A significant cohort of children with central nervous system tumors will fail initial therapeutic intervention and demonstrate recurrent disease. Treatment of children with these recurrent tumors requires a comprehensive multidisciplinary approach, with consideration of both histologic classification and anatomic location of the tumor. The choice of the specific therapeutic modality selected should reflect institutional experience and seek to advance the treatment of brain tumors in children. Children at Duke Medical Center with biologically indolent tumors and clinical or significant radiographic evidence of recurrence (low-grade/benign tumors with greater than 2-year recurrence-free interval) are usually treated by repeat surgical intervention. Children whose initial therapy did not include radiotherapy are considered for irradiation, while those previously irradiated are observed or occasionally considered for chemotherapy. Children with biologically aggressive tumors (high-grade lesions or early recurrence) are offered neurosurgical intervention if there is considerable mass effect, and subsequently enrolled on phase II chemotherapy protocols, reflecting an institutional commitment to exploring the role of this modality in the treatment of pediatric brain tumors. Children with recurrent brain tumors may derive benefit from this aggressive comprehensive approach, achieving a prolonged and quality survival.