Neurosurg Rev (2012) 35:341349

DOI 10.1007/s10143-011-0371-0

ORIGINAL ARTICLE

Endoscopic telovelar approach to the fourth ventricle:

anatomic study
Antonio Di Ieva & Mika Komatsu & Fuminari Komatsu &
Manfred Tschabitscher

Received: 18 May 2011 / Revised: 24 August 2011 / Accepted: 8 October 2011 / Published online: 15 December 2011
# Springer-Verlag 2011

Abstract The telovelar approach allows reliable access to the

fourth ventricle and avoids the splitting of the vermis and its
associated posterior vermal split syndrome. Our objective
was to describe the endoscopic topographical anatomy of the
telovelum approach to the fourth ventricle as accessed by the
cerebellomedullary corridor. A series of 20 fresh and fixed
injected anatomical specimens were used. The endoscopic
equipment consisted of rigid endoscopes with different lens
angles, while the extradural step required the use of the
microscope and/or the exoscope. All the anatomical landmarks and relationships within the fourth ventricle and the
cerebellomedullary fissure were identified by means of the
endoscopic microscope/exoscope-assisted telovelar approach.
In conclusion, we showed that the endoscope is a valid tool to
gain an anatomic understanding of the fourth ventricle reached
by means of the telovelar approach.

ventricle. This method avoids splitting the vermis or removing part of the cerebellum [26, 27, 29, 31, 37], therefore
avoiding the associated posterior vermal split syndrome
[2, 5, 9, 19]. The anatomical key to this approach is the
telovelum, the sheet formed by the tela choroidea and the
inferior medullary velum that covers the lower part of the
roof of the fourth ventricle. The telovelum can be reached
and explored also endoscopically through the cerebellomedullary fissure, the natural cleft between the tonsils, the
vermis, and the medulla. Within this study, we describe
the endoscopic topographical anatomy of the telovelum
approach to the fourth ventricle accessed via the cerebellomedullary corridor.

Keywords Anatomy . Cerebellomedullary fissure .

Endoscopy . Exoscopy . Telovelar approach . Fourth ventricle

This anatomic study was performed in the Microsurgical

and Endoscopic Laboratory of the Department of Systematic
Anatomy at the Medical University of Vienna, Austria. A
series of 20 fresh and fixed anatomical specimens were
used. The arteries were injected with red silicon; in some
specimens the veins were also injected with blue silicon.
One specimen was not injected in order to study the
syntopy of the telovelum, focusing on its endoscopic
relationship with the surrounding anatomical structures.
The endoscopic equipment consisted of 2.7- or 4-mmdiameter rigid endoscopes with various viewing angles
(0, 30, 45, and 70) (Karl Storz Endoscopy, Tuttlingen,
Germany). For the extradural macroscopic step, an exoscope
was used (VITOM SPINE, model E10511, Karl Storz,
Tuttlingen, Germany) fixed to a mechanical holder 20
40 cm far from the field. The exoscope was left in situ for the
described maneuvers so that the intracranial steps were
exoscope assisted. In some cases, an operative microscope

Introduction
In the last few years, the telovelar approach has been demonstrated as a reliable approach to access the fourth
A. Di Ieva (*) : M. Komatsu : F. Komatsu : M. Tschabitscher
Center for Anatomy and Cell Biology, Department of Systematic
Anatomy, Medical University of Vienna,
Waehringerstrasse 13,
1090 Vienna, Austria
e-mail: diieva@hotmail.com
A. Di Ieva
Department of Neurosurgery, Medical University of Vienna,
Vienna, Austria

Materials

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was used for the extradural step and to follow the endoscopic
procedure, even if the exoscope was preferred for the image
acquisition, in a special way because it was fixed far enough
from the operative field to not interfere with the surgical
maneuvers. For the illumination, we used a 300-W xenon
fiber optic light source (Xenon Nova300, Karl Storz Endoscopy, Tuttlingen, Germany). A digital high-definition (HD)
video camera with a camera control unit was used to
visualize the images on an HD wide flat screen (two
million pixels). The AIDA compact HD System (Karl Storz,
Tuttlingen, Germany) was used to record the images and
video sequences.

Methods
The heads were positioned to achieve a surgical suboccipital
approach. Under microscopic or exoscopic magnification, a
3-cm midline skin incision was made above the craniocervical junction. The dissection was performed by splitting the
muscles mediolaterally in order to access and expose the

Fig. 1 Exo-endoscopic approach to the fourth ventricle. a Exoscopic

suboccipital approach to the median craniocervical junction, with
exposure of the occipital bone, the posterior arch of the atlas, and the
atlantooccipital membrane. The dotted circular lines show the site of
the craniotomy. b Opening the dura mater in the C0-C1 region and the
arachnoid of the cerebellomedullary cistern (cisterna magna). Lateral
reflection of the meningeal layers and exposure of the medulla and
cerebellar tonsils is also demonstrated. c Introduction of the endoscope
onto the field. d The endoscopic procedure can be exoscope assisted,

Neurosurg Rev (2012) 35:341349

inferior portion of the occipital squama, the inferior edge of

the foramen magnum, the craniocervical junction, the atlantooccipital membrane, and the posterior arch of the atlas
(Fig. 1a). Inserting the craniotome into the inferior edge of
the foramen magnum, a 2-cm occipital craniotomy was
performed (Fig. 1a). Removing the posterior arch of the
atlas was never considered necessary. After opening and
removing the atlantooccipital membrane, the dura mater
overlying the craniocervical junction was exposed and incised longitudinally for approximately 2 cm (Fig. 1b), also
to create the space to insert the spatulas for the eventual
retraction of the cerebellar tonsils. Through the durotomy it
was possible to insert various angled endoscopes (0, 30, 45,
and 70) into the cisterna magna (Figs. 1c, d and 2e). The
endoscopic approach to the cisterna cerebellomedullaris
(cisterna magna) and the fourth ventricle was microscope
or exoscope assisted. The exoscope was often used for the
acquisition of the video images of the endoscopic procedure
(Fig. 1d). After inspection of the cisterna magna, the arachnoid was removed to approach the fourth ventricle via a
medial transcysternal route [30, 33] (Fig. 1e, f). To visualize

as shown in the picture. Introduction of the tip of the endoscope into

the foramen of Magendie by the transforaminal median route. e The
introduction in the foramen of Magendie of an endoscope with a 70angled optic oriented towards the roof of the fourth ventricle allows
visualization of the ventricular surface of the tela choroidea with the
related choroidal plexi and choroidal arteries. f The transforaminal
approach allows the visualization of the rhomboid fossa and the floor
of the fourth ventricle

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343

Fig. 2 The cerebellomedullary fissure, the fourth ventricle and the

synthopy of the telovelum, demonstrated via exoscopic anatomical
dissection. a The elevation of the tonsil reveals the attachments of
the tela choroidea (arrows), which borders the medial sides of the
fourth ventricle and continues superiorly in the arachnoid covering
the mesial surfaces of the cerebellar tonsils. b The vallecula can be
split to allow access to the inferior vermis. Here the superior part of the
arachnoid that form the tela choroidea, like a tent (showed by the
arrows), is visible covering the mesial surfaces of the tonsils. c The
partial resection of the right tonsil reveals its relationships with the
cerebellar biventral lobe and with the telovelum, allowing visualization
of its anatomical affiliations (nidus avis, marked with an asterisk). d
The complete resection of the tonsil allows visualization of the retroand sovratonsillar segments of the PICA. e The introduction of the
endoscope in the fourth ventricle allows, by means of transillumination, the visualization of the attachments of the tela choroidea inferiorly

and superiorly to the telovelar junction. f The removal of both tonsils

and the complete resection of the telovelum allow inspection of the
fourth ventricle structures. The four corners of the rhomboid fossa are
visible (obex/foramen of Magendie, opening of the aqueduct of Sylvius, and the two lateral recesses with the foramen of Luschka). The
striae medullares divide the floor in a superior pontine triangle and an
inferior medullary triangle, which ends in the calamus scriptorius. g
The inferior triangle's base is on the striae medullares and the vertex is
on the obex. In this location, one can visualize the funiculus separans, a
thickening of the ependyma bordering the area postrema, and the
ligula, which is the medullary insertion of the membrana tectoria. ct
cuneate tubercle; Fac. Col. facial collicus; Fovea inf. fovea inferior
with the vagal trigone overlying the dorsal motor nucleus of the vagus
and the nucleus of the solitary tract; gt gracile tubercle (clava); Med.
vestib. area medullary vestibular area; St. med. striae medullares; Trig.
Hypog trigonum of the hypoglossal nerve

the roof of the fourth ventricle and the telovelum, the following methods were used: (a) mediolateral displacement of

the cerebellar tonsils using spatulas and (b) tonsillar resections, even if the latter was used only to show the anatomic

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relationships but not considered strictly necessary for the

endoscopic telovelar approach.

Results
The introduction of the endoscope into the cisterna magna
offers a panoramic view of the inferomedial part of the
cerebellar hemispheres, the inferior portion of the vermis,
the branches of the posterior inferior cerebellar artery (PICA), the posterior cerebellar and medullary veins, the cerebellomedullary fissure, and the foramen of Magendie
(Figs. 1c and 2bd). A preliminary inspection of the fourth
ventricle can be performed by means of the classic medial
transcysternal route [30, 33]; the introduction of the endoscope into the foramen of Magendie gives a wide panoramic
view of the fourth ventricle (Fig. 1e, f). The endoscope is
introduced into the foramen of Magendie, obtaining a wide
panoramic view of the floor of the rhomboid fossa, the
superior velum, the superior and middle cerebellar
peduncles, the opening of the aqueduct in the fourth ventricle, and the interior aspect of the telovelum with the related
choroid plexus. The insertion of the angled endoscope (particularly 45 and 70) into the foramen of Magendie allows
visualization of the ventral (ventricular) surface of the tela
choroidea where it is possible to identify the choroid plexus
and its related vessels (Fig. 1e). A broad panoramic view of
the fields can be obtained by rotating the scope on its axis.
The lateral displacement of the tonsils (unilaterally or
bilaterally) allows for endoscopic navigation of the cerebellomedullary fissure (Fig. 2b). The distance of the displacement ranged from 0 to 10 mm, depending on the anatomical
conditions (e.g., the size of the tonsils and the intertonsillar
distance). In six cases (30%), in fact, the intertonsillar distance was inferior to 5 mm, and it was necessary to displace
the tonsils 1 cm laterally, in order to achieve the cerebellomedullary fissure. In ten cases (50%), the required displacement was less than 5 mm, while in four cases (20%) the
intertonsillar distance was quite wide (10 mm), requiring no
lateralization. The introduction of the endoscope in the
medullotonsillar space allowed the exploration of the cerebellomedullary fissure and tela choroidea. The tela choroidea was cut unilaterally or bilaterally by starting the incision
at the level of the foramen of Magendie and following it
laterally to the foramen of Luschka. The inferior margin of
the tela choroidea was found at a distance from the obex
ranging 212 mm, forming in the middle the foramen of
Magendie (average diameter, 5 mm). Opening the telovelum
bilaterally provided complete access to the floor and body of
the fourth ventricle, from the aqueduct to the obex, rostrocaudally, reaching the lateral recesses mediolaterally
(Fig. 2f). Opening the telovelum unilaterally allowed the
introduction of the endoscope and the opportunity to

Neurosurg Rev (2012) 35:341349

visualize, by means of the 30, 45, and 70 angled scopes,

the contralateral structures (Fig. 3f). To achieve good visualization of the complete intraventricular structures, it was
deemed unnecessary to cut the telovelar junction, limiting
the resection to the lateral attachments of the tela choroidea.
Moreover, a partial opening of the tela choroidea was considered sufficient to introduce and move the endoscope and
any surgical tools within the fourth ventricle (Fig. 3).
The endoscopic panoramic view of the cerebellomedullary fissure makes it possible to observe the branches of the
posterior cerebellar arteries, the foramen of Magendie, the
obex, and the tela choroidea (Figs. 1b, c and 2ad). The
medial anatomic landmarks are the pyramid and the uvula
(inferior portion of the vermis) in the posterior cerebellar
incisura (Fig. 1d). The nodule of the vermis faces the lower
half of the roof of the fourth ventricle. The vallecula is the
inferior continuation of the posterior cerebella fissure, separating the two tonsils. The depth of the vallecula depends
on the anatomical conformation of the tonsilsvirtual in
some cases (very tied tonsils) or very widewhen the
mesial tonsillar portions face each other at a distance of
about 1 cm. The resection of the tonsils reveals the socalled nidus avis (bird's nest) [35] and the relationships
between the tonsillar faces and the inferior medullary velum,
tela choroidea, uvula and biventral lobules, in the space
called the telovelotonsillar cleft, where the portions of the
PICA (retrotonsillar and subtonsillar portions of the telovelotonsillar segment of the PICA) run (Fig. 2c, d, f).
Starting at the foramen of Magendie, the taenia along the
inferior cerebellar peduncles can be cut to reach the lateral
recess, on a single side or bilaterally (Fig. 2f). The tela
choroidea can be elevated rostrally (unilaterally or bilaterally) in order to obtain access to the fourth ventricle; the
arachnoid of the vermian cistern can be dissected, splitting
the uvulotonsillar cleft.
The telovelum is formed by two thin, membranous
layers: the tela choroidea and the inferior medullary velum
[17, 20, 31, 32]. The site where the two membranes attach to
each other is the telovelar junction (Fig. 2e). The cranial
extension of the tela choroidea is the uvulotonsillar space;
according to Matsushima's definition [27], this space is a
tent formed by two layers of arachnoid, which cover the
mesial and posterior faces of the tonsils. In some cases,
when the tonsil was tied tightly, the vallecula became a
virtual space and these two arachonidal layers seemed to
be fused in a kind of tonsillar falx. However, careful
dissection always revealed the existence of the two separated layers, covering the mesial tonsillar surfaces, reaching
rostrally to the uvula and continuing into the arachnoid
covering the pyramid (Fig. 2a, b). On the ventricular surface
of the tela choroidea, one can recognize the choroid plexus
with its associated choroidal arteries, which originate from
the supratonsillar segment of the PICA (Fig. 1e) [11]. Some

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345

Fig. 3 Endoscopic telovelar

approach. By using an appropriate insertion point for the
endoscope, angle of visualization
and angled lens, it is possible to
visualize the anatomical structures within the fourth ventricle.
AS Opening of the aqueduct of
Sylvius; ChPl choroid plexus;
FColl facial colliculus; inf CP
inferior cerebellar peduncle;
infFov inferior fovea; LR lateral
recess; me medial eminence;
mVA medullary vestibular area;
ms median sulcus; pSL paramedian sulcus limitans; pVA
pontine vestibular area; SMV
superior medullary velum; sup
CP superior cerebellar peduncle;
supFov superior fovea

veins originate from the lateral edge of the nodule and

uvula, crossing the telovelar junction and taking some outflows from the telovelum [28].
The entire floor of the fourth ventricle is visible in its
typical rhomboid shape. The four corners of the rhombus, formed by the opening of the aqueduct proximally,
the foramen of Magendie caudally and medially, and the
two foramina of Luschka laterally are endoscopically
visible (Fig. 3). The median sulcus divides the floor into
two symmetrical halves; this sulcus serves as a good corridor to follow when advancing the endoscope along the
floor of the fourth ventricle. It is also a very visible and
constant landmark to be used to avoid losing orientation
intraventricullary, especially when the angled optics are
used (Figs. 2f, g and 3ae). The striae medullares (the dorsal
pontocerebellar fibers and parts of the dorsal acoustic striae)
[32] are very well visualized in their mediolateral variable
course; in our specimens we found an average of 52 striae
on each side, in accordance with some previously published
data (Fig. 2f) [45]. The striae divide the floor into a superior
pontine triangle and an inferior medullary triangle, which
ends in the calamus scriptorius. The striae medullares are the
inferior triangle's base while the obex is the vertex of the

inferior triangle; here the funiculus separans, a thickening of

the ependyma bordering the area postrema, is visible
(Fig. 2g). The median sulcus is easily visible crossing medially in the triangle, bordered paramedially by the two
paired sulci limitantes (Figs. 2g and 3e). The sulcus limitans
is discontinuous; it is more prominent in the pontine and
medullary portions of the floor. The points in which the
sulcus limitans deepens correspond to two endoscopically
visible depressions: the superior and the inferior fovea
(Fig. 3b, e) [31]. Lateral to the sulci limitans, the endoscope
demonstrates the vagal trigone (corresponding to the dorsal
motor nucleus of the vagus and the nucleus of the solitary
tract) and its lateral depression, the fovea inferior, in the
inferior portion (Figs. 2g and 3e). More laterally, the vestibular area is visualized, corresponding to the vestibular nuclei
(Fig. 3c, f). The visible prominence in this area is the
auditory tubercle, which overlies the dorsal cochlear nucleus
and the cochlear part of the vestibulocochlear nerve. The
dark, triangular field between the trigonum hypoglossi and
the lower part of the area acoustica is the ala cinerea,
corresponding to the sensory nucleus of the vagus and
glossopharyngeal nerves. At the lower end of the ala cinera,
the funiculus separans is visible as a narrow, translucent

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ridge; more inferiorly, closely related to the clava, there is

the area postrema.
The sulcus medianus continues in the superior triangle,
ending at the superior angle of the rhomboid fossa where the
opening of the aqueduct is visible (Fig. 3). The sulcus limitans divides the superior triangle in a similar fashion with a
mediana area, where the median eminence (containing the
facial colliculus) and a lateral pontine vestibular area. A
good landmark for endoscopic navigation through the lateral
recesses is the superior fovea (fovea trigemini), which corresponds to the motor trigeminal nucleus (Fig. 3b). More
superiorly, at the upper end of the sulcus limitans, lies the
locus coeruleus although it is not endoscopically (or even by
the operating microscope) identifiable.
On the roof of the fourth ventricle lies the superior
medullar velum medially and the cerebellar peduncles
more laterally, each one separated by a very welldefined sulcus: the superior cerebellar peduncle medially
and the inferior cerebellar peduncle laterally (Fig. 3). The
dentate tubercle, formed in the fourth ventricle by the impression of the overlying dentate nucleus, is visible in the
superolateral portion of the roof (Fig. 3e). The lateral portions of the cerebellar peduncles are very well visualized
using the angled endoscopes. The angled lenses, especially
the 45 and 70 lenses, permit visualization of the lateral
recesses to the foramina of Luschka, which open in the
inferior cerebellopontine cisterns. If the tela choroidea is
opened only on one side, the introduction of the endoscope
with the angled lens allows for visualization of the contralateral
recesses (Fig. 3f).

Discussion
It is known that the cerebellomedullary fissure is a useful
route by which to approach the fourth ventricle and avoid
splitting the vermis [6, 16, 18, 19, 26, 27, 31, 43, 44, 46].
The opening of the tela choroidea and eventually the inferior
medullary velum (telovelar approach) allows for complete
visualization of the fourth ventricle also including the most
proximal and lateral portions, from the aqueduct to the
lateral regions around the lateral recesses. This has been
demonstrated in several previous surgical reports and in
qualitative and quantitative anatomic studies [8, 19, 26,
27, 31, 36, 37, 40].
The fourth ventricle can also be approached endoscopically. The paradigm of modern neurosurgery, to offer therapies by means of minimal surgery and less traumatic
approaches, has developed into the philosophy of minimally
invasive neurosurgery [9, 33, 34] or, more appropriately,
minimally traumatizing neurosurgery [42]. It should be
emphasized that endoscope is an additional tool which can
be used in neurosurgical procedures as well in anatomical

Neurosurg Rev (2012) 35:341349

studies, even if no randomized controlled studies have never

been performed to prove its clinical advantages when compared to the operations performed by means of microscope.
In the 1990s, the first reports detailing endoscopic caudal
exploration of the fourth ventricle and the aqueduct were
published [3, 15, 30, 33, 39]. Subsequently, other surgical or
anatomical reports were published detailing the anatomy of
the fourth ventricle as visualized by the endoscope using a
transaqueductal approach [10, 13, 22, 23, 38, 41].
From the first anatomic reports that the fourth ventricle
and aqueduct could be approached endoscopically, not only
from the third ventricle but also through a tailored craniocervical approach [30, 33], other applications of this surgical
approach were investigated. In some selected cases, this
endoscopic approach has been used in the management of
obstructive hydrocephalus due to aqueduct obstruction, reestablishing the free communication between the third and
fourth ventricle [4, 14, 41]. However, this approach via the
foramen of Magendie limits the introduction and manipulation of other surgical tools within the lateral recesses of the
fourth ventricle; these limits are overcome with the telovelar
approach. Matsushima et al., who pioneered the technique
of the telovelar approach, emphasized that a detailed understanding of the anatomy of the fissure and its surroundings
is required to perform this kind of approach [26, 27].
The microsurgical exploration of the fourth ventricle by
means of the telovelar approach can also be performed
endoscopically. We chose to demonstrate this for two reasons: (a) to show the feasibility of the technique and (b) to
offer a different perspective on the same anatomical structures, improving the anatomical orientation of the surgeons
who perform this type of surgery in this very complex
region. It is important to emphasize that this manuscript
does not advocate for the superiority of the endoscopic
approach over the microsurgical method. In the best scenario,
endoscopic assistance in the microsurgical treatment of
lesions involving the fourth ventricle could allow visualization
around corners including those opposite to the microsurgical field, allowing a less invasive and traumatic surgery. The topographical relationships between the
anatomic structures and landmarks are fundamental in
neuroendoscopy. Working in an anatomical training lab
is essential to develop a sense of spatial orientation; such
a lab allows the surgeon to compare different images of
the same anatomical area and to form a three-dimensional
mental image of the fourth ventricle. This type of training is
very helpful in understanding pathoanatomic topography.
There is no microsurgical or endoscopic anatomy: the
anatomy stays the same although it is visualized differently
through a microscope and an endoscope. It is important to
develop spatial orientation to understand surgical anatomy,
bearing in mind that the apparent differences in the same
structures when they are seen laterally or medially, rostrally

Neurosurg Rev (2012) 35:341349

or caudally, or through the operative microscope or through an

endoscope [42].
In our study, we found a large variability in the insertion
points of the inferior limits of the tela choroidea. As demonstrated by Barr in 1948 [1], the outlets of the fourth
ventricle have a highly variable shape and dimension. At
the level of the foramen of Magendie, the different insertions of the caudolateral margins of the telovelum could
justify this variability. Thus, even if no neurologic deficits
are associated with the opening of the telovelum of the
fourth ventricle, in cases in which the foramen of Magendie
is very small, a wide resection of the attachment of the tela
choroidea is required for the introduction and manipulation
of the endoscope and any surgical tools. In cases in which
the foramen is very wide, the resection of the tela can be
limited. The opening of the tela choroidea on the lateral
margins allows the introduction of the endoscope to
visualize all of the intraventricular anatomical structures.
The additional opening of the inferior medullary velum
offers a more cranial visualization of the fourth ventricle,
even if it is not generally required. It is interesting that
the sense of three dimensionality in the two-dimensional
endoscopic images can be suggested by the shadows
and intensity of colors caused by the protuberances and
depressions, as on the floor of the fourth ventricle at the
level of the foveae (Fig. 3b, e).
The intracranial and intraventricular endoscopic approach
can be microscope or exoscope assisted. It has recently been
suggested that exoscopes could be used in neurosurgical
procedures, particularly in spinal operations [24, 25].
Exoscopes are telescopes that, like microscopes, are not
introduced into the surgical field. They offer very high
quality images with very good illumination and, as they
are fixed to a holder remote from the operating field, they
do not interfere with the handling of surgical instruments.
However, their technical limitations include the fact that the
images are focused centrally (and are therefore less focused
peripherally) and, like endoscopes, they lack true stereopsis.
We have recently begun using exoscopy for anatomical
dissections and image acquisition [7, 42], suggesting its
use especially in anatomical laboratories where the purchase
of an operative microscope is limited by some economical
reasons.
A relative advantage of the endoscopic telovelar approach
is that it requires less space than the normal microscopic
approach so that the opening of telovelum, the resection of
some choroidal vessels, and the lateralization of the tonsils can
be limited. The latter is very important as excessive stretching
of the tonsils can cause a compression on the related dentate
nuclei and cerebellar peduncles. It is known that the neurologic deficits related to dentate nuclei injury are disturbances
much more serious than the ones caused by vermis splitting
[12, 21]. Moreover, the craniotomy performed in our study

347

was relatively small and no specimens required laminectomy of the atlas.

Using the described approach, the visualization of the
anatomical structures of the fourth ventricle is optimal and
the space to maneuver surgical tools seems to be adequate.
However, the surgeon must recall that the movements of the
tip of the endoscope within the fourth ventricle should be very
accurate; a soft pressure of the tip of the endoscope against
the anatomical structures can cause injuries, particularly on
the protruding structures (e.g., cerebellar peduncles, dentate
tubercle, and facial collicus).

Conclusion
The natural cleft of the cerebellomedullary fissure, between
the vermis, the tonsils, and the medulla, can be the corridor
for the introduction of the endoscope into the fourth ventricle by means of the telovelar approach, allowing complete
visualization of the ventricular cavity without splitting the
vermis. Considering that the telovelar approach is recommended for the treatment of lesions occupying the cerebellomedullary fissure and the fourth ventricle, especially its
lateral recesses, the endoscope can be a valid tool for gaining a better anatomic understanding of this complicated
neuroanatomic region; it may also be a potential tool to be
used for microsurgical endoscope-assisted operations.
Acknowledgments The authors wish to thank the FMEA (Society
for the Promotion of Research in Microsurgical and Endoscopic Anatomy)
for paying the costs related to this research.
Disclosure The authors have no personal financial or institutional
interest in the devices described in this article.

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Comments
Toshio Matsushima, Saga, Japan
The authors studied the surgical anatomy of the fourth ventricle
through the telovelar approach using endoscopy. We call this approach
transcerebellomedullary fissure approach.
However, surgical indications using this method will be limited. It
seems difficult to remove large fourth ventricular tumors such as
medulloblastomas or ependymomas by this method. This endoscopic

Neurosurg Rev (2012) 35:341349

less invasive surgery seems good for small tumors or biopsy, especially
lesions around the fastigium and lateral recess, which are difficult
regions for observation in the microsurgery. As the authors mention,
this endoscopic surgery had better be performed with microsurgery.
The authors point out that excessive stretching of the tonsils can
cause a compression on the related dentate nuclei and cerebellar
peduncles. However, in our experiences of microsurgery the retraction
of the tonsils did not cause any neurological deficits when the cerebellomedullary fissure is sufficiently opened. This is a well-written
paper on endoscopic study with detailed description and will highly
contribute to the surgical treatment of the fourth ventricular lesions in
the future.
Dattatraya Muzumdar, Mumbai, India
Di Ieva et al. report a cadaveric study in 20 fresh and fixed injected
anatomical specimens exploring the endoscopic anatomy of the fourth
ventricle through a telovelar approach. They conclude that the endoscope can be a valid tool for gaining a better anatomic understanding of
this complicated neuroanatomic region; it may also be a potential tool
to be used for surgical endoscopeexoscope-assisted operations. The
manuscript is well written, elaborate, and informative. The dissections
are noteworthy and reveal the finer aspects of the anatomy. Microsurgical anatomy of the fourth ventricle is described in the literature but
there are no elaborate articles about the use of endoscope in this area.
They discuss the limitations of the study was well.
Fourth ventricle is a limited space harboring critical neurovascular
structures as well as the brain stem. The anatomy is complex and the
lesions occurring in this limited space are formidable. Exploration of
the fourth ventricle through the telovelar approach using the endoscope
can be an aid or adjunct to the resection of the complex tumors in this
region. The telovelar approach allows reliable access to the fourth

349
ventricle. It avoids the splitting of the vermis which is usually associated with cerebellar mutism. Endoscopic telovelar approach is truly a
mimimally invasive surgery since it requires less space than the normal
microscopic approach and limits the opening of telovelum. A digital
HD video camera provides a panoramic view of the fields allowing for
complete visualization of the fourth ventricle including the most proximal and lateral portions, from the aqueduct to the lateral regions
around the lateral recesses.
Anatomical laboratory training in endoscopy is indispensable and
paramount to develop a sense of spatial orientation. The laboratory
allows the surgeon to compare different images of the same anatomical
area allowing formation of a three-dimensional mental image of the
fourth ventricle. It is very helpful in understanding pathoanatomic
topography. As a futuristic procedure of minimal access surgery and
less traumatic approaches, it can be correctly termed as minimally
invasive neurosurgery or minimally traumatizing neurosurgery.
Richard Lochhead, Robert F. Spetzler, Phoenix, USA
Di Ieva et al. present a cadaveric anatomical study entitled Endoscopic Telovelar Approach to the Fourth Ventricle: Anatomical Study.
The authors use a rigid endoscope with different lenses to describe the
fourth ventricular anatomy via the telovelar approach. They discuss
various endoscopic approaches to the fourth ventricle with endoscopic
photographs to demonstrate the fourth ventricular anatomy that can be
visualized with minimal dissection and no brain retraction. This article
addresses a need for increased understanding of fourth ventricular
anatomy through minimally invasive techniques, and the authors are
to be commended. Further work in this field may include quantification
of the endoscopic access through the different approaches to improve
understanding of the anatomical landmarks that can be visualized in
each approach without tissue retraction.