The natural history of cerebral cavernous malformations (CMs) is varied, according to their anatomic position. Although many are silent and the risk of persisting disability after 1 bleed is low, some lesions behave more aggressively. At present, it is not possible to predict future behavior at presentation, but subsequent hemorrhages often cause cumulative morbidity, particularly from deep-seated lesions.

Surgery for symptomatic hemispheric CMs, and a subset of deep-seated eloquent lesions, may be safe if performed by experienced clinicians.

Stereotactic radiosurgery is a safe and effective treatment alternative for cerebral CM. There is a dramatic decrease in rebleed rate after a 2-year latency period, whereas using current protocols radiation-induced morbidity is low.

We propose a simple management algorithm that recommends early stereotactic radiosurgery, even after only 1 event in neurologically intact or minimally disabled patients harboring deep-seated CMs.