Surgical management of pediatric pineal region tumors: an overview of current strategies.

[BACKGROUND] Tumors of the pineal region represent a rare and heterogeneous group of pediatric intracranial neoplasms, accounting for 3-8% of childhood brain tumors. Their deep midline location and proximity to critical neurovascular structures make surgical management particularly challenging. Over the past two decades, refinements in microsurgical and endoscopic techniques have markedly changed the surgical landscape. This systematic review aims to provide an updated overview of surgical strategies, outcomes, and complications in pediatric pineal region tumors.

[METHODS] A systematic review was conducted following PRISMA guidelines. PubMed and Embase were searched for studies published between January 2000 and December 2025 reporting surgical outcomes in patients aged ≤ 18 years with pineal region tumors. Methodological quality was assessed using the Newcastle-Ottawa Scale. Twenty-two studies including 624 pediatric patients were analyzed qualitatively.

[RESULTS] Patient age ranged from 4 months to 18 years (mean 10 years), with a male-to-female ratio of 2.5:1. Germ cell tumors were the most common histology, followed by pineoblastomas, teratomas, and astrocytomas. The main surgical approaches included supracerebellar infratentorial (SCITA), occipital transtentorial (OTA), occipital interhemispheric transtentorial (OITA), and transcallosal routes, as well as endoscopic or endoscope-assisted techniques. Gross total resection (GTR) was achieved in 40-100% of cases. Transient postoperative morbidity ranged between 15-25%, with Parinaud's syndrome and ataxia being most frequent. Permanent deficits occurred in < 10% of patients, and overall mortality varied by histology and ranged from 0 to 20%.

[CONCLUSIONS] Both microsurgical and endoscopic approaches achieve high rates of GTR with excellent functional outcomes. Minimally invasive techniques increasingly complement traditional microsurgical routes, aiming to reduce morbidity and improve CSF management. Future multicentric prospective studies are essential to establish evidence-based guidelines for pediatric pineal tumor surgery.