Technical NoteUse of Paine's Technique: Projecting Puncture Point to the Skull and Skin
Introduction
Early prevention of rebleeding from ruptured aneurysm is an essential aspect of the management of patients with aneurysmal subarachnoid hemorrhage (aSAH).1 Achieving a brain that is relaxed and a comfortable operative field is essential for successful aneurysm surgery. Raising the patient's head to gain more venous return, hyperventilation to maintain moderate partial pressure of carbon dioxide, and osmotic diuresis are generally used to maintain adequate brain relaxation. Drainage of cerebrospinal fluid (CSF) from the Sylvian fissure also can be effective.
Paine's point, defined as a point 2.5 cm superior from the floor of the anterior cranial fossa and 2.5 cm anterior to the Sylvian fissure, provides an approach to the frontal horn of the lateral ventricle (Figure 1A).2 This point is often used in the pterional approach to aneurysmal surgery because of its safety and reliability.3 Paine's technique, namely ventriculostomy via Paine's point, is particularly valid in patients with severe cerebral edema or acute hydrocephalus because it allows drainage of CSF before the exposure of the cerebral cisterns. Moreover, postoperative irrigation therapy with urokinase is possible from the drainage tube to prevent vasospasm in the aftermath of aSAH.4
Despite its advantages, Paine's point is currently determined by landmarks that are only identifiable after opening the dura mater. In this study, we attempted to project these landmarks to the cranium and scalp to facilitate the use of this portal for ventriculostomy for other surgeries except for the ones that require a pterional approach.
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Methods
With respect to the surface anatomy of cranium, the anterior cranial fossa is represented by the supraorbital margin, and the Sylvian fissure is marked by the depression that is located on the opposite side of the sphenoid ridge (Figure 1B). We investigated these landmarks with the help of 3-dimensional computed tomographic images and identified surface markers for Paine's point on the skull; the point approximated the anterior edge of the temporal muscle. Subsequently, we adapted landmarks on
Results
Paine's point was projected to a point located 2.5 cm superior to the supraorbital margin on the linea temporalis (superior temporal line) on the skull and 2.5 cm superior to the eyebrow on the anterior edge of the temporal muscle on the skin. During the surgery for aSAH with ruptured aneurysm of Acom, additional skin incision was not necessary because the anterior edge of temporal muscle was visible in bilateral frontal craniotomy. Furthermore, in addition to intraoperative ventriculostomy,
Discussion
Various approaches for ventricular puncture have been described.5 A modified approach based on the Paine's point, which avoids penetration of the caudate nucleus,6, 7 and key burr-hole puncture method at a specific angle8 have been reported previously for intraoperative ventriculostomy. In the popular pterional approach, however, the specific location and direction of Paine's technique is more reliable and has been used successfully for many aneurysm surgeries at our facility. In the original
Conclusions
By establishing a puncture point on the skull and skin, use of Paine's point for ventriculostomy via an interhemispheric approach or for simple burr-hole surgery is a safe and reliable method.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.