PURPOSE: The increasing availability of advanced neuroimaging has led to a rise in incidental findings among pediatric patients. Management strategies include immediate surgical intervention, observation or surgery upon progression. These are influenced by imaging characteristics, lesion behavior over time, patient/family preferences, and the lesion's surgical risks. The thalamus's eloquent location often warrants a more conservative approach. Identifying features predictive of growth could help inform clinical decisions regarding surveillance and potential intervention. METHODS: We retrospectively analyzed 44 pediatric patients with 46 thalamic incidentalomas, assessing radiological characteristics, temporal changes, and factors predictive of progression. Progression was defined as a change in size and/or new/increased contrast enhancement. Prognostic factors for progression (demographics, initial tumor volume, extension beyond thalamus, changes in enhancement, margin characteristics) were assessed for significance. RESULTS: Of 46 incidentalomas, 40 were followed longitudinally. Nine incidentalomas (22.5%) showed regression, while nine (22.5%) progressed. The average time to regression was 947 days, and to progression, 516 days. Three patients underwent biopsy due to progressive changes; each was diagnosed with low-grade glioma. Statistical analysis revealed that initial incidentaloma volume, extension beyond the thalamus, and contrast enhancement were significantly associated with progression (p = 0.025, p < 0.001, and p = 0.001, respectively). CONCLUSIONS: Most pediatric thalamic incidentalomas are small, stable, and likely low-grade. However, approximately one-fifth exhibit progressive features, warranting prolonged surveillance. Larger initial volume, extra-thalamic extension, and contrast enhancement are significant predictors of progression and may justify earlier intervention. Individualized management remains essential, balancing natural history with surgical risk.

Center for Pediatric Neuro Oncology University Hospital Motol 5 Úvalu 84 Prague 150 00 Czech Republic

Department of Neurosurgery 2nd Faculty of Medicine Charles University and Motol University Hospital Prague Czech Republic

Department of Pathology and Molecular Medicine 2nd Faculty of Medicine Charles University and University Hospital Motol Prague Czech Republic

Department of Pediatric Haematology and Oncology 2nd Faculty of Medicine Charles University and University Hospital Motol Prague Czech Republic

Department of Pediatric Oncology University Hospital Brno and Faculty of Medicine Masaryk University Brno Czech Republic

Department of Radiology 2nd Faculty of Medicine Charles University and University Hospital Motol Prague Czech Republic

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