Cavernous malformations (CMs) are abnormal vascular formations of the brain with an estimated incidence of 0.4%-0.8% in the general population.1 CMs have the potential to cause significant morbidity, and have been associated with epileptic seizures, intracranial hemorrhage, and focal neurological deficits.2 Management options include non-treatment, surgical resection, and radiosurgery. We review here the efficacy of different management strategies for cavernous malformations and highlight the specific role of radiosurgery.

One of the major complications of cerebral cavernous malformations is intracranial hemorrhage. To optimize patient treatment, it is beneficial to be able to identify patients that are at an increased risk of developing a hemorrhage and would most benefit from intervention. The overall rate of hemorrhage in patients with CMs has been estimated to be 2.25%.3 The rate of hemorrhage, however, is significantly affected by the initial symptom presentation. Patients presenting with a hemorrhage have significantly higher rates of rehemorrhage compared to patients presenting due to incidental findings.3,4 Flemming et al. found that patients presenting with hemorrhage had an overall annual rate of hemorrhage of 6.19% compared to patients presenting without hemorrhage of 0.33%. With increasing use of MR imaging, the percentage of cavernous malformations found incidentally approaches 40%.1 Because the risk of hemorrhage is low in patients with CMs found incidentally, surgical or radiosurgery management may not be indicated. In contrast, patients presenting with symptoms of hemorrhage should be considered for therapeutic intervention due to a high risk for subsequent hemorrhage.

One option for the management of cavernous malformations is surgical intervention by CM resection. There is conflicting evidence in the literature regarding the effectiveness of CM resection, likely due to different methodologies used for determining efficacy. When post-operative outcomes are compared to pre-operative values, significant improvement is observed as demonstrated by improvements in the modified Rankin scale and decreased annual hemorrhage rate.5,6 However, the results are limited by the fact that studies did not include a control group of patients that did not receive surgery. A recent retrospective study by Moultrie and colleagues compared the outcome of patients treated with surgical to conservative management. Patients who underwent CM resection had worsened short-term disability scores, increased risk of developing intracranial hemorrhage, and new focal neurologic deficits.7