of the mastoid
and through the posterior limit of the squamous suture. (figure 18)
Figure 19.

11 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

The Euryon was found to be over the superior aspect of the supramarginalis gyrus (SMG). The
SMG and Angular Gyrus (AG) belong to the inferior parietal lobule and is separated from the
superior parietal lobe by the intraparetal sulcus, as you can see on figure 19 and 20.
Figure 20.

The Sulcus that separates the Supramarginalis Gyrus (SMG) and the Angular Gyrus is named
"The intermediary sulcus of Jensen" (ISJ) (Figure 20). The ISJ usually continues with the IPS.
The SMG is the gyrus found at the most posterior point along the Sylvian fissure and the AG is
in the gyrus found at the most posterior point of the superior temporal sulcus (STS). Regarding
to the possible surgical complications on parietal approaches, in the dominant hemisphere
language impairments can be related to the damage of the SMG and AG (Wernickes area).

5- POSTERIOR AND OCCIPITAL POINTS

5a-Posterior temporal key point.

12 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

Figure 21.

Deep in the Superior Temporal Sulcus (STS) we can access to the inferior horn of the lateral
ventricle. On its posterior third portion the ventricular atrium also can be approached. (Figure
21).
Figure 22.

The POSTERIOR TEMPORAL POINT lies normaly unterneath the most posterior portion of the
superiot temporal gyrus and it is located 3 cm vertically above the meeting point between the
parietomastoid suture (figure 22 and 23)
Figure 23.

13 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

The Posterior Temporal Point (PTP) was shown to be 2-3 cm posterior and inferior to the
Sylvian fissure.

5b-Occipital key point.

Figure 24.

The most prominent occipital cranial point is called "The opisthocranion" (fig.24) Figure 25.

14 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

The opisthocranion is related to the superior aspect of the calcarine fissure and the base of the
cuneus. The distance from the opisthocranion to the occipital base or inion is of approximately 2
cm and corresponds to the occipital Lingual gyrus (green). The distance from Lambda to the
opisthocranion is between 2 and 4 cm and indicates the occipital cuneus (purple). see fig 25.
Figure 26.

Interhemispheric approaches through occipital craniotomies done below the lambda usually
have the advantage of dealing with fewer bridging veins than in parietal craniotomies.

6-REFERENCES
R.S. Tubbs, G. Salter, J. Oakes. Superficial surgical landmarks for the transverse sinus and
torcular herophili. J. Neurosurg. 93: 279-281, 2000 S. Gusmao, R. Leal, A. Arantes. Pontos
referencias nos accesos cranianos. Arq Neuropsiquiatr. 2003; 61 (2-A): 305-308. Martinez F.,
Laxague A., Vida L., et al. Anatoma topogrfica del asterion. Neurocirugia 2005; 16: 441-446.
Ribas G.C., Ferreira R., Junqueira A. Anaglyfphic three-dimensional stereoscopic printing:
revivan of an old method for anatomical and sufical teaching and reporting. J. Neurosurg 95:
1057-1066, 2001. Ribas G. C., Ribas E.C., Junqueira C. The anterior sylvian point and the
suprasylvian operculum. Neurosurg Focus 18 (6b), 2005. Kendir S. , Acar H.I., Comert A., et al.

15 / 16

3D Neuroanatomy
medical atlas
http://www.3dneuroanatomy.com

Window anatomy for neurosurgical approaches. J. Neurosurg. April 10. 2009 Ribas G.C.,
Yasuda A., Ribas E.C., Nishikuni K. Surgical Anatomy of microneurosurgical sulcal key points.
Neurosurgery 59: ONS 177-210. 2006.

16 / 16
Powered by TCPDF (www.tcpdf.org)