Functional outcomes and anatomy-based surgical strategy in 57 pineal region tumors.

Background: Pineal region tumors are uncommon lesions that present significant surgical challenges due to their deep location, proximity to critical neurovascular structures, and frequent association with obstructive hydrocephalus. Although several operative corridors are available, factors influencing postoperative functional recovery remain poorly defined. This study evaluated clinical, radiological, and surgical determinants of functional outcomes following surgery for pineal region tumors. Methods: We retrospectively reviewed 57 consecutive patients who underwent surgical treatment for pineal region tumors between March 2016 and August 2025 at a tertiary neurosurgical center. Clinical, radiological, operative, pathological, and follow-up data were analyzed. Functional outcomes were assessed using the Karnofsky Performance Scale (KPS). Primary functional outcome was postoperative change in ΔKPS, with admission KPS analyzed separately to identify baseline determinants of preoperative functional status. Results: The mean age was 36.5 years, and 59.6% of patients were male. Gross total resection was achieved in 42 patients (73.7%), subtotal resection in 7 (12.3%), and biopsy alone in 8 (14.0%). Hydrocephalus was present in 45 patients (78.9%), with 12 (21.1%) ultimately requiring permanent cerebrospinal fluid diversion. The posterior interhemispheric transsplenial approach was the most commonly used surgical corridor (36.8%). Increasing age and larger tumor volume independently predicted lower admission KPS scores, whereas lower preoperative KPS was associated with greater postoperative functional improvement. Surgical approach, extent of resection, pathology, and hydrocephalus treatment strategy were not significantly associated with functional recovery. The complication rate was 10.5%, with one perioperative mortality. Conclusion: Favorable functional outcomes and high resection rates can be achieved using multiple microsurgical and endoscopic approaches when operative corridor selection is tailored to individual anatomy. Within the limitations of this retrospective cohort, postoperative functional recovery was more strongly associated with baseline patient- and tumor-related factors than with the operative corridor selected. No statistically significant association between surgical approach and postoperative functional recovery was identified.