Background: Vascular pineal malformations are rare and technically demanding lesions. Because the locations of these lesions, endovascular techniques and radiosurgery have been increasingly used in the recent decades to accomplish safe occlusion. Nevertheless, microsurgical treatment may be required sometimes. Methods: We present a retrospective review of the vascular pineal malformations operated by the senior author. Moreover, we report illustrative cases for the various types of vascular lesions with a careful analysis of the different microsurgical stages. Results: Eighteen patients with pineal vascular lesions were operated on between 1980 and 2015: 6 patients had vein of Galen malformations, 5 plexiform arteriovenous malformations, 6 cavernous malformations, and 1 patient had a ruptured medial posterior choroidal artery aneurysm. A complete resection and occlusion was possible in all vascular malformations. Conclusions: The pineal region is an infrequent but challenging location for vascular lesions. A careful and stepwise operative strategy for the different types of vascular lesion is paramount to accomplish an effective and safe microsurgical treatment when other alternatives fail or are not available.