Objective: Evaluation the efficiency of the telovelar approach for 4th ventricular lesions through identifying and preserving neurovascular structures. Methods: Forty cases of fourth ventricular tumours using the telovelar approach Results: It provides adequate exposure in all cases. The brainstem and posterior inferior cerebellar artery (PICA) were early identified and preserved in all cases. Potential tumour attachment was observed at the floor of the fourth ventricle in twenty two (55%) cases, 5 of them were brain stem glioma. 16 of the remaining 17 cases (94%) had focal attachment at any area of the caudal fourth ventricular floor and two cases (11, 7%) was attached at any area of the lateral aspect of the rostral fourth ventricular floor which was the only point of attachment in one of them. None of these tumours infiltrated the area of the cerebral aqueduct. Gross total excision was achieved in 45% of cases and near total excision was possible in 25% due to focal tumour attachment at one or more of the previously mentioned areas. However, debulking was possible in 30%. Conclusions: The main advantage of the telovelar approach is the early identification and preservation of the brain stem and PICA and in addition it allow for assessment of potential tumour attachment at the aforementioned areas.The perspective of the telovelar approach should be directed towards the advantage of early identification and preservation of the brain stem and PICA and in addition it allow for assessment of potential tumour attachment at the aforementioned areas