Navigating the Eloquent Brain: A Multicenter Study on the Safety and Efficacy of Symptomatic Cavernoma Resection

Background/Objectives: Surgical management of cerebral cavernous malformations (CCMs) within eloquent brain regions presents a high risk of neurological deficits. This study describes the clinical outcomes and technical feasibility of microsurgical resection for symptomatic eloquent CCMs, detailing the integration of advanced intraoperative adjuncts aimed at optimization of seizure control and functional preservation. Methods: We conducted a retrospective multicenter analysis of nine adult patients who underwent microsurgical resection for symptomatic eloquent CCMs between January 2021 and December 2025 across two tertiary centers in Slovenia. Intraoperative modalities included 100% neuronavigation, 55.6% intraoperative ultrasound, 77.8% intraoperative neuromonitoring (IONM) with motor and somatosensory evoked potentials, and 22.2% awake craniotomies. Results: Seizures were the primary clinical presentation in 77.8% of patients (66.7% medically refractory), and the overall hemorrhage rate was 66.7%. Gross total resection of the CCM was achieved in 100% of cases, with complete hemosiderin rim removal in 80% of applicable lesions. Early postoperative complications occurred in four patients, but at the maximum 48-month follow-up, 100% of the cohort achieved complete seizure control, and 44.4% successfully discontinued antiepileptic drugs. Long-term focal neurological deficits persisted in only two patients, while 77.8% were able to work following surgery. Conclusions: Microsurgical resection remains a well-established treatment modality for symptomatic CCMs. In this small, descriptive series of patients with lesions in functionally critical regions, high rates of gross total resection and favorable long-term seizure freedom were observed. These findings suggest that a multimodal approach combining anatomical neuronavigation with functional IONM may help minimize permanent morbidity, though larger cohorts are required to establish definitive efficacy.