Neurosurg Focus 19 (2):E1, 2005

Suboccipital burr holes and craniectomies

GUILHERME C. RIBAS, M.D., ALBERT L. RHOTON JR., M.D., OSWALDO R. CRUZ, M.D.,
AND DAVID PEACE, M.S.

Department of Neurosurgery, University of Florida, Gainesville, Florida; and Departments of

Neurosurgery and Surgery (Clinical Anatomy Discipline), University of São Paulo Medical School,
São Paulo, Brazil

Object. The goal of this study was to delimit the external cranial projection of the transverse and sigmoid sinuses,
and to establish initial strategic systematized burr hole sites for lateral infratentorial suboccipital approaches based on
external cranial landmarks particularly related to the lambdoid, occipitomastoid, and parietomastoid sutures.
Methods. The external cranial projection of the transverse and sigmoid sinuses was studied through their external
outlining obtained with the aid of multiple small perforations made from inside to outside along the inner margins of
the sinuses of 50 paired temporoparietooccipital regions in 25 dried adult human skulls. The burr hole placement was
studied by evaluating the supratentorial, over-the-sinuses, and infratentorial components of 1-cm-diameter openings
made at strategic sites identified in the initial part of the study, which was performed in another 50 paired tem-
poroparietooccipital regions.
The asterion and the midpoint of the inion–asterion line were found to be particularly related to the inferior half of
the transverse sinus; the transverse and sigmoid sinuses’ transition occurs 1 cm anteriorly to the asterion across the
parietomastoid suture, and the most superior part of the sigmoid sinus is located anteriorly to the occipitomastoid
suture, with its posterior margin crossing this suture posteriorly to the most superior aspect of the mastoid process,
which is located at the most superior level of the mastoid notch. Burr holes made at the midpoint of the inion–asteri-
on line, at the asterion, 1 cm anterior to the asterion, just inferiorly to the parietomastoid suture, and over the occipito-
mastoid suture at the most superior level of the mastoid notch are appropriate to expose the inferior half of the trans-
verse sinus at its midpoint, the inferior half of the transverse sinus at its most lateral aspect, the transverse and sigmoid
sinuses’ transition, and the posterior margin of the basal aspect of the sigmoid sinus, respectively.
Conclusions. These findings allow an estimation of the transverse and sigmoid sinuses’ external cranial projection.
The asterion and the most posterior part of the parietomastoid suture constitute a suitable initial burr hole site at which
to perform an upper or asterional suboccipital craniectomy to expose the superior aspect of the cerebellopontine angle
(CPA). The occipitomastoid suture at the most superior aspect of the mastoid notch constitutes an adequate initial burr
hole site at which to perform a basal suboccipital craniectomy to expose the lower portion of the CPA. The sites can
be used together as initial burr hole sites to perform wide suboccipital exposures, because they already constitute nat-
ural infratentorial lateral limits.

KEY WORDS • cranial suture • transverse sinus • sigmoid sinus • burr hole •
craniotomy • suboccipital approach • cerebellopontine angle • posterior fossa

Whereas the frontotemporal approaches are relatively
systematized in the sense that the craniotomies proceed
from defined burr hole sites,76,78 the lateral suboccipital ap-
proaches are performed from various and nonstandardized
initial burr hole placements. Because the transverse and
sigmoid sinuses are the natural limits of these exposures,
the knowledge of their cranial topography constitutes the
main factor in the planning of these posterior approaches.
The lambdoid, occipitomastoid, and parietomastoid su-
tures are easily recognizable structures on the external cran-
ial surface.35,42,47,49,60–63,69–72 For this reason we initially inves-
tigated their relationships with the transverse and sigmoid
sinuses, and based on these findings, we evaluated the topo-
Abbreviation used in this paper: CPA = cerebellopontine angle.
graphic profiles of strategic burr hole sites related to these
sutures (Fig. 1).
MATERIALS AND METHODS
This study was conducted in two stages, in each of which 50
paired temporoparietooccipital regions in 25 adult human dried
skulls were studied through observations and measurements.57
In the first part, the anatomical relationships of the lambdoid,
occipitomastoid, and parietomastoid sutures to the transverse and
sigmoid sinuses were studied in 25 adult human uncataloged skulls,
originally from India, at the Theodore Gildred Microsurgical Edu-
cation Center of the Department of Neurological Surgery of the Un-
iversity of Florida. The calvariae of the skulls were removed above
the lambda and the superior orbital ridges, the transverse and sig-
moid sinuses superior and inferior margins were drawn on the outer

Neurosurg. Focus / Volume 19 / August, 2005 1

 G. C. Ribas, et al.

Fig. 1. Photographs of dried adult human skulls showing the external cranial surface (left) and the internal cranial surface (right).

surface of the skulls after multiple small perforations were made on
its bone landmarks from inside to outside, and the main points to be
studied were identified.
The second part of the study was done at the Anatomical Museum
of the Biomedical Sciences Institute of the University of São Paulo
through observations and measurements obtained in 25 adult human
skulls cataloged according to their race, sex, and age (Table 1).The
calvariae had already been removed in these skulls, and the points to
be studied were lightly marked with a pencil.
The burr hole study was conducted by evaluation of the posteri-
or fossa, the area over the sinuses, and supratentorial components of
1-cm-diameter burr holes placed at strategic sites related to the cran-
ial sutures. The burr holes were plotted with the aid of a circular de-
vice adapted to a compass, and the measurements of the height of
each burr hole’s topographic components provided the data to elab-
orate its topographic profile.
An extensive statistical analysis was done to compare the results
among the different sides, sexes, and races.
(Fig. 2). The analysis of its distance to the superior and
inferior margins of the transverse sinus, and of the sinus
height at this point, led us to conclude that the asterion is
particularly related to the inferior half of the transverse
sinus. The topography of the transverse sinus segment pos-
terior to the lambdoid and occipitomastoid sutures was
evaluated through the disposition of the inion–asterion line
in relation to the sinus (Fig. 3).
The analysis of the distances to both margins from the
midpoint of the inion–asterion line, and the sinus height at
that point, showed that its position in relation to the trans-
verse sinus is similar to the disposition of the asterion,
being also related to the inferior aspect of the sinus sulcus
(Fig. 4).
The topography of the part of the transverse sinus ante-

RESULTS
Anatomical Relationships of the Lambdoid, Occipitomastoid,
and Parietomastoid Sutures With the Transverse and Sigmoid
Sinuses
Anatomical Relationships of the Lambdoid and Occipitomas-
toid Sutures With the Transverse Sinus. The relationships of
the lambdoid and occipitomastoid sutures with the trans-
verse sinus were evaluated through the asterion position
Fig. 2. Schematic drawing showing the variation of the asteri-
on’s position in relation to the transverse sinus (mean values, tak-
ing into account variations between races). Values in all schematic
TABLE 1 drawings except Fig. 3 are given in centimeters, and commas
Identification of the 25 catalogued skulls studied denote decimal points.

Feature Value

race
African-American 7
Caucasian 9
mixed 9
sex
F 11
M 14
age (yrs)
min 18.0
max 60.0
mean 33.9
Fig. 3. Schematic drawing showing the disposition of the
median 34.0
inion–asterion line in relation to the transverse sinus.

2 Neurosurg. Focus / Volume 19 / August, 2005

Suboccipital burr holes and craniectomies
Fig. 4. Schematic drawing showing variation in the position of
the midpoint of the inion–asterion line in relation to the transverse
sinus (mean values, taking into account variations between races).
Fig. 5. Schematic drawing showing the disposition of the most
anterosuperior and anteroinferior points in the asterion and trans-
verse sinus (T.S.; mean values according to race).
Fig. 6. Schematic drawing showing variations in the position of
the most anterosuperior and anteroinferior points in the transverse
sinus in relation to the parietomastoid suture (mean values, taking
into account variations between races).
Fig. 7. Schematic drawing showing variations in the position of
the parietomastoid suture/squamous suture meeting point in rela-
tion to the transverse sinus superior margin/middle fossa floor level
(mean values, taking into account variations between races).
Neurosurg. Focus / Volume 19 / August, 2005
Fig. 8. Schematic drawing showing variations in the position of
the occipitomastoid suture/sigmoid sinus posterior margin crossing
point along the occipitomastoid suture (mean values, taking into
account variations between races).
rior to the lambdoid and occipitomastoid sutures was eval-
uated through analysis of the disposition of its most antero-
superior and anteroinferior points in relation to the asteri-
on. These points, which were equivalents to the superior
and inferior aspects, respectively, of the transverse sinus/
sigmoid sinus transition, presented the disposition depicted
in Fig. 5 in relation to the asterion.
Anatomical Relationships of the Parietomastoid Suture
With the Transverse Sinus. These relationships were initial-
ly evaluated through analysis of the transverse sinus’ most
anterosuperior and its most anteroinferior points in relation
to this suture. Whereas the position of the point corre-
sponding to the superior aspect of the sinuses’ transition
varied from 0.1 to 0.3 cm above the parietomastoid suture,
the point corresponding to the inferior aspect of the sinus-
es’ transition was situated below the suture at a mean dis-
tance of 0.8 cm, regardless of the race, sex, and side of the
skulls (Fig. 6).
The easily identifiable parietomastoid suture/squamous
suture meeting point was particularly studied in terms of its
position in relation to the superior margin of the transverse
sinus or to the middle fossa floor/tentorium, and was
shown to be related with this level (Fig. 7).
Anatomical Relationships of the Occipitomastoid Suture
With the Sigmoid Sinus. These relationships were evaluated
by studying the topography of the occipitomastoid suture/
sigmoid sinus posterior margin crossing point. The analy-
sis of the distances of this crossing point to the asterion and
to the jugular foramen identified its position along the oc-
cipitomastoid suture (Fig. 8).
This point was also shown to be closely related to the in-
ion–mastoid tip line level and to the posterior aspect of the
mastoid notch (Figs. 9 and 10).
Study of Burr Hole Sites Related to Lambdoid, Occipito-
mastoid, and Parietomastoid Sutures
The results presented here were determined through
evaluation of the 1-cm burr holes’ mean topographic pro-
files in six openings made in three different groups that
were studied for specific purposes.
Burr Holes at the Asterion and at the Midpoint of the In-
ion–Asterion Line. As shown in Fig. 11, these results prove
that both burr holes are adequate to expose the transverse
sinus, with the second one being more appropriate to ex-
pose both the sinus and the posterior fossa compartment.
3
 G. C. Ribas, et al.

Fig. 9. Schematic drawing showing variations in the position of

the occipitomastoid suture/sigmoid sinus posterior margin crossing
point in relation to the level of the inion–mastoid tip line (mean val-
ues, taking into account variations between races).

Burr Holes Anterior to the Asterion. As shown in Fig. 12,

these two burr holes were also evaluated for their potential Fig. 11. Schematic drawings showing topographic profiles of
to expose the inferior aspect of the transverse sinus/sig- the 1-cm-diameter burr hole centered on the asterion (1), and cen-
moid sinus transition, and the latter proved to be more ap- tered on the midpoint of the inion–asterion line (2).
propriate for this purpose, yielding results not dependent
on race, sex, or side of the skull (Table 2).
Burr Holes Over the Occipitomastoid Suture. As shown in
Fig. 13, the comparison of their topographic profiles shows
that both burr hole sites are appropriate to expose the sig-
moid sinus posterior margin and the posterior fossa com-
partment.

DISCUSSION
The suboccipital approach to the CPA used nowadays is
still based on the unilateral craniectomy described by Dan-
dy8,9 in 1929 and in 1934, which was later made through a
straight lateral incision as proposed by Adson1 in 1941, and
then extended laterally and inferiorly as was already em-
phasized by Bucy7 in 1951. The microsurgical techniques
introduced by Rand and Kurze51 in 1965 enabled the devel-
opment of acoustic tumor exposure, particularly by drilling
of the posterior meatal wall.
Although they obtain very similar CPA exposures, the
most experienced neurosurgeons in this field perform their
craniectomies differently according to their own experi- Fig. 12. Schematic drawings showing topographic profiles of
the 1-cm-diameter burr hole with its superior base on the asterion
and on the parietomastoid suture (3), and centered 1 cm anteriorly
to the asterion and with its superior base on the parietomastoid
suture (4).

TABLE 2
Exposure of the inferior aspect
of the transverse sinus/sigmoid sinus transition*
Exposure (%)

Site Yes No

burr hole 3 34 66
Fig. 10. Schematic drawing showing variations in the position burr hole 4 84 16
of the occipitomastoid suture/sigmoid sinus posterior margin cross- * Exposure of the inferior aspect by the 1-cm burr hole with its superior
ing point in relation to the posterior and superior aspect of the mas- base on the asterion and on the parietomastoid suture, and by the 1-cm burr
toid notch (mean values, taking into account variations between hole centered 1 cm anteriorly to the asterion and with its superior base on
races). the parietomastoid suture.

4 Neurosurg. Focus / Volume 19 / August, 2005

Suboccipital burr holes and craniectomies
Fig. 13. Schematic drawings showing topographic profiles of
the 1-cm-diameter burr hole over the occipitomastoid suture at the
level of the posterior aspect of the mastoid notch (5), and centered
on the intersection point of the occipitomastoid suture/inion–mas-
toid tip line (6).
ence,37,38,44,45,52,53,55,56,58,59,67,68,76,77,79,80 placing the initial burr
holes randomly or over nonspecific anatomical sites.
Malis37 placed his initial burr hole behind the occipito-
mastoid suture, between the asterion and the posterior as-
pect of the mastoid notch, hence below the transverse sinus
and posterior to the sigmoid sinus according to our find-
ings. The lateral suboccipital craniotomy described by Yaş-
argil and colleagues76,77,80 is done from “two infratentorial
burr holes located on the superior nuchal line and one su-
pratentorial burr hole placed 2 to 3 centimeters above this
line.”76 Considering our results pertinent to the inion–aste-
rion line, which is higher than the superior nuchal line,6 and
the mean topographic profile of the burr hole centered 1 cm
above its midpoint, the highest burr hole proposed by Yaş-
argil might not be supratentorial in some circumstances.
Ojemann and Martuza46 described this approach as a “cran-
iectomy that exposes the lateral two thirds of the cerebellar
hemisphere and the transverse and sigmoid sinuses medial
margins.” Samii and Draf58,59 and Rhoton52,53,56 also empha-
sized the importance of the lateral extension, without point-
ing to specific landmarks for the burr holes and craniecto-
my placements.
Our study was based on the assumption that there is a
precise relationship between the location and the volume of
the venous sinuses and the markings on the skull, which
has already been confirmed by previous authors.43,73–75 The
easy identification of these markings on the internal sur-
face, and of the sutures on the external surface of the skull,
made this study feasible. The main conclusions reached
from the statistical analysis of the anatomical relationships
of the lambdoid, occipitomastoid, and parietomastoid su-
tures in the transverse and sigmoid sinuses part of the study
were as follows: 1) the asterion and the midpoint of the
inion–asterion line are particularly related to the inferior
half of the transverse sinus; 2) the superior and inferior
points of the transverse and sigmoid sinus junction are sit-
uated above and below, respectively, the posterior part of
Neurosurg. Focus / Volume 19 / August, 2005
the parietomastoid suture; 3) the meeting point of the pari-
etomastoid and squamous sutures is located at the level of
the posterior part of the middle fossa floor; and 4) the
occipitomastoid suture and the crossing point of the sig-
moid sinus posterior margin are situated at the level of the
superior and posterior aspect of the mastoid notch, and also
correspond to the level of the intersection point of the
occipitomastoid suture with the imaginary line of the in-
ion–mastoid tip.
In the study of burr hole sites there were no significant
differences regarding the topographic profiles of the sexes
and sides of the skull. The main conclusions reached in this
part of the study were as follows: first, burr holes centered
at the asterion (1) and at the midpoint of the inion–asterion
line (2) are adequate to expose the transverse sinus; second,
burr holes with their superior base on the asterion and on
the parietomastoid suture (3) and centered 1 cm anterior to
the asterion with their superior base on the parietomastoid
suture (4) are sufficient to expose the inferior aspect of the
transverse sinus next to the transverse sinus/sigmoid sinus
transition, with the latter site more often involving the infe-
rior aspect of the sinuses’ transition; and third, burr holes
over the occipitomastoid suture at the posterior level of the
mastoid notch (5) and centered on the intersection point of
the occipitomastoid suture/inion–mastoid tip line (6) are
suitable to expose the posterior aspect of the sigmoid sinus
and the posterior fossa compartment.57
The results of this study allowed the delineation of the
transverse and the sigmoid sinuses externally based on the
identification of external bone landmarks, and provided
the groundwork for the part of the study relating to burr
hole sites. That part of the study was conducted to estab-
lish systematized lateral suboccipital approaches to expose
the superior aspect, the inferior aspect, and wide access to
the CPA.
Delineation of the Transverse and Sigmoid Sinuses
Allowing an error range of 0.5 cm, the results of this
study enabled the transverse and sigmoid sinuses’ margins
to be progressively traced on the skull’s outer surface from
the suture identification. Because the asterion is specifical-
ly related to the inferior half of the transverse sinus, its iden-
tification, together with the knowledge of the sinus height
at this point (1 cm), permit its inferior and superior margins
to be delineated at the level of the asterion. The occipito-
mastoid suture and crossing point of the sigmoid sinus’
posterior margin can be identified along the suture at the
level of the most superior aspect of the mastoid notch, and/
or at the level of this suture’s point of intersection with the
imaginary line of the inion–mastoid tip, and allow the pos-
terior margin of the sigmoid sinus to be outlined. The
knowledge of the relationship of the inion–asterion line and
its midpoint with the inferior aspect of the proximal portion
of the transverse sinus permits its delineation, and by using
parallelism the superior margins can then be completed
(Fig. 14).
ASTERIONAL SUBOCCIPITAL CRANIECTOMY
A circumscribed craniectomy systematically started
through a burr hole centered on the asterion, and extended
mainly along the parietomastoid suture is particularly ap-
5

propriate for the approach to the upper portion of the CPA
(Figs. 15 and 16), because it provides exposure of the infe-
rior aspect of the distal portion of the transverse sinus and
its transition into the sigmoid sinus. The extension of the
bone removal depends on the surgical plan and on the
experience of the surgeon.
The cranial approach required for posterior fossa neuro-
vascular decompression of the trigeminal nerve constitutes
the prototype of a high lateral suboccipital craniectomy, be-
cause the cerebellum has to be predominantly retracted
along the tentorial aspect of its anterolateral margin30,41 due
to the trigeminal nerve/vascular relationships14,18,19,41,54 and
to avoid stretching the facial nerve.
Although varying in size and shape, the craniectomies
performed nowadays for this purpose are very similar to the
one described by Dandy8 in 1929 when he proposed the
partial section of the trigeminal sensory root for the treat-
ment of tic douloureux, emphasizing the importance of the
inferior aspect of the transverse sinus/sigmoid sinus transi-
tion exposure to approach the fifth cranial nerve. Jannet-
ta,20,24,29,31,32 who popularized and further developed the neu-
rovascular decompression technique originally described
by Gardner and Miklos11 in 1959 and Rand and Kurze50 in
1981, performed this procedure through a high suboccipi-
tal craniectomy that measured 1.5 to 2.3 3 3 cm,21 expos-
ing the distal part of the transverse sinus. According to
Jannetta,31 the sigmoid sinus has to be exposed only in
dolichocephalic patients. Rhoton55,56 described his approach
for this purpose as a 4-cm suboccipital craniectomy, and
Fukushima did it through a 1- to 1.5-cm-diameter bone
removal situated “above the superior nuchal line and below
the asterion.” (Fukushima, personal communication, 1989)
Fig. 14. Photograph showing delineation of the margins of the
transverse and sigmoid sinuses and their main points based on
identification of the lambdoid, occipitomastoid, and parietomastoid
sutures.
6 Neurosurg. Focus / Volume 19 / August, 2005
G. C. Ribas, et al.
It is interesting to note that the Gray’s Anatomy text-
book,72 despite being strictly anatomical, describes the aste-
rion region as “a point for trephining over the transverse
sinus.”
The burr hole centered 1 cm anteriorly to the asterion
and with its superior base on the parietomastoid suture con-
stitutes another option to initiate an exposure of the upper
part of the angle, because this burr hole generally already
exposes the inferior aspect of the transverse sinus/sigmoid
sinus transition. This burr hole site is approximately equiv-
alent to the one located 3 to 5 mm below the posterior
extremity of the supramastoid crest proposed by Hakuba
and colleagues15–17 to expose the junction of the transverse,
sigmoid, and superior petrosal sinuses.
According to our findings, the burr hole site located
“medially and inferiorly to the asterion” as proposed by Al-
Mefty3 to expose the posterior fossa at the level of the
transverse sinus/sigmoid sinus junction may be too posteri-
or and inferior for its purpose. The initial burr hole for a
suboccipital craniectomy placed at the superior nuchal line/
occipitomastoid suture intersection point as proposed by
Guthrie, et al.,13 might also be inferior to the transverse and
posterior to the sigmoid sinus. Day, et al.,10 also described
the asterion over the transverse sinus and posterior to its
transition to sigmoid sinus.
BASAL SUBOCCIPITAL CRANIECTOMY
Because exposure of the proximal aspects of the facial
and vestibulocochlear nerves and related vessels36,39,
41,48
requires the opening of the cerebellopontine and cere-
bellomedullary cisterns40 to allow retraction of the cerebel-
lum petrosal surface and flocculus, the suboccipital ap-
proach for neurovascular decompression of the facial nerve
is ideally made through a more basal craniectomy.4,5,22,23,25,33
For this purpose, and for the exploration of the vestibulo-
Fig. 15. Schematic drawing showing the area of bone removal
from the asterion to expose the inferior aspect of the transverse
sinus/sigmoid sinus transition.
Suboccipital burr holes and craniectomies

Fig. 16. Photographs showing asterional suboccipital craniectomy steps (A–C) and microsurgical exposure (D) of the superior aspect of
the CPA.

cochlear, glossopharyngeal, and vagus nerves, Jannetta and approach described by Bremond, et al.,6 as a 3-cm craniec-
colleagues21–23,25–28,33,34 proposed a 2.5- to 4-cm-diameter ba- tomy located in the angle between the superior nuchal line
sal and lateral craniectomy. and a line tangential to the occipitomastoid margin, and to
A basal suboccipital craniectomy can be systematically the retrosigmoid approach proposed by Sterkers,66 which
started through a burr hole placed over the occipitomastoid consisted of a 3-cm bone removal situated between the
suture at the level of the most posterior aspect of the mas- superior and inferior nuchal lines.
toid notch, and/or at the intersection point of the occipi-
tomastoid suture/inion–mastoid process tip line, because
these burr holes already expose both the posterior fossa
compartment and the sigmoid sinus. The extension of the
craniectomy will also depend on each particular case, but
even very circumscribed bone removals started at this point
will provide an adequate exposure of the posterior aspect of
the internal meatus, of the facial–vestibulocochlear nerve
complex and related vessels, and of the glossopharyngeal,
vagus, and accessory nerves and related structures (Figs. 17
and 18). The surgeries for removal of small acoustic tumors
and for the aforementioned nerves’ neurovascular decom-
pression could be systematically done with such a crani-
ectomy.
Fukushima (personal communication, 1989) suggested
that this procedure be accomplished through a 1- to 1.5-cm-
diameter bone removal situated “one finger below the Fig. 17. Schematic drawing showing the initial burr hole site
superior nuchal line,” which is approximately equivalent to over the occipitomastoid suture at the level of the posterior aspect
the initial burr hole proposed here. The basal suboccipital of the mastoid notch and/or at the intersection point of the occipito-
craniectomy itself is equivalent to the “minima” posterior mastoid suture/inion–mastoid tip.

Neurosurg. Focus / Volume 19 / August, 2005 7

 G. C. Ribas, et al.

Fig. 18. Photographs showing basal suboccipital

craniectomy steps (A–C), and microsurgical exposure
(D) of the inferior aspect of the CPA.

WIDE SUBOCCIPITAL CRANIECTOMY

More extensive suboccipital craniectomies, as are usual-
ly required for the surgical treatment of CPA tumors, could
be systematically initiated through the two burr holes just
mentioned for the upper and lower approaches to the CPA:
with its center on the asterion (1), and over the occipito-
mastoid suture at the most posterior aspect of the mastoid
notch (2), because they generally already expose the inferi-
or margin of the transverse sinus and the posterior margin
of the sigmoid sinus, which constitute the natural limits of
this approach. From these two initial burr holes the craniec-
tomy can be extended as much as necessary (Figs. 19–21).
Gardner, et al.,11 proposed extending a suboccipital craniec-
tomy inferiorly along the occipitomastoid suture for sur-
gery of glomus jugulare tumors, which is adequate consid-
ering the relationships of the inferior part of this suture with Fig. 19. Photograph showing the initial burr hole sites proposed
the sigmoid sinus. Descriptions of suboccipital bone re- for wide lateral suboccipital exposures.

8 Neurosurg. Focus / Volume 19 / August, 2005

Suboccipital burr holes and craniectomies
Fig. 20. Photographs showing a wide CPA craniectomy (A) and a microsurgical view (B) of the angle.
moval in more recent texts often relate the transverse and
sigmoid sinuses with the asterion and with the occipito-
mastoid suture behind the mastoid process, respectively, in
their illustrations, but usually without giving further ana-
tomical details.2,3,64,65
CONCLUSIONS
The asterion and the most posterior part of the parieto-
mastoid suture are related to the most lateral aspect of the
inferior margin of the transverse sinus and with the transi-
tion between the transverse and sigmoid sinuses, and hence
constitute proper sites at which to start and to delimit the
exposure of the superior aspect of the CPA. The occipito-
mastoid suture at the level of the mastoid notch is particu-
larly related to the posterior margin of the sigmoid sinus,
and hence constitutes a proper initial burr hole site at which
to perform a basal suboccipital craniectomy to expose the
lower portion of the CPA. Both can be used as initial burr
hole sites to perform wide suboccipital exposures, because
they already constitute natural infratentorial lateral limits.
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3. Al-Mefty O: Surgery of the Cranial Base. Boston: Kluwer
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4. Almeida GM, Teixeira MJ, Salles AFY: Espasmo hemifacial,
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Fig. 21. A and B: Preoperative (A) and postoperative (B) magnetic resonance images of an acoustic tumor located at the right CPA and
resected in a 50-year-old man. C–H: Intraoperative photographs showing the anatomy and approaches. Intraoperative identification of the
asterion, lambdoid, occipitomastoid, and parietomastoid sutures, with the patient in the sitting position (C). Initial burrholes placed just ante-
riorly to the asterion to expose the transition between the transverse and sigmoid sinuses (1), and over the occipitomastoid suture just poste-
riorly to the mastoid process at the most posterior level of the mastoid notch (2), which lies just posteriorly to the posterior margin of the sig-
moid sinus (D). Wide suboccipital craniectomy site (E). Dural opening (F). Exposure of the tumor (G). Skull base view of the facial nerve
after removal of the tumor (H).

10 Neurosurg. Focus / Volume 19 / August, 2005

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Manuscript received June 9, 2005.
Accepted in final form July 18, 2005.
Address reprint requests to: Guilherme C. Ribas M.D., R Eduar-
do Monteiro 567, Sao Paulo 05614-120 Brazil. email: guilherme@
ribas.med.br.
Neurosurg. Focus / Volume 19 / August, 2005