Aim:This study aims to present our surgical experience with brainstem cavernomas and to emphasize the importance of the brainstem’s internal structures. Material and Methods:Based on the clinical data of 25 symptomatic patients who underwent surgery for brainstem cavernomas, we reviewed their radiological findings, surgical indications, surgical timing, postoperative remnants, and outcomes. We also performed a statistical analysis of seven parameters that, based on our clinical experience, may influence outcomes in these challenging cases.Results:There were 14 male and 11 female patients, with a mean age of 36.6 years (range: 20–66 years). All patients were symptomatic and had experienced at least one episode of bleeding. Complete resection was achieved in 23 patients (92%), while two (8%) required reoperation for residual cavernoma. Postoperative mortality occurred in one patient (4%) due to malignant hyperthermia. As a result, the mean modified Rankin Scale (mRS) scores at admission, discharge, and last follow-up were 2.44, 2.14, and 1.86, respectively. Statistical analyses demonstrated that preoperative neurological status was an important parameter affecting outcome (p = 0.002).Conclusion:Brainstem cavernoma is a benign pathology, but it occurs in a malignant location. Therefore, advanced techniques, such as tractography, neuronavigation and neuromonitoring, should be employed in these challenging cases. However, we believe that a thorough knowledge of brainstem neuroanatomy and meticulous surgical technique are even more critical.