We describe the use of the subtonsillar-transcerebellomedullary approach to laterally placed fourth ventricle and brain-stem lesions. The subtonsillar-transcerebellomedullary approach to the fourth ventricle and the lateral brainstem was used in six patients: three patients with tumours of the fourth ventricle and brainstem (two ependymomas and one papillary thyroid carcinoma metastasis), two patients with cavernous angiomas of the brainstem and one patient with a distal posterior inferior cerebellar artery (PICA) aneurysm. The microsurgical anatomy of this approach was studied in five cadaveric head specimens. The rumours and cavernous angiomas were removed and the distal PICA aneurysm was clipped successfully. In all patients the Karnofsky performance scale (KPS) was equal to or better than the preoperative status on follow-up examinations. The anatomical studies also revealed the extensive exposure provided with this approach. The subtonsillar-transcerebellomedullary approach is recommended for lesions occupying the cerebellomedullary fissure, and the lateral aspect of the fourth ventricle.