Management of cerebral cavernous malformations during pregnancy: a systematic review and case illustration

Abstract Background Cerebral cavernous malformations (CCMs) are vascular anomalies that may pose unique challenges during pregnancy due to potential hormonal and hemodynamic influences on lesion behavior, including risks of growth or hemorrhage. Management strategies must balance maternal neurological safety with fetal well-being, yet evidence-based guidelines remain limited. Methods A systematic review was conducted following PRISMA guidelines. Databases (PubMed, Embase, Scopus, Web of Science) were searched from inception to July 2025 using terms such as “cerebral cavernous malformation,” “cavernoma,” “pregnancy,” “management.” Inclusion criteria encompassed English-language studies reporting CCMs in pregnant women. Data extraction focused on epidemiology, hemorrhage risk, management (conservative, microsurgical, radiosurgical), and outcomes. Risk of bias was assessed using Newcastle-Ottawa and Joanna Briggs Institute tools. A case illustration exemplifies clinical decision-making. Results Of 1256 records, 45 studies (512 pregnancies, 478 women) were included. Hemorrhage risk was 1.1–3.6% per pregnancy, comparable to non-pregnant rates (0.7–1.1% annually), with brainstem lesions showing higher risk. Conservative management was used in 68%, microsurgery (second trimester) in 22%, and stereotactic radiosurgery (SRS) in 10%, often postpartum. Maternal mortality was 0.8%, with 92% favorable fetal outcomes. Conclusions Pregnancy does not significantly elevate CCM hemorrhage risk, supporting conservative management for asymptomatic lesions. Second-trimester microsurgery is safe for progressive cases; postpartum SRS suits inaccessible lesions. Multidisciplinary approaches optimize outcomes.