We present a 56-year-old man who suffered from trigeminal neuropathic pain secondary to nerve compression due to a giant posterior fossa AVM. He consulted ten years ago for intermittent, paroxysmal, severe, electrical, and triggerable left V2-V3 pain episodes. Initially, he was examined in another center, where the diagnosis of a left cerebellar AVM Spetzler-Martin grade V was made (). Throughout these ten years a total of five attempts of embolization were made. None of them achieved a complete occlusion of the AVM. Furthermore, the patient suffered left side facial palsy (House & Brackmann grade III), dysmetria, unsteady gait and progression of the TNP due to post-embolization sequelae. When the patient consulted in our center, he was unable to control pain with 1200 mg of carbamazepine per day. He had already been under treatment with pregabalin 225 mg per day, acetaminophen 3000 mg per day, amitriptyline 50 mg per day and tramadol 200 mg per day. From all the therapeutic options available, we declined the microvascular decompression of the trigeminal nerve due to the presence of the giant AVM, or stereotactic radiosurgery because of the AVM's diffuse nidus. We analyzed that any procedure through the foramen ovale, such as radiofrequency or neuropraxia, was risky because of an anomalous vein drainage located near the Gasserian ganglion. After a multidisciplinary discussion, with the ethics committee approval, we proposed a safe and reversible treatment, although it required a larger approach and involved greater risk: MCS.