Cerebral cavernous malformations (CMs) are clusters of abnormally-formed, thin-walled blood vessels that tend to hemorrhage, resulting in focal neurological deficits, seizures, and even death, depending on the location of the lesion and extent of bleeding. Management of cerebral CMs can be reduced to the decision to observe or to surgically resect. The objective of the paper was to review options for surgical management of cerebral CMs. A university-based CM practice was examined for: 1) anatomical distribution of operatively managed CMs; and 2) surgical approaches to eloquent CMs. Although cerebral CMs can occur throughout the brain and can lead to significant neurological morbidity, even in highly eloquent locations, such as the brainstem, thalamus, and basal ganglia, experience demonstrates that the majority of CMs can be safely resected and that patients tend to experience long-term improvement in neurological function. The keys to good patient outcomes lie in appropriate patient selection and in thoughtful choice of a surgical approach that minimizes transgression of normal structures.