BACKGROUND: Intracranial pial arteriovenous fistulas (PAVFs) are rare cerebrovascular lesions with high mortality rates. We report a rare case of pediatric PAVF at the basilar artery tip and its treatment with surgical clipping aided by a trapping-evacuation technique in a hybrid operating room. CASE DESCRIPTION: An 18-month-old boy was admitted with hypoevolutism and 4-month history of weakness in the left extremities. Magnetic resonance imaging showed a giant aneurysm-like malformation in the area of midbrain and pons. Angiography showed a high-flow PAVF fed by the basilar artery and bilateral P1 segments of the posterior cerebral artery, with deep draining veins into the transverse sinus and straight sinus. Given the intrinsic characteristics of the lesion, such as deep location, giant fistula and varix, and multiple feeding arteries, clipping of PAVF was performed in a hybrid operating room aided by a trapping-evacuation technique to clearly identify and block the shunting point. CONCLUSIONS: The successful obliteration of the lesion is reported. In addition, a brief review of literature comparing endovascular embolization, surgical disconnection, and hybrid technique for treatment of PAVF is included.