Surgical experience with angiographically occult vascular malformations, specifically cavernous malformations (CMs), has increased substantially over recent years. CMs are generally well-circumscribed, low-pressure vascular lesions amenable to resection. Overall, results obtained with operative management have been favorable; however, the location of the lesion impacts significantly on the outcome and morbidity of surgery, with those located within deep and brain stem regions carrying a higher incidence of persistent neurologic complications. As knowledge emerges regarding the long-term natural history of these lesions, the role of operative intervention in cases where surgical morbidity is high will become better defined.