Over the last 2 decades, there have been dramatic advancements in our understanding of and the ability to treat brainstem cavernous malformations (BCMs). Once thought untreatable, BCMs are now being more aggressively and safely treated microsurgically as a result of advances in monitoring and imaging technologies, as well as refinement of surgical techniques. BCMs deemed inoperable are being treated with radiosurgery, and experience with dosing and targeting has improved the safety of this treatment modality as well. Much work remains to be done, and prospective randomized trials would undoubtedly further existing knowledge.