OBJECTIVE: To summarize the clinical characteristics, selection of surgical approach, and key points of microsurgical resection techniques of brainstem cavernous hemangioma, and to evaluate the efficacy of surgical treatment of brainstem cavernous hemangioma. METHODS: The clinical data and surgical treatment of 41 cases of brainstem cavernous hemangioma microsurgically resected between January 2003 and April 2011 were retrospectively analyzed. RESULTS: In this group of 41 patients, the ages ranged from 8 to 62 years old, including 2 cases in children under 14 years old (4.9%), 33 cases in those between 20 and 50 years old (80.5%), 6 cases in those over 50 years old (14.6%), and an average age of 35.5 years old; 23 cases in men and 18 cases in women, with a male-to-female ratio of 1.3:1; common symptoms and signs included: headache, dizziness, cerebrospinal fluid The common symptoms and signs included: headache, dizziness, increased intracranial pressure due to obstruction of circulation in 7 cases (7/41), cranial nerve dysfunction in 26 cases (26/41), impaired long tract signs such as numbness and muscle weakness in 28 cases (28/41), and impaired motor ataxia and balance in 12 cases (12/41) with damage to pontine fibers; location of lesions: midbrain in 9 cases, including 8 cases located in the pedunculopontine and pontocerebellar junction areas of the midbrain. The lesions were located in the ventral part of the pontocerebral arm in 12 cases, of which 9 cases were located in the superior part of the pontocerebral arm and took the inferior temporal incision to the cerebellar curtain, 3 cases were located in the inferior part of the pontocerebral arm and the lateral part of the pontine junction area and took the posterior occipital sigmoid sinus approach or the distal lateral approach; those located in the dorsal part of the pontocerebrum and the base of the four ventricles In 15 cases, the suboccipital posterior median approach was adopted via the base of the fourth ventricle, and incision was made from the inferior or superior facial triangle to reduce the damage to the facial auditory nerve, medial longitudinal bundle and other important structures; in 5 cases located in the medulla oblongata, the suboccipital posterior median approach was adopted via the cerebellar medullary fissure; the selection of all surgical approaches followed the principle of “taking the thinnest point on the surface of the brainstem where the lesion is protruding and entering from the shortest distance from the lesion”. All surgical accesses were selected based on the principle of “access by incision at the shortest distance from the lesion at the thinnest point on the surface of the brainstem” and were strictly separated along the interface of iron-hemoglobin deposits. Intraoperative navigation can help locate the lesion site and the brainstem incision site. Intraoperative brainstem evoked potential (SSEP) and auditory evoked potential (AEP) monitoring was performed, and in some cases, the base of the fourth ventricle was directly stimulated for localization monitoring. 41 cavernous hemangioma lesions were reviewed postoperatively, 35 were completely resected, and 6 had a small residual mass; there were no surgical deaths, and 27 had improved preoperative neurological deficits; 14 patients had new postoperative neurological deficits (e.g., facial palsy). In 14 patients, new neurological deficits (such as facial palsy and adductor nerve palsy) or exacerbation of existing neurological deficits occurred after surgery, among which 2 cases had affected respiratory function and resumed spontaneous breathing after one week of artificially assisted breathing; most of the patients with neurological deficits recovered during the mean follow-up period of 38 months, 1 patient with residual tumor had rebleeding, and the rest did not see recurrence. Conclusion: Brainstem cavernous hemangioma occurs in young and middle-aged people, and is most common in the pontine brain. Intraoperative navigation and brainstem electrophysiological monitoring are helpful in reducing surgical injuries and complications.