OBJECTIVE: The surgical treatment of cavernous malformations involving the posterior limb of the internal capsule (PLIC-CMs) is challenging. The aim of this study was to determine the utility and predictive value of pre-operative diffusion tensor imaging (DTI) in the surgical treatment of PLIC-CMs. METHODS: Patients with PLIC-CMs who were surgically treated between September 2012 and June 2015 were reviewed. All patients underwent preoperative DTI. Three major fiber tracts were selected for evaluation: 1) corticospinal tract (CST); 2) arcuate fasciculus (AF); and 3) optic radiation (OR). The utility of preoperative DTI for surgical approach selection and intraoperative navigation was documented. An involvement grading system of the major fibers was applied to determine the predictive value of preoperative DTI. A last modified Rankin Scale (mRS) score of 0-2 was considered a good outcome, and a last mRS >2 was considered a poor outcome. RESULTS: Thirteen patients with 13 PLIC-CMs were reviewed in this study. All the lesions were radically resected via the corridor formed by CST, AF, and OR. None of the patents suffered from mRS >3, and 7 patients (53.8%) got good outcomes at the last clinic visit. The difference between the preoperative mRS scores and last mRS scores was not significant (P = 0.673). The involvement grade of the fiber tracts was significantly associated with the surgical outcome (P = 0.011). CONCLUSIONS: Preoperative DTI may be a promising tool to determine the surgical approach and predict the surgical outcomes in patients with PLIC-CMs.