Endoscopic transclival decompression for ventral brainstem tuberculous abscess: illustrative case.

backgroundCNS tuberculosis (TB) remains a major global health challenge, affecting all age groups regardless of immune status. It is associated with high morbidity and mortality, with stroke and hydrocephalus as common complications. Brainstem tuberculomas and tuberculous abscesses are rare manifestations of CNS TB and pose significant management challenges. OBSERVATIONS: An 18-year-old immunocompetent male developed acute quadriparesis and decreased consciousness from complicated brainstem tuberculomas with brainstem compression. He underwent urgent surgical decompression and drainage of purulent material via an endoscopic endonasal transclival approach (EETA), with the continuation of antituberculous therapy and corticosteroids. Intraoperative findings included a solid granuloma and inflammatory debris. Molecular analysis confirmed Mycobacterium tuberculosis. Postoperatively, the patient achieved a remarkable recovery from quadriparesis, along with multiple cranial nerve (CN) deficits (CNs VI, VII, and VIII). LESSONS: CNS tuberculomas typically respond to medical treatment and rarely necessitate surgical intervention. However, tuberculous abscesses represent a distinct clinical entity, particularly in the vicinity of the basal cisterns and the brainstem area. Urgent surgical treatment is essential to relieve brainstem compression, reduce inflammation, lower the risk of stroke, and enhance neurological recovery. The EETA provides a safe and effective strategy for both diagnostic biopsy and ventral brainstem decompression. https://thejns.org/doi/10.3171/CASE25613.