Controversies in Cavernous Malformation Management: A Comprehensive Review of Current Literature

Intracranial cavernous malformations (CMs) are angiographically occult, slow-flow vascular lesions composed of dilated, mulberry-like capillary clusters lacking intervening brain parenchyma. CMs typically have a low annual hemorrhage risk and are often discovered incidentally. Most patients are asymptomatic or exhibit mild neurological symptoms at the time of diagnosis. Despite decades of investigation, the optimal management of CMs remains controversial. Key clinical dilemmas include identifying which lesions warrant active treatment and when, selecting the best therapeutic approach based on patient age and lesion location (eloquent vs. non-eloquent areas), and determining how to address the hemosiderin rim often found surrounding the malformation. Additional questions involve the role of radiosurgery and appropriate management strategies during pregnancy. This review critically evaluates current literature concerning the natural history and treatment strategies for CMs, emphasizing evidence-based approaches to these unresolved issues. By summarizing and interpreting recent findings, we aim to provide a concise yet comprehensive overview to support clinicians in tailoring patient-specific management plans for this complex neurovascular pathology.