Secondary trigeminal neuralgia due to vertebrobasilar dolichoectasia is a rare entity. Surgical therapy via pterional craniotomy approach and anterior petrosectomy has already been described in literature. We present an 81-year female patient suffering from left sided trigeminal neuralgia due to vertebrobasilar dolichoectasia. We show in this case report a macrovascular decompression of a dolichoectatic vertebral artery via Kawase approach. Successful decompression under continuous intraoperative neuromonitoring via pure Kawase approach and ventro-lateral transposition of a dolichoectatic vertebral artery through a polyester-titanium sling was achieved. Postoperative the patient described an immediate improvement of the trigeminal neuralgia symptoms. At the two-month postoperative follow-up the patient remained trigeminal neuralgia painless free and suffered from a regredient facial nerve palsy. We report for the first time a successful macrovascular decompression of a dolichoectatic vertebral artery via Kawase approach under continuous intraoperative neuromonitoring. In-contrast to traditional suboccipital retrosigmoidal approach our strategy obtains sufficient working space and angles. Thus, adequate transposition of the dolichoectatic vessel could be achieved.