Pediatric Brain Tumor Surgery

Many childhood brain tumors are cured by the operation alone. Knowing when to stop matters as much as knowing how far to go.

In the ACNS0121 trial of 356 children with ependymoma, five-year event-free survival reached 68.5 percent after complete or near-complete removal followed by radiotherapy, against 37.2 percent after a subtotal removal.

The tumors behind the word

Brain and spinal cord tumors make up the largest group of solid tumors in children. In the United States the CBTRUS registry counts about six new cases a year for every 100,000 children and teenagers, and its 2025 report covers every diagnosis made between 2018 and 2022, while many of the tumors behind that figure grow slowly, never spread beyond the brain, and are cured by surgery alone in a good share of children.

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The type of tumor, more than its size, decides how hard the surgeon pushes.

Signs that bring a child to the scanner

Morning headaches that ease after vomiting, a child who suddenly walks like a toddler again or bumps into door frames, a squint that appears out of nowhere, a head that grows faster than the chart allows in a baby, a seizure with no fever, a change in school performance, or a growth or puberty problem that the pediatrician cannot explain. Most of these come from pressure, because many childhood tumors sit near the fluid channels of the brain and block them, a condition called hydrocephalus. The diagnosis then moves quickly. A tumor in the cerebellum shows itself through balance and vomiting, one near the optic nerves through failing sight or wandering eyes, one in the brainstem through a facial droop, a squint and trouble swallowing that develop over weeks, and one near the pituitary gland through slow growth, early or late puberty, or a child who drinks and urinates far more than before. For a tumor with a typical appearance on MRI, the operation itself becomes the biopsy. For one that looks like a diffuse midline glioma, a small biopsy or no surgery at all can be the right plan.

Maximal safe resection

Every pediatric neurosurgeon works to the same two-word rule. Maximal means taking as much tumor as the anatomy allows. Safe means stopping before a child loses speech, movement, vision or the ability to swallow.

For some tumors the extent of removal drives everything that follows. The Children's Oncology Group trial ACNS0121, published in the Journal of Clinical Oncology in 2019, followed 356 children with ependymoma. Children whose tumor had been removed completely or near completely and who then had radiotherapy reached a five-year event-free survival of 68.5 percent, against 37.2 percent after a subtotal removal, and children with a classic ependymoma removed completely from the cerebral hemispheres were watched without radiotherapy. A second operation to remove residual ependymoma before radiotherapy forms part of the plan for exactly that reason.

For ependymoma, complete removal followed by radiotherapy nearly doubled five-year event-free survival.

When less surgery is the better operation

For other tumors, a small remnant left on a vital structure does no harm. Great Ormond Street Hospital in London reviewed 200 children with pilocytic astrocytoma of the cerebellum, published in the Journal of Neurosurgery Pediatrics in 2024, and found complete removal at the first operation in 74.5 percent. Many children with a small remnant were simply watched. Children who went through repeated operations had more hormone problems, hearing loss and learning difficulties, and the authors recommended scans over reflex re-operation when a remnant stays stable. A Prague series of 21 children with low-grade gliomas deep in the thalamus reached the same conclusion from the other side, with every child alive at a median of six years even though complete removal had been possible in only six.

What helps the surgeon see

Several technologies make a maximal safe resection safer, and published hospital pages in Istanbul name them all. None replaces the surgeon's judgment.

• Neuronavigation. A navigation system matches the patient's MRI to instruments in the surgeon's hand, so the tumor margins and nearby fiber tracts show on screen throughout the operation.
• Neuromonitoring. Electrodes watch motor, sensory and cranial nerve pathways and warn the surgeon before a structure gets hurt, which matters most near the brainstem.
• Intraoperative MRI. A scan during surgery, before the wound is closed. In a series of 255 operations at Alder Hey Children's Hospital in Liverpool, the scan led to further removal in 27.5 percent of operations aiming for complete removal, with infection in 1 percent of children.
• Endoscopes. Thin cameras reach tumors inside the ventricles and treat blocked fluid pathways without opening the brain widely.

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Pressure in the head comes first

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Removing the tumor reopens the fluid channels by itself in many children, so many never need a permanent shunt.

Shunts can block, sometimes years later.

Families leave with a written description of the signs, because a blocked shunt needs a hospital the same day wherever the child is.

Operation day and the first week

One parent stays in the room on the companion bed throughout.

Risks, with what is done about each

Brain surgery carries real risks. Each of them has a plan.

Before you sign the consent form, the surgeon goes through these risks for your child's own tumor and its exact position.

When the pathology changes the plan

Pathology results on the removed tumor arrive within days, and molecular tests that now define many childhood brain tumors take one to three weeks. Those results decide whether the child needs radiotherapy, chemotherapy, both, or nothing beyond regular scans. Radiotherapy and chemotherapy are both delivered at Biruni Hospital, on the same site as the surgery, so a child whose plan grows continues with the team that operated, using the same scans and the surgeon's own record of what remained and where. Families who would rather continue at home leave with a written handover for their own pediatric oncologist and neurosurgeon, the pathology slides and blocks for any further testing, every scan on disc, and a radiotherapy and chemotherapy plan written out in full. Radiotherapy for children under three is planned with extra care, because the developing brain is most sensitive at that age, and chemotherapy often bridges the gap until the child is older.

How long a family stays in Istanbul

Ten to fourteen days covers the operation alone in most cases, according to the published packages, and fourteen to twenty-one days once the tests before surgery and the recovery after it are counted. That window holds the preparation, the operation, intensive care, the ward days, the first MRI, the removal of stitches and the first pathology results. When radiotherapy follows in Istanbul, the family stays for the full course of daily weekday sessions, which runs to six weeks for many childhood brain tumors, and chemotherapy can then continue at home under a written protocol.

Clearance to fly

Flying waits for three things. A healed wound, a stable child, and a postoperative scan without trapped air or new fluid. The surgeon writes the clearance date into the discharge letter, and families rarely fly before the second week after surgery.

The clearance date goes into the discharge letter, in writing.

What drives the cost

Tumor location sets the length of the operation and the nights in intensive care. The type sets what follows. A pilocytic astrocytoma removed completely may need nothing more than scans, while a medulloblastoma adds weeks of radiotherapy and months of chemotherapy. Hydrocephalus treatment, a second operation for residual tumor, rehabilitation, molecular pathology, repeat MRI scans and the number of hospital nights each move the total, and a child who needs speech therapy or physiotherapy for weeks adds outpatient sessions to the plan.

Published packages for brain tumor surgery in Istanbul list the consultations, anesthesia, surgical materials including the dural graft, tests and imaging before surgery, intensive care and ward nights, airport transfers and an interpreter, while flights, medicines after discharge, specialized pathology and extended rehabilitation sit outside many of them. Hotel nights are billed separately, by the day.

A quote you can compare names the operation, counts the intensive care and ward nights, and says whether the MRI scans, the molecular pathology and rehabilitation sit inside it. That figure comes only from a pediatric neurosurgeon reading your child's own MRI. The review costs nothing.

Traveling with your child

From the first WhatsApp message to the day you fly, one coordinator handles the case, and that number keeps working once you are home. English, Arabic, French, Russian, Serbian, Romanian and Spanish are covered by the team directly. An interpreter joins for any other language. A companion bed in the child's room lets a parent stay every night of the admission, while the hotel for the nights before and after is booked by the international patients office. Consulates usually ask for an invitation letter naming the hospital and the treating doctor, and that letter goes out about ten days ahead of the flight. Transfers from the airport and between hotel and hospital are arranged. The kitchen cooks halal, vegetarian and diabetic meals. There is a prayer room on site, and if you would like a female physician, say so in the first message and the request goes to the department.

Send the MRI images on disc, the full set rather than a few pictures.

Once you are back home

Follow-up rests on MRI. Scans come every three to six months in the first years and less often after that. Tumors that can spread through the spinal fluid need a spine MRI as well. Your local team arranges the scans, and the coordinator passes the images back to the neurosurgeon in Istanbul, who compares each one with the first postoperative scan and replies through the same WhatsApp number.

School and growing up

Most children go back to school within weeks of surgery alone.

After radiotherapy

Children who had radiotherapy need regular checks of growth, hormones, hearing, vision and learning for years, and many benefit from extra support at school, which the discharge summary describes for teachers in plain terms.

A severe headache with vomiting, new drowsiness, a seizure, fever with a red or leaking wound, or swelling along a shunt. Each needs a doctor the same day. The local emergency department sees the child first, using the English discharge file, and the coordinator relays the details to the neurosurgeon who operated.

Pediatric brain tumor surgery FAQ