All physiological functions of the elderly are declining to varying degrees, and there are more underlying diseases in the elderly, which can be more difficult to deal with if combined with brain tumors. At present, people over 60 years old are generally defined as elderly people, and with the gradual increase of elderly population, more and more elderly people are diagnosed with brain tumors. However, most brain tumors require craniotomy, and the special physiological function of the elderly, can they tolerate craniotomy or not? In fact, it still depends on the specific physical condition of the elderly. Many elderly people in their 70s or even 80s are still in good physical condition and do not have serious underlying diseases. However, not all elderly people are able to tolerate craniotomy. If an elderly person has various underlying diseases such as cardiac, hepatic, and renal insufficiency, and usually has poor physical strength, and the tumor in the brain is considered malignant, it may be difficult to tolerate craniotomy when assessed by cardiac, pulmonary, hepatic, and renal functions. Such elderly people would not be suitable for radical surgical treatment, but should be treated in a more moderate way, such as through puncture biopsy to clarify the nature of the tumor and the targeted drugs that may be effective. The number of brain tumors found in the elderly is increasing, and the management of brain tumors in the elderly needs to be considered in the context of the patient’s general physical status, underlying diseases and other factors, so that invasive craniotomy, or puncture biopsy or even observation can be chosen as the treatment modality.