Abstract
BACKGROUND: Brainstem cavernous malformations (BSCMs) are rare vascular lesions, most frequently located in the pons. Their surgical management is particularly demanding due to the dense concentration within the brainstem of eloquent neural pathways and nuclei. Among various surgical routes, the endoscopic endonasal transclival approach (EETA) has been established as a valuable option for treating selected ventrally located lesions. OBSERVATIONS: The authors report the case of a 54-year-old woman with a ventral pontine cavernous malformation (CM) presenting with recurrent hemorrhagic episodes, all resolving without neurological sequelae. Based on the anterior midline location of the lesion within the pons and the posterolateral displacement of the corticospinal tracts (CSTs) on preoperative tractography, an EETA was deemed the most suitable approach. Gross-total removal was achieved without neurological worsening or postoperative CSF leakage. LESSONS: This case supports the use of EETA as a safe and effective surgical route for ventral pontine CMs with anterior surface presentation. Accurate preoperative planning, including assessment of CST displacement via diffusion tensor imaging, and direct intraoperative cortical stimualtion are essential for identifying a safe entry point. Although technically demanding and not universally applicable, EETA offers a direct surgical corridor that minimizes neurovascular manipulation and facilitates favorable outcomes in selected cases. https://thejns.org/doi/10.3171/CASE25356.