Background: Surgical resection of lesions in the posterior incisural space presents a significant surgical challenge, which may result in postoperative visual complications and other neurological deficits. We, therefore, describe a retractorless interhemispheric transtentorial approach that avoids surrounding brain structures with positive outcomes and no complications or visual damage. Case Description: We present four cases of lesions in the posterior incisural space that was treated with a retractorless interhemispheric transtentorial approach. Two patients were previously seen at another institution for a falcotentorial meningioma. We resected the meningiomas with a parietal-occipital interhemispheric transtentorial approach with no neurological deficits. A third patient presented with a large superior vermian hemangioblastoma with a steep angle of the tentorium. The fourth patient had a large upper vermian metastatic lesion with progressive enlargement, which was refractory to radiation treatments and chemotherapy, and we achieved partial resection. Postoperative visual function was completely preserved in all patients. Conclusion: A carefully executed retractorless interhemispheric approach in select cases is an effective option to reduce morbidity and prevent visual complications when removing lesions in the posterior tentorial incisure.

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