Cerebral cavernous malformations in pregnancy: A systematic review of case reports and case series of hemorrhagic risk and outcomes

Cavernous malformations (CMs) are vascular lesions that can lead to seizures or hemorrhage. Although pregnancy involves hormonal and circulatory changes that might influence CM behavior, whether it increases the risk of bleeding is unclear. We performed a systematic review using PubMed/MEDLINE and Scopus of published reports describing pregnant women diagnosed with cerebral or spinal CMs. The study question was framed using the PEO strategy, with pregnant women with cavernous angioma as the population, hemorrhage as the exposure, and clinical outcomes as the endpoints. The search was updated to July 12th, 2025 with no time restrictions. This review followed the PRISMA 2020 guidelines. Thirty-two studies were selected accounting for 94 patients. Most lesions were localized in the brainstem and supratentorial regions. Among patients that were symptomatic during gestation, hemorrhage occurred in 70.9% and seizures in 34.1%. However, a secondary analysis limited to comparative studies consistently showed a low hemorrhage rate during pregnancy, ranging from 0.9% to 3%. Most patients were managed conservatively. Surgical intervention was reserved for cases with acute neurological deterioration or persistent hemorrhage, located below the tentorium. Although, more on prudence than evidence, cesarean delivery was frequently chosen. The secondary analysis on the larger cohorts confirms that pregnancy does not increase the risk of bleeding. Treatment, however, must be postponed after delivery. Nonetheless, in cases where early intervention is unavoidable, due to topography and severity of maternal symptoms, surgery might be an option. Additionally, close monitoring in the early postpartum period remains indispensable.