Abstract
Surgical access to lesions in the fourth ventricle may be achieved utilizing transvermian or transtelovelar trajectories. We performed a search of the PubMed database for studies describing the microsurgical details and evaluating the clinical utility of the telovelar surgical approach. The telovelar approach has proven to be a safe, effective, and versatile alternative to the transvermian approach. The operative strategy utilizes midline suboccipital craniotomy without or with C1 laminectomy, followed by cerebellar hemispheric and tonsillar retraction, and wide durotomy. Access is generously provided to the fourth ventricle from calamus scriptorius to Sylvian aqueduct and foramen Luschkae bilaterally. Anatomic dissection studies evaluating and comparing the relative benefits of the operative exposure offered by these approaches have demonstrated improved access to the lateral recess gained by the telovelar trajectory and facilitated exposure of rostral reaches of the fourth ventricle by the vermian trajectory. In general, operative exposure may be significantly improved with tonsillar retraction or resection, bilateral telovelar opening, and performing C1 laminectomy in order to improve access to the rostral fourth ventricle, which may be variably combined depending on location of pathology. Cerebellar mutism, a high incidence of which occurs with vermian approaches, is not commonly observed with use of the telovelar trajectory, though injury to the dentate nuclei may precipitate this syndrome. Deficits incurred with the vermian approach may include cerebellar mutism, dysequilibrium, truncal ataxia, posterior fossa syndrome, cranial nucleopathies and nerve palsies, and vascular injury to the posterior inferior cerebellar artery. The telovelar surgical approach has proven a safe and useful alternative to the transvermian trajectory. A significantly lower incidence of cerebellar mutism and cerebellogenic deficits represents the principal advantage of the telovelar approach. Further studies are necessary in order to prospectively evaluate and compare extents of resection, morbidity, and mortality utilizing the telovelar versus vermian approaches for microsurgically resecting fourth ventricular tumors.
Similar content being viewed by others
References
Dandy WE (1945) Brain tumors: general diagnosis and treatment. In: Surgery of the Brain. W.F. Prior, Hagerstown
Fulton JF, Dow RS (1937) The cerebellum: a summary of functional localization. Yale J Biol Med 10:89–119
Larsell O (1937) The cerebellum. A review and interpretation. Arch Neurol Psychiatr 38:580–607
Tomita T (1996) Medulloblastomas. In: Youmans JR, Becker DP (eds) Neurological surgery: a comprehensive reference guide to the diagnosis and management of neurosurgical problems. W.B. Saunders, Philadelphia, pp 2570–2592
Wen DY, Heros RC (1993) Surgical approaches to the brain stem. Neurosurg Clin N Am 4:457–468
Rekate HL, Grubb RL, Aram DM, Hahn JF, Ratcheson RA (1985) Muteness of cerebellar origin. Arch Neurol 42:697–698
Dailey AT, McKhann GM 2nd, Berger MS (1995) The pathophysiology of oral pharyngeal apraxia and mutism following posterior fossa tumor resection in children. J Neurosurg 83:467–475
Dietze DD Jr, Mickle JP (1990) Cerebellar mutism after posterior fossa surgery. Pediatr Neurosurg 16:25–31
Pollack I, Polinko P, Albright AL et al (1995) Mutism and pseudobulbar symptoms after resection of posterior fossa tumors in children: incidence and pathophysiology. Neurosurgery 37:885–893
Van Calenbergh F, Van De Laar A, Plets C et al (1995) Transient cerebellar mutism after posterior fossa surgery in children. Neurosurgery 37:894–898
Grill J, Viguier D, Kieffer V et al (2004) Critical risk factors for intellectual impairment in children with posterior fossa tumors: the role of cerebellar damage. J Neurosurg 101:152–158
Fraioli B, Guidetti (1975) Effects of stereotactic lesions of the dentate nucleus of the cerebellum in man. Appl Neurophysiol 38:81–90
Konczak J, Schoch B, Dimitrova A, Gizewski E, Timmann D (2005) Functional recovery of children and adolescents after cerebellar tumour resection. Brain 128:1428–1441
Deshmukh VR, Figueiredo EG, Deshmukh P et al (2006) Quantification and comparison of telovelar and transvermian approaches to the fourth ventricle. Neurosurgery 58:ONS-202-206
Jittapiromsak P, Little AS, Deshmukh P et al (2008) Comparative analysis of the retrosigmoid and lateral supracerebellar infratentorial approaches along the lateral surface of the pontomesencephalic junction: a different perspective. Neurosurgery 62:ONS279–ONS287 discussion ONS287-288
Jittapiromsak P, Sabuncuoglu H, Deshmukh P et al (2010) Accessing the recesses of the fourth ventricle: comparison of tonsillar retraction and resection in the telovelar approach. Neurosurgery 66(3 Suppl Operative):30–39 discussion 39-40
Kawashima M, Matsushima T, Nakahara Y, Takase Y, Masuoka J, Ohata K (2009) Trans-cerebellomedullary fissure approach with special reference to lateral route. Neurosurg Rev 32:457–464
Kellogg JX, Piatt JH Jr (1997) Resection of fourth ventricle tumors without splitting the vermis: the cerebellomedullary fissure approach. Pediatr Neurosurg 27:28–33
Matsushima T, Fukui M, Inoue T, Natori Y, Baba T, Fujii K (1992) Microsurgical and magnetic resonance imaging anatomy of the cerebellomedullary fissure and its application during fourth ventricle surgery. Neurosurgery 30:325–330
Matsushima T, Inoue T, Inamura T, Natori Y, Ikezaki K, Fukui M (2001) Transcerebellomedullary fissure approach with special reference to methods of dissecting the fissure. J Neurosurg 94:257–264
Mussi A, Rhoton A (2000) Telovelar approach to the fourth ventricle: microsurgical anatomy. J Neuosurg 92:812–823
Yasargil MG (1988) Microneurosurgery, vol 3B. Georg Thieme Verlag, Stuttgart
Yasargil MG (1996) Microneurosurgery, vol 4B. Thieme, New York, pp 63–64
Yaşargil MG (2003) Comment on: subtonsillar approach to the foramen of Luschka: an anatomic and clinical study. Neurosurgery 52:866
Ziyal IM, Sekhar LN, Salas E (1999) Subtonsillar–transcerebellomedullary approach to the lesions involving the fourth ventricle, the cerebellomedullary fissure and lateral brainstem. Br J Neurosurg 13:276–284
Jean WC, Abdel Aziz KM, Keller JT, van Loveren H (2003) Subtonsillar approach to the foramen of Luschka: an anatomic and clinical study. Neurosurgery 52:860–866
Li ZQ, Lan Q (2009) Microsurgical anatomy and quantitative assessment of suboccipital median transcerebellomedullary fissure keyhole approach [in Chinese]. Zhonghua Yi Xue Za Zhi 89:2754–2758
Tanriover N, Ulm A, Rhoton AL Jr et al (2004) Comparison of the transvermian and telovelar approaches to the fourth ventricle. J Neurosurg 101:484–498
Zhang L, Wang Z, Yu C (2001) Microanatomical study of transcerebellomedullary fissure approach [in Chinese]. Zhonghua Yi Xue Za Zhi 81:788–791
Zhang J, Wang Z, Jia G (2001) Resection of neoplasm in fourth ventricle and at the back of pons through cerebellomedullary fissure approach. Zhonghua Yi Xue Za Zhi 81:645–647
El-Bahy K (2005) Telovelar approach to the fourth ventricle: operative findings and results in 16 cases. Acta Neurochir 147:137–142
Rajesh BJ, Rao BR, Menon G, Abraham M, Easwer HV, Nair S (2007) Telovelar approach: technical issues for large fourth ventricle tumors. Childs Nerv Syst 23:555–558
Rhoton AL Jr (2000) Cerebellum and fourth ventricle. Neurosurgery 47:S7–S27
Rhoton AL Jr (2000) The posterior fossa veins. Neurosurgery 47:S69–S92
Rhoton AL Jr (2000) The cerebellar arteries. Neurosurgery 47:S29–S68
Lister JR, Rhoton AL Jr, Matsushima T et al (1982) Microsurgical anatomy of the posterior inferior cerebellar artery. Neurosurgery 10:170–199
Matsushima T, Rhoton AL Jr, Lenkey C (1982) Microsurgery of the fourth ventricle. Part 1: microsurgical anatomy. Neurosurgery 11:631–667
Gok A, Alptekin M, Erkutlu I (2004) Surgical approach to the fourth ventricle cavity through the cerebellomedullary fissure. Neurosurg Rev 27:50–54
Lee CC, Lin CF, Yang TF et al (2012) Telovelar approach for choroid plexus papilloma in the foramen of Luschka: a safe way using a neuromonitor. Clin Neurol Neurosurg 114:249–253
Sharifi G, Jahanbakhshi A, Sabeti S (2008) A large choroid plexus papilloma removed by the cerebellomedullary fissure approach. Case report and review of the literature. Turk Neurosurg 18:302–306
Zaheer SN, Wood M (2010) Experiences with the telovelar approach to fourth ventricular tumors in children. Pediatr Neurosurg 46:340–343
Di Ieva A, Komatsu M, Komatsu F et al (2012) Endoscopic telovelar approach to the fourth ventricle: anatomic study. Neurosurg Rev 35:341–348 discussion 348-349
Ziehen T (1903) Macroscopic and microscopic anatomy of the brain. In: von Bardeleben K (ed) Handbook of Human Anatomy. Fischer (Ger), Jena
Naidich TP, Duvernoy HM, Delman BN et al (2009) Duvernoy’s Atlas of the human brain stem and cerebellum. Springer Wien, New York
Matsushima T, Rhoton AL Jr, de Oliveira E et al (1983) Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg 59:63–105
Lawton MT, Quiñones-Hinojosa A, Jun P et al (2006) The supratonsillar approach to the inferior cerebellar peduncle: anatomy, surgical technique, and clinical application to cavernous malformations. Neurosurgery 59:ONS244–ONS251
Frazier CH (1905) Remarks upon the surgical aspects of tumors of the cerebellum. N Y State J Med 18(272-280):332–337
Dandy WE (1966) The Brain. In: Lewis D (ed) Practice of Surgery. WF Prior, Hagerstown, pp 452–458
Kempe LG (1970) Operative Neurosurgery, vol 2. Springer-Verlag, New York, pp 14–17
Steinbok P, Cochrane DD, Perrin R et al (2003) Mutism after posterior fossa tumour resection in children: incomplete recovery on long-term follow-up. Pediatr Neurosurg 39:179–183
Liu R, Kasper EM (2014) Bilateral telovelar approach: a safe route revisited for resections of various large fourth ventricle tumors. Surg Neurol Int 30:5–16
Han S, Wang Z, Wang Y, Wu A (2013) Transcerebellomedullary fissure approach to lesions of the fourth ventricle: less is more? Acta Neurochir 155:1011–1016
Tomasello F, Conti A, Cardali S, la Torre D, Angileri FF (2015) Telovelar approach to fourth ventricle tumors: highlights and limitations. World Neurosurg 83:1141–1147
Huo L, Bi C, Fang J, Wang Y, Zhang M, Chen F (2009) Microsurgical treatment and prevention of postoperative complications for the fourth ventricle tumors in adults. Zhong Nan Da Xue Xue Bao Yi Xue Ban 34:642–645
Shigeno T, Kumai J, Endo M, Hotta S (2002) Surgery of AVM of the inferior medullary velum by the uvulotonsillar approach—advantage of moving of the cerebellar tonsil: technical case report. No Shinkei Geka 30:87–92
Shimoji K, Miyajima M, Karagiozov K, Yatomi K, Matsushima T, Arai H (2009) Surgical considerations in fourth ventricular ependymoma with the transcerebellomedullary fissure approach in focus. Childs Nerv Syst 25:1221–1228
Talacchi A, De Micheli E, Lombardo C et al (1999) Choroid plexus papilloma of the cerebellopontine angle: a twelve patient series. Surg Neurol 51:621–629
Rhoton AL Jr (2007) Telovelar approach to the fourth ventricle. Neurosurgery 61:54–193
Kashimura H, Inoue T, Ogasawara K et al (2003) Preoperative evaluation of neural tracts by use of three-dimensional anisotropy contrast imaging in a patient with brainstem cavernous angioma: technical case report. Neurosurgery 52:1226–1229
Mattos JP (2006) Comment on: microsurgical anatomy of the cochlear nuclei. Neurosurgery 58:738
Figueiredo EG, Beer-Furlan A, Welling LC, Ribas EC, Schafranski M, Crawford N, Teixeira MJ, Rhoton al Jr, Spetzler RF, Preul MC (2016) Microsurgical approaches to the ambient cistern region: an anatomic and qualitative study. World Neurosurg 87:584–590
Bertrand G (1973) Chapter 26. Dynamic factors in the evolution of syringomyelia and syringobulbia. Clin Neurosurg 20:322–333
Fischer EG (1995) Posterior fossa decompression for Chiari I deformity, including resection of the cerebellar tonsils. Childs Nerv Syst 11:625–629
Guyotat J, Bret P, Jouanneau E, Ricci AC, Lapras C (1998) Syringomyelia associated with type I Chiari malformation. A 21-year retrospective study on 75 cases treated by foramen magnum decompression with a special emphasis on the value of tonsils resection. Acta Neurochir 140:745–754
Williams B (1978) A critical appraisal of posterior fossa surgery for communicating syringomyelia. Brain 101:223–250
Williams B (1990) Syringomyelia. Neurosurg Clin N Am 1:653–685
Depreitere B, Van Calenbergh F, van Loon J et al (2000) Posterior fossa decompression in syringomyelia associated with a Chiari malformation: a retrospective analysis of 22 patients. Clin Neurol Neurosurg 102:91–96
Lazareff JA, Galarza M, Gravori T, Spinks TJ (2002) Tonsillectomy without craniectomy for the management of infantile Chiari I malformation. J Neurosurg 97:1018–1022
Lee SH, Park SH, Kim JS, Kim HJ, Yunusov F, Zee DS (2014) Isolated unilateral infarction of the cerebellar tonsil: ocular motor findings. Ann Neurol 75:429–434
Bense S, Best C, Buchholz HG, Wiener V, Schreckenberger M, Bartenstein P, Dieterich M (2006) 18F-fluorodeoxyglucose hypometabolism in cerebellar tonsil and flocculus in downbeat nystagmus. Neuroreport. 17:599–603
Erşahin Y, Mutluer S, Cağli S, Duman Y (1996) Cerebellar mutism: report of seven cases and review of the literature. Neurosurgery 38:60–66
Johnston TB (1934) A note on the peduncle of the flocculus and the posterior medullary velum. J Anat 68:471–479
Lang J (1991) Clinical anatomy of the posterior cranial fossa and its foramina. Georg Thieme Verlag Stuttgart, New York
Fujii K, Lenkey C, Rhoton AL Jr (1980) Microsurgical anatomy of the choroidal arteries. Fourth ventricle and cerebellopontine angles. J Neurosurg 52:504–524
Ghali MGZ, Zhang YJ, Kan P, Britz GW (2019) Posteroinferior cerebellar artery aneurysms: Influence of angioanatomy on the safety of flow diversion treatment. 14(4):1063-1067
Fries G, Perneczky A (1998) Endoscope-assisted brain surgery: part 2—analysis of 380 procedures. Neurosurgery 42:226–231
Perneckzy A, Tschabitscher M, Resch KDM (1993) Endoscopic anatomy for neurosurgery. Georg Thieme Verlag, Stuttgart
Perneczky A, Fries G (1998) Endoscope-assisted brain surgery: part 1—evolution, basic concept, and current technique. Neurosurgery 42:219–224
Tschabitscher M, Di Ieva A (2013) Practical guidelines for setting up an endoscopic/skull base cadaver laboratory. World Neurosurg 79:S16.e1–S16.e7
Bergsneider M (1999) Endoscopic removal of cysticercal cysts within the fourth ventricle. Technical note. J Neurosurg 91:340–345
Hamada H, Hayashi N, Endo S et al (1999) Endoscopic aqueductal plasty via the fourth ventricle through the cerebellar hemisphere under navigating system guidance technical note. Neurol Med Chir (Tokyo) 39:950–954
Matula C, Reinprecht A, Roessler K (1996) Endoscopic exploration of the IVth ventricle. Minim Invasive Neurosurg 39:86–92
Stefanov I, Stefanov A, Westman J (1996) A new method for transcutaneous coaxial neuroendoscopy. Anat Embryol (Berl) 194:319–326
Cinalli G, Spennato P, Savarese L, Ruggiero C, Aliberti F, Cuomo L, Cianciulli E, Maggi G (2006) Endoscopic aqueductoplasty and placement of a stent in the cerebral aqueduct in the management of isolated fourth ventricle in children. J Neurosurg 104:21–27
Gawish I, Reisch R, Perneczky A (2005) Endoscopic aqueductoplasty through a tailored craniocervical approach. J Neurosurg 103:778–782
Toyota S, Taki T, Oshino S, Hashiba T, Oku Y, Hayakawa T, Yoshimine T (2004) A neuroendoscopic approach to the aqueduct via the fourth ventricle combined with suboccipital craniectomy. Minim Invasive Neurosurg 47:312–315
Liby P, Torres VL, Taborsky J, Kyncl M, Tichy M (2018) Electromagnetic navigation-guided neuroendoscopic transfrontal transaqueductal fenestration of expansive posterior fossa arachnoid cyst with simultaneous endoscopic third ventriculostomy in an infant. Childs Nerv Syst 34(11):2309–2312
Galzio RJ, Tschabitscher M (2010) Endoscope-assisted microneurosurgery. principles, methodology and applications. Verlag Endo, Tuttlingen
Longatti P, Fiorindi A, Feletti A et al (2008) Endoscopic anatomy of the fourth ventricle. Laboratory investigation. J Neurosurg 109:530–535
Longatti P, Fiorindi A, Martinuzzi A et al (2009) Primary obstruction of the fourth ventricle outlets: neuroendoscopic approach and anatomic description. Neurosurgery 65:1078–1085 discussion 1085-6
Sansone JM, Iskandar BJ (2005) Endoscopic cerebral aqueductoplasty: a trans-fourth ventricle approach. J Neurosurg 103:388–392
Erşahin Y (2007) Endoscopic aqueductoplasty. Childs Nerv Syst 23(2):143–150
Barr ML (1948) Observations on the foramen of Magendie in a series of human brains. Brain 1:281–289
Di Ieva A, Tschabitscher M, Galzio RJ et al (2011) The veins of the nucleus dentatus: anatomical and radiological findings. Neuro-Image 54:74–79
Mamelak AN, Danielpour M, Black KL, Hagike M, Berci G (2008) (2008) A high-definition exoscope system for neurosurgery and other microsurgical disciplines: preliminary report. Surg Innov 15:38–46
Mamelak AN, Nobuto T, Berci G (2010) Initial clinical experience with a high-definition exoscope system for microneurosurgery. Neurosurgery 67:476–483
Eissa EM (2018) The role of the telovelar approach in fourth ventricular surgery: a new perspective. Turk Neurosurg 28:523–529
Kumabe T, Fujimura M, Jokura H, Tominaga T (2008) Surgical treatment for choroidplexus tumors in the fourth ventricle: brain stem infiltration hinders total extirpation. Neurosurg Rev 31:165–172 discussion 172
Piatt JH, Kellogg JX (2000) A hazard of combining the infratentorial supracerebellar and the cerebellomedullary fissure approaches: cerebellar venous insufficiency. Pediatr Neurosurg 33:243–248
Lozier AP, Bruce JN (2003) Surgical approaches to posterior third ventricular tumors. Neurosurg Clin N Am 14:527–545
Majchrzak H, Tymowski M, Majchrzak K, Stepień T (2007) Surgical approaches topathological lesions of the middle cerebellar peduncle and the lateral partof the pons - clinical observation. Neurol Neurochir Pol 41:436–444
Raheja A, Bowers CA, Couldwell WT (2017) Midline telovelar and retrosigmoid suboccipital approaches for fenestration of multiple dilated Virchow-Robin spaces in the brainstem. Oper Neurosurg (Hagerstown) 13:645–646
Grissenauer CJ, Tubbs RS, Cohen-Gadol AA (2013) Analysis of single-staged resection of a fourth ventricular tumor via a combined infratentorial-supracerebellar and telovelar approach: case report and review of the literature. Int J Surg Case Rep 4:842–845
Hermann EJ, Rittierodt M, Krauss JK (2008) Combined transventricular and supracerebellar infratentorial approach preserving the vermis in giant pediatric posterior fossa midline tumors. Neurosurgery 63:ONS30–ONS35 discussion ONS35-37
Koziarski A, Zielinski G, Podgorski JK et al (2004) One stage removalof periaqueductal glioma in adult via infratentorial supracerebel-lar and transaqueductal approaches. Acta Neurochir 146:169–173
Cohen-Gadol AA (2014) Large pontine cavernous malformations: resection via the telovelar approach and mapping of the fourth ventricular floor: 3-dimensional operative video. Neurosurgery 10(Suppl 4):655 discussion 655
Dandy WE (1969) Practice of surgery. In: Lewis D (ed) The Brain. Harper & Row, New York, pp 452–458
Holmes G (2007) The Croonian lectures on the clinical symptoms of cerebellar disease and their interpretation. Lecture I. 1922. Cerebellum. 6(2):142–147 discussion 141
Holmes G (2007) The Croonian Lectures on the clinical symptoms of cerebellar disease and their interpretation. Lecture II. 1922. Cerebellum. 6(2):148–153 discussion 141
Robertson PL, Muraszko KM, Holmes EJ et al (2006) Incidence and severity of postoperative cerebellar mutism syndrome in children with medulloblastoma: a prospective study by the Children’s Oncology Group. J Neurosurg Pediatr 105:444–451
Doxey D, Bruce D, Sklar F, Swift D, Shapiro K (1999) Posterior fossa syndrome: identifiable risk factors and irreversible complications. Pediatr Neurosurg 31:131–136
Author information
Authors and Affiliations
Contributions
G.Z.G. and M.G.Z.G.: conception and design, acquisition of data, analysis and interpretation of data, drafting article and critically revising for intellectual content; approval of final version of manuscript
Corresponding author
Ethics declarations
Conflict of interest
The author has no conflicts of interest to declare.
Ethical approval
All procedures performed in the studies involving human participants described by the works of cited authors were in accordance with the ethical standards committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Ghali, M.G.Z. Telovelar surgical approach. Neurosurg Rev 44, 61–76 (2021). https://doi.org/10.1007/s10143-019-01190-5
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10143-019-01190-5