• Fareed Jumah, Michael S Rallo, Travis Quinoa, Bharath Raju, Vinayak Narayan, Gaurav Gupta, and Anil Nanda.
• Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School University Hospital, New Brunswick, New Jersey, USA.
• World Neurosurg. 2020 Jul 1; 139: 121-131.

ObjectivesManagement of incidental asymptomatic brain tumors in children is controversial due to lack of clear evidence-based guidelines. We present this systematic review in an attempt to highlight an optimal treatment paradigm.MethodsThis systematic review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Databases were searched up to August 2019 using the keywords "incidental," "brain tumor," and "pediatric." Our main focus was on brain lesions suspected for neoplasm, diagnosed incidentally on neuroimaging in an otherwise asymptomatic patient <18 years old. Cystic, vascular, and inflammatory brain lesions were excluded.ResultsFourteen studies comprising 308 patients were included. All cases were diagnosed using magnetic resonance imaging. The most common indications for imaging were headache (93; 30%) and trauma (72; 23%). Lesion distribution was supratentorial (179; 58%), infratentorial (121; 40%), and intraventricular (8; 3%). Of 308 cases, 243 (79%) were managed with neuroradiological surveillance and 57 (19%) by upfront surgical excision. Of those managed conservatively, 177 (73%) remained stable within a mean follow-up of 30 months, 54 (22%) progressed, and 12 (5%) spontaneously regressed. Meanwhile, upfront excision achieved complete remission in all 57 cases over a mean follow-up of 68.3 months.ConclusionA small body of evidence has emerged, highlighting the marked heterogeneity and contradictory results between the available studies, limiting our ability to draw solid conclusions. At this point, the decision between surgery and "watchful waiting" should be tailored on an individual patient basis depending on suspicion of malignancy, clinical or radiologic progression, and parental preference.Copyright © 2020 Elsevier Inc. All rights reserved.

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