A 30-year-old female presented with rapid onset of acute dysarthria and left oculomotor paralysis. The MRI showed ruptured anterior midbrain cavernoma. A conservative approach was adopted as the patient was stable. However, one month later she experienced a new bleed with right hemiparesis, diplopia and severe dysarthria. The haemorrhage extended to the surface of the midbrain anteriorly and extended posteriorly without reaching the surface of the safe entry zone. The approach to a cavernous malformation via safe zones are not always feasible due to the proximity of several critical neural structures as in this case. The resection via a posterolateral route using the supracerebellar infratentorial approach was performed successfully.