The Impact of Post-Craniotomy Subdural Effusion in Pediatric Brain Tumors

The Impact of Post-Craniotomy Subdural Effusion in Pediatric Brain Tumors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of Post-Craniotomy Subdural Effusion in Pediatric Brain Tumors Ju-En Nien, Tzu-Chin Lin, Yi-Lun Wang, Tsung-Yen Chang, Shih-Hsiang Chen, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4812313/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Over recent decades, survival rates in pediatric brain tumors (PBT) have been significantly improved due to technological advancements in surgical approaches and intensified chemotherapy. Although disease relapse rates have been reduced, these treatments still come with unavoidable complications. Subdural effusion (SDE) is a significant complication that can occur after craniotomy, with its incidence depending on the surgical approach and potentially affecting the prognosis of the disease. The objective of this study is to examine the impact of post-craniotomy SDE on survival outcomes in patients with PBT. Methods Our study utilized a retrospective chart review to examine children diagnosed with PBT at Chang Gung Memorial Hospital between January 2013 and December 2023. Survival benefits were assessed using Kaplan-Meier analysis, while differences in continuous variables were examined using Student's t-tests. The statistical analyses were conducted using GraphPad Prism version 9.0 software. Results The study included 178 children diagnosed with PBT, and their progress was tracked for a median duration of 3.8 years (IQR 1.6–7.0). The diagnoses consisted of a variety of brain tumors. The incidence of post-craniotomy SDE was 21.3%. The majority of cases (66%) were managed through observation, while surgical intervention was necessary for 34% of cases. The study found that the presence of SDE was associated with slightly lower survival rates (18.4% vs. 15.0%) and slightly higher disease relapse rates (44.7% vs. 35.7%), although these differences did not reach statistical significance. Conclusion SDE is still a frequent complication that occurs after craniotomy in PBT patients. The presence of SDE can have a negative impact on both survival rates and the likelihood of disease relapse in PBT. Pediatric brain tumor post-craniotomy complications subdural effusion overall survival relapse free survival Figures Figure 1 Figure 2 Introduction The overall survival (OS) of pediatric brain tumors (PBT) has improved from less than 40% to 60–80% in the past decades [ 1 , 2 ]. This notable survival outcome is largely attributed to technical improvements in surgery, personalized irradiation programs, and the introduction of multi-agent chemotherapy. The increased intensity of multidisciplinary treatments addresses the historically bleak prognosis of PBT but inevitably leads to the development of upfront treatment-related morbidity and complications [ 3 – 5 ]. Clinical physicians have dedicated themselves to striking a balance between treatment efficacy and the associated toxicity. Subdural effusion (SDE) is a common complication following brain surgery, with its incidence varying across different craniotomy approaches [ 6 – 9 ]. In most cases, the presence of SDE does not necessitate emergent management unless it reaches a considerable size or leads to progressive elevation of intracranial pressure. While not typically life-threatening, SDE appears to be associated with cortical/ependymal defects. Compromised dural integrity may facilitate disease dissemination, potentially impacting survival outcomes negatively [ 10 , 11 ]. Research efforts have often focused on refining surgical techniques and developing novel therapies, yet little is known about the impact of complications such as SDE on survival outcomes. This study aims to investigate the prognostic impact of SDE in patients with PBT. Materials & Methods Case Enrollment This retrospective cohort study enrolled pediatric patients diagnosed with brain tumors at Chang Gung Memorial Hospital between January 2013 and December 2023. Patients with less than one year of follow-up were excluded. This study was approved by the Chang Gung Memorial Hospital Institutional review board (Project number 202401075B0). Diagnosis Confirmation Diagnosis of PBT was confirmed through histopathological and radiological assessments. Tumors were categorized into glioma, germ cell tumors (GCTs), medulloblastoma (MB), embryonal tumors, atypical teratoid/rhabdoid tumors, craniopharyngioma, and others. Resected tumor slides were independently reviewed by an expert pathologist, with consultation from another pathologist in cases of inconclusive results. Evaluation of Treatment Response Radiological evaluations were conducted every 3–6 months to assess treatment response, guided by clinical expertise. Statistical Analysis Kaplan-Meier analysis was used to plot survival and relapse curves. Student’s t-tests were employed to analyze differences in continuous variables such as age at diagnosis, follow-up duration, survival period, and relapse-free interval. Chi-square tests were used to assess differences in categorical variables including PBT subtype, gender, surgical approach, presence of SDE, relapse, and mortality. All statistical analyses were performed using GraphPad Prism version 9.0 software. Results A total of 178 children diagnosed with PBT were included in the study cohort. The median follow-up duration was 3.8 years (IQR 1.6–7.0). Baseline characteristics are summarized in Table 1 . Major PBT subtypes included glioma (40.4%), GCTs (25.3%), and MB (14.6%). The survival analysis of PBT subtypes was shown in Fig. 1 . The PBT with low-grade glioma (LGG) subtype exhibited the best prognosis, with a 5-year OS rate of 97.8%. The high-grade glioma (HGG) subtype harbored the poorest prognosis, with a 5-year OS rate of 36.7%. Post-craniotomy SDE occurred in 21.3% of cases. Management was predominantly observational (66%), with surgical intervention required in 34% due to larger SDE size or symptomatic illness. Frontal and occipital approaches were associated with an increased risk of SDE. Table 1 Baseline characteristics of the PBT cohort. Characteristics Median (IQR) Age at diagnosis (years) 9.7 (5.6–13.7) Follow-up duration (years) 3.8 (1.6–7.0) Male-to-Female ratio 1.7 PBT subtype Germinoma 31 (17.4%) NGGCT 14 (7.9%) ATRT 2 (1.1%) Embryonic tumor 7 (3.9%) DIPG 10 (5.6%) Craniopharyngioma 14 (7.9%) LGG 47 (26.4%) HGG 15 (8.4%) MB 26 (14.6%) Others 12 (6.8%) Surgical approach Trans-frontal 84 (47.2%) Trans-temporal 6 (3.4%) Trans-occipital 79 (44.3%) Trans-sphenoid 6 (3.4%) Trans-parietal 3 (1.7%) Presence of SDE 38 (21.3%) Relapse event 67 (37.6%) Mortality event 28 (15.7%) Abbreviations: ATRT, atypical teratoid/thabdoid tumor; DIPG, diffuse intrinsic pontine glioma; HGG, high-grade glioma; LGG, low-grade glioma; MB, medulloblastoma; NGGCT, non-germinomatous germ cell tumor; PBT, pediatric brain tumor; SDE, subdural effusion. The cohort was stratified into SDE-present and SDE-absent subgroups for prognosis analysis (Table 2 ). Both groups were similar in tumor subtype composition, gender, follow-up duration, and age at diagnosis. Mortality rates were 18.4% and 15% in the SDE-present and SDE-absent groups, respectively (P = 0.6075). Relapse rates were 44.7% and 35.7% in the SDE-present and SDE-absent groups, respectively (P = 0.3086). Kaplan-Meier survival analysis was depicted in Fig. 2 , showing 5-year OS and relapse-free survival (RFS) rates of 75.7% vs. 82.9% (P = 0.58) and 51.0% vs. 58.7% (P = 0.37), respectively. Although not statistically significant, the presence of SDE trended towards poorer survival and higher relapse rates. Table 2 Comparisons between SDE-present and SDE-absent subgroups. SDE-present (n = 38) SDE-absent (n = 140) P Value Age at diagnosis (yeas) 6.7 (3.7–14.4) 10 (6.3–13.5) 0.1774 Follow-up duration (years) 2.9 (1.6–5.7) 4.1 (1.6–7.2) 0.2472 Male-to-Female ratio 2.2 1.5 0.2590 Major PBT subtype 0.1025 Germinoma 4 (10.5%) 28 (20%) NGGCT 2 (5.3%) 11 (7.9%) LGG 7 (18.4%) 40 (28.6%) HGG 3 (7.9%) 12 (8.6%) MB 10 (26.3%) 16 (11.4%) Mortality rate 18.4% 15.0% 0.6075 Relapse rate 44.7% 35.7% 0.3086 5-year OS rate 75.7% 82.9% 0.58 5-year RFS rate 51.0% 58.7% 0.37 Abbreviations: HGG, high-grade glioma; LGG, low-grade glioma; MB, medulloblastoma; NGGCT, non-germinomatous germ cell tumor; OS, overall survival; PBT, pediatric brain tumor; RFS, relapse-free survival; SDE, subdural effusion. Discussion OS in PBT has increased from < 40% to 60–80% due to advancements in multi-agent chemotherapy, surgical techniques, and supportive care [ 1 , 2 ]. The application of intensified chemotherapy leads to a better prognosis even in advanced-stage PBT. Furthermore, the utility of autologous stem cell rescue has allowed clinical physicians to initiate more intense high-dose chemotherapy, with the hope that OS and RFS would improve significantly. In this cohort, OS and RFS were 84.3% and 62.4%, respectively, comparable to data from developed countries. Although the OS and RFS outcomes in this cohort were comparable to those reported in developed countries, a notably poorer RFS was identified in the glioma subgroup, including LGG and HGG. Traditionally, surgical resection is the treatment of choice for patients with LGG or HGG, with chemotherapy or radiotherapy reserved for unresectable tumors or cases of incomplete resection [ 12 ]. Despite these treatments, the relapse rate remains high. Recent advances in molecular studies have identified the MAPK pathway as playing a pivotal role in the oncogenesis of malignant gliomas. Several targeted therapies targeting this pathway have been utilized to mitigate the risk of relapse in malignant gliomas, with promising results overall [ 13 ]. In our cohort, relapsed LGG and HGG patients would be treated with targeted therapy as salvage treatment if available, which leads to a better OS compared to conventional chemotherapy. Historically, research has focused on multidisciplinary treatments such as chemotherapy, targeted therapy, and immunotherapy, with less emphasis on surgical outcomes and complications [ 3 , 4 ]. SDE, a common post-craniotomy complication observed in 21.3% of cases in this cohort study, correlated with trends towards poorer OS and RFS, although statistical significance was not reached. Some studies advocate that the presence of SDE appears to be an indicator of dural damage, which may lead to the risk of disease dissemination [ 6 , 14 ]. Maintaining dural integrity during surgery, particularly in frontal and occipital approaches, may mitigate SDE risk and improve patient outcomes. Limitations of this study include its retrospective design and reliance on data from a single institution, which may introduce bias. Larger, prospective studies are necessary to validate these findings and further explore the impact of SDE and surgical approaches on outcomes in pediatric brain tumor patients. Conclusion SDE is still a frequent complication that occurs after craniotomy in PBT patients. The risk of SDE is higher with frontal and occipital craniotomy approaches. The presence of SDE can have a negative impact on both survival rates and the likelihood of disease relapse in PBT. Declarations Conflicts of Interest The authors declared no conflicsts of interest. Funding This research received no external funding. Author Contribution Conceptualization Chieh-Tsai Wu; methodology and formal analysis Tzu-Chin Lin; writing—original draft preparation Yi-Lun Wang and Ju-En Nien; writing—review and editing Ju-En Nien, Shih-Hsiang Chen, Tang-Her Jaing, and Tsung-Yen Chang; visualization Yi-Lun Wang; project administration Tang-Her Jaing and Chieh-Tsai Wu; All authors have read and agreed to the published version of the manuscript. References Plant-Fox AS, O'Halloran K, Goldman S (2021) Pediatric brain tumors: the era of molecular diagnostics, targeted and immune-based therapeutics, and a focus on long term neurologic sequelae. Curr Probl Cancer 45:100777 Pollack IF, Agnihotri S, Broniscer A (2019) Childhood brain tumors: current management, biological insights, and future directions. J Neurosurg Pediatr 23:261–273 Wang SS, Bandopadhayay P, Jenkins MR (2019) Towards Immunotherapy for Pediatric Brain Tumors. Trends Immunol 40:748–761 Malik JR, Podany AT, Khan P, Shaffer CL, Siddiqui JA, Baranowska-Kortylewicz J, Le J, Fletcher CV, Ether SA, Avedissian SN (2023) Chemotherapy in pediatric brain tumor and the challenge of the blood-brain barrier. Cancer Med 12:21075–21096 Brown TJ, Brennan MC, Li M, Church EW, Brandmeir NJ, Rakszawski KL, Patel AS, Rizk EB, Suki D, Sawaya R, Glantz M (2016) Association of the Extent of Resection With Survival in Glioblastoma: A Systematic Review and Meta-analysis. JAMA Oncol 2:1460–1469 Jung TY, Jung S, Jin SG, Jin YH, Kim IY, Kang SS, Kim SH (2007) Prevention of postoperative subdural fluid collections following transcortical transventricular approach. Surg Neurol 68:172–176 discussion 176 Ferguson SD, Levine NB, Suki D, Tsung AJ, Lang FF, Sawaya R, Weinberg JS, McCutcheon IE (2018) The surgical treatment of tumors of the fourth ventricle: a single-institution experience. J Neurosurg 128:339–351 Silva AHD, Aquilina K (2019) Surgical approaches in pediatric neuro-oncology. Cancer Metastasis Rev 38:723–747 Cinalli G, Spennato P, Ruggiero C, Aliberti F, Trischitta V, Buonocore MC, Cianciulli E, Maggi G (2007) Complications following endoscopic intracranial procedures in children. Childs Nerv Syst 23:633–644 Anetsberger S, Mellal A, Garvayo M, Diezi M, Perez MH, Beck Popovic M, Renella R, Cossu G, Daniel RT, Starnoni D, Messerer M (2023) Predictive Factors for the Occurrence of Perioperative Complications in Pediatric Posterior Fossa Tumors. World Neurosurg 172:e508–e516 John JK, Robin AM, Pabaney AH, Rammo RA, Schultz LR, Sadry NS, Lee IY (2017) Complications of ventricular entry during craniotomy for brain tumor resection. J Neurosurg 127:426–432 de Blank P, Bandopadhayay P, Haas-Kogan D, Fouladi M, Fangusaro J (2019) Management of pediatric low-grade glioma. Curr Opin Pediatr 31:21–27 de Blank P, Fouladi M, Huse JT (2020) Molecular markers and targeted therapy in pediatric low-grade glioma. J Neurooncol 150:5–15 Mirone G, Ruggiero C, Spennato P, Aliberti F, Trischitta V, Cinalli G (2015) Cortical gluing and Ringer lactate solution inflation to avoid cortical mantle collapse and subdural fluid collections in pediatric neurosurgery: safety and feasibility. Childs Nerv Syst 31:945–951 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4812313","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":345147215,"identity":"f90721f6-6107-401a-b52d-debe1c082141","order_by":0,"name":"Ju-En Nien","email":"","orcid":"","institution":"Chang Gung Memorial Hospital at Linkou","correspondingAuthor":false,"prefix":"","firstName":"Ju-En","middleName":"","lastName":"Nien","suffix":""},{"id":345147216,"identity":"db2f1a83-4d55-41d4-867d-288b73cf2138","order_by":1,"name":"Tzu-Chin Lin","email":"","orcid":"","institution":"Chang Gung Memorial Hospital at 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University","correspondingAuthor":false,"prefix":"","firstName":"Tang-Her","middleName":"","lastName":"Jaing","suffix":""}],"badges":[],"createdAt":"2024-07-27 09:31:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4812313/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4812313/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64004664,"identity":"d57461f0-5a65-47c9-9810-0e1f82c148e9","added_by":"auto","created_at":"2024-09-04 21:27:19","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":425386,"visible":true,"origin":"","legend":"\u003cp\u003eThe Kaplan-Meier analysis among different subtypes of PBT.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4812313/v1/436c1902e39a2f42e7dc181d.jpeg"},{"id":64004666,"identity":"b5836d71-32de-47c3-ad82-bfa216bcd8b4","added_by":"auto","created_at":"2024-09-04 21:27:19","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":280440,"visible":true,"origin":"","legend":"\u003cp\u003eThe Kaplan-Meier survival analysis among SDE-present and SDE-absent subgroups.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4812313/v1/c0faf76aefbf142abe8d5862.jpeg"},{"id":64005963,"identity":"72e0a66a-88cc-494b-acfb-b0fef3642eee","added_by":"auto","created_at":"2024-09-04 21:43:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1041451,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4812313/v1/e514c01c-d22e-4382-a102-359967f0fb4d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of Post-Craniotomy Subdural Effusion in Pediatric Brain Tumors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe overall survival (OS) of pediatric brain tumors (PBT) has improved from less than 40% to 60\u0026ndash;80% in the past decades [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This notable survival outcome is largely attributed to technical improvements in surgery, personalized irradiation programs, and the introduction of multi-agent chemotherapy. The increased intensity of multidisciplinary treatments addresses the historically bleak prognosis of PBT but inevitably leads to the development of upfront treatment-related morbidity and complications [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Clinical physicians have dedicated themselves to striking a balance between treatment efficacy and the associated toxicity.\u003c/p\u003e \u003cp\u003eSubdural effusion (SDE) is a common complication following brain surgery, with its incidence varying across different craniotomy approaches [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In most cases, the presence of SDE does not necessitate emergent management unless it reaches a considerable size or leads to progressive elevation of intracranial pressure. While not typically life-threatening, SDE appears to be associated with cortical/ependymal defects. Compromised dural integrity may facilitate disease dissemination, potentially impacting survival outcomes negatively [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Research efforts have often focused on refining surgical techniques and developing novel therapies, yet little is known about the impact of complications such as SDE on survival outcomes. This study aims to investigate the prognostic impact of SDE in patients with PBT.\u003c/p\u003e"},{"header":"Materials \u0026 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCase Enrollment\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study enrolled pediatric patients diagnosed with brain tumors at Chang Gung Memorial Hospital between January 2013 and December 2023. Patients with less than one year of follow-up were excluded. This study was approved by the Chang Gung Memorial Hospital Institutional review board (Project number 202401075B0).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDiagnosis Confirmation\u003c/h2\u003e \u003cp\u003eDiagnosis of PBT was confirmed through histopathological and radiological assessments. Tumors were categorized into glioma, germ cell tumors (GCTs), medulloblastoma (MB), embryonal tumors, atypical teratoid/rhabdoid tumors, craniopharyngioma, and others. Resected tumor slides were independently reviewed by an expert pathologist, with consultation from another pathologist in cases of inconclusive results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEvaluation of Treatment Response\u003c/h2\u003e \u003cp\u003eRadiological evaluations were conducted every 3\u0026ndash;6 months to assess treatment response, guided by clinical expertise.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eKaplan-Meier analysis was used to plot survival and relapse curves. Student\u0026rsquo;s t-tests were employed to analyze differences in continuous variables such as age at diagnosis, follow-up duration, survival period, and relapse-free interval. Chi-square tests were used to assess differences in categorical variables including PBT subtype, gender, surgical approach, presence of SDE, relapse, and mortality. All statistical analyses were performed using GraphPad Prism version 9.0 software.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 178 children diagnosed with PBT were included in the study cohort. The median follow-up duration was 3.8 years (IQR 1.6\u0026ndash;7.0). Baseline characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Major PBT subtypes included glioma (40.4%), GCTs (25.3%), and MB (14.6%). The survival analysis of PBT subtypes was shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The PBT with low-grade glioma (LGG) subtype exhibited the best prognosis, with a 5-year OS rate of 97.8%. The high-grade glioma (HGG) subtype harbored the poorest prognosis, with a 5-year OS rate of 36.7%. Post-craniotomy SDE occurred in 21.3% of cases. Management was predominantly observational (66%), with surgical intervention required in 34% due to larger SDE size or symptomatic illness. Frontal and occipital approaches were associated with an increased risk of SDE.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the PBT cohort.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at diagnosis (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.7 (5.6\u0026ndash;13.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up duration (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.8 (1.6\u0026ndash;7.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale-to-Female ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBT subtype\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGerminoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31 (17.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNGGCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eATRT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (1.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmbryonic tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDIPG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCraniopharyngioma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLGG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47 (26.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHGG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (8.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (14.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (6.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrans-frontal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e84 (47.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrans-temporal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrans-occipital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e79 (44.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrans-sphenoid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrans-parietal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresence of SDE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (21.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelapse event\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67 (37.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality event\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (15.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eAbbreviations: ATRT, atypical teratoid/thabdoid tumor; DIPG, diffuse intrinsic pontine glioma; HGG, high-grade glioma; LGG, low-grade glioma; MB, medulloblastoma; NGGCT, non-germinomatous germ cell tumor; PBT, pediatric brain tumor; SDE, subdural effusion.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe cohort was stratified into SDE-present and SDE-absent subgroups for prognosis analysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Both groups were similar in tumor subtype composition, gender, follow-up duration, and age at diagnosis. Mortality rates were 18.4% and 15% in the SDE-present and SDE-absent groups, respectively (P\u0026thinsp;=\u0026thinsp;0.6075). Relapse rates were 44.7% and 35.7% in the SDE-present and SDE-absent groups, respectively (P\u0026thinsp;=\u0026thinsp;0.3086). Kaplan-Meier survival analysis was depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, showing 5-year OS and relapse-free survival (RFS) rates of 75.7% vs. 82.9% (P\u0026thinsp;=\u0026thinsp;0.58) and 51.0% vs. 58.7% (P\u0026thinsp;=\u0026thinsp;0.37), respectively. Although not statistically significant, the presence of SDE trended towards poorer survival and higher relapse rates.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons between SDE-present and SDE-absent subgroups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSDE-present\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSDE-absent\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;140)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at diagnosis (yeas)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.7 (3.7\u0026ndash;14.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (6.3\u0026ndash;13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.1774\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up duration (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.9 (1.6\u0026ndash;5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.1 (1.6\u0026ndash;7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.2472\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale-to-Female ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.2590\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor PBT subtype\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.1025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGerminoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNGGCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLGG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (18.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHGG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (26.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (11.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6075\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelapse rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.3086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5-year OS rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5-year RFS rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations: HGG, high-grade glioma; LGG, low-grade glioma; MB, medulloblastoma; NGGCT, non-germinomatous germ cell tumor; OS, overall survival; PBT, pediatric brain tumor; RFS, relapse-free survival; SDE, subdural effusion.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOS in PBT has increased from \u0026lt;\u0026thinsp;40% to 60\u0026ndash;80% due to advancements in multi-agent chemotherapy, surgical techniques, and supportive care [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The application of intensified chemotherapy leads to a better prognosis even in advanced-stage PBT. Furthermore, the utility of autologous stem cell rescue has allowed clinical physicians to initiate more intense high-dose chemotherapy, with the hope that OS and RFS would improve significantly. In this cohort, OS and RFS were 84.3% and 62.4%, respectively, comparable to data from developed countries.\u003c/p\u003e \u003cp\u003eAlthough the OS and RFS outcomes in this cohort were comparable to those reported in developed countries, a notably poorer RFS was identified in the glioma subgroup, including LGG and HGG. Traditionally, surgical resection is the treatment of choice for patients with LGG or HGG, with chemotherapy or radiotherapy reserved for unresectable tumors or cases of incomplete resection [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Despite these treatments, the relapse rate remains high. Recent advances in molecular studies have identified the MAPK pathway as playing a pivotal role in the oncogenesis of malignant gliomas. Several targeted therapies targeting this pathway have been utilized to mitigate the risk of relapse in malignant gliomas, with promising results overall [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In our cohort, relapsed LGG and HGG patients would be treated with targeted therapy as salvage treatment if available, which leads to a better OS compared to conventional chemotherapy.\u003c/p\u003e \u003cp\u003eHistorically, research has focused on multidisciplinary treatments such as chemotherapy, targeted therapy, and immunotherapy, with less emphasis on surgical outcomes and complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. SDE, a common post-craniotomy complication observed in 21.3% of cases in this cohort study, correlated with trends towards poorer OS and RFS, although statistical significance was not reached. Some studies advocate that the presence of SDE appears to be an indicator of dural damage, which may lead to the risk of disease dissemination [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Maintaining dural integrity during surgery, particularly in frontal and occipital approaches, may mitigate SDE risk and improve patient outcomes.\u003c/p\u003e \u003cp\u003eLimitations of this study include its retrospective design and reliance on data from a single institution, which may introduce bias. Larger, prospective studies are necessary to validate these findings and further explore the impact of SDE and surgical approaches on outcomes in pediatric brain tumor patients.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSDE is still a frequent complication that occurs after craniotomy in PBT patients. The risk of SDE is higher with frontal and occipital craniotomy approaches. The presence of SDE can have a negative impact on both survival rates and the likelihood of disease relapse in PBT.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflicts of Interest\u003c/h2\u003e \u003cp\u003eThe authors declared no conflicsts of interest.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization Chieh-Tsai Wu; methodology and formal analysis Tzu-Chin Lin; writing\u0026mdash;original draft preparation Yi-Lun Wang and Ju-En Nien; writing\u0026mdash;review and editing Ju-En Nien, Shih-Hsiang Chen, Tang-Her Jaing, and Tsung-Yen Chang; visualization Yi-Lun Wang; project administration Tang-Her Jaing and Chieh-Tsai Wu; All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePlant-Fox AS, O'Halloran K, Goldman S (2021) Pediatric brain tumors: the era of molecular diagnostics, targeted and immune-based therapeutics, and a focus on long term neurologic sequelae. Curr Probl Cancer 45:100777\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePollack IF, Agnihotri S, Broniscer A (2019) Childhood brain tumors: current management, biological insights, and future directions. J Neurosurg Pediatr 23:261\u0026ndash;273\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang SS, Bandopadhayay P, Jenkins MR (2019) Towards Immunotherapy for Pediatric Brain Tumors. Trends Immunol 40:748\u0026ndash;761\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalik JR, Podany AT, Khan P, Shaffer CL, Siddiqui JA, Baranowska-Kortylewicz J, Le J, Fletcher CV, Ether SA, Avedissian SN (2023) Chemotherapy in pediatric brain tumor and the challenge of the blood-brain barrier. Cancer Med 12:21075\u0026ndash;21096\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown TJ, Brennan MC, Li M, Church EW, Brandmeir NJ, Rakszawski KL, Patel AS, Rizk EB, Suki D, Sawaya R, Glantz M (2016) Association of the Extent of Resection With Survival in Glioblastoma: A Systematic Review and Meta-analysis. JAMA Oncol 2:1460\u0026ndash;1469\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJung TY, Jung S, Jin SG, Jin YH, Kim IY, Kang SS, Kim SH (2007) Prevention of postoperative subdural fluid collections following transcortical transventricular approach. Surg Neurol 68:172\u0026ndash;176 discussion 176\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerguson SD, Levine NB, Suki D, Tsung AJ, Lang FF, Sawaya R, Weinberg JS, McCutcheon IE (2018) The surgical treatment of tumors of the fourth ventricle: a single-institution experience. J Neurosurg 128:339\u0026ndash;351\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilva AHD, Aquilina K (2019) Surgical approaches in pediatric neuro-oncology. Cancer Metastasis Rev 38:723\u0026ndash;747\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCinalli G, Spennato P, Ruggiero C, Aliberti F, Trischitta V, Buonocore MC, Cianciulli E, Maggi G (2007) Complications following endoscopic intracranial procedures in children. Childs Nerv Syst 23:633\u0026ndash;644\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnetsberger S, Mellal A, Garvayo M, Diezi M, Perez MH, Beck Popovic M, Renella R, Cossu G, Daniel RT, Starnoni D, Messerer M (2023) Predictive Factors for the Occurrence of Perioperative Complications in Pediatric Posterior Fossa Tumors. World Neurosurg 172:e508\u0026ndash;e516\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohn JK, Robin AM, Pabaney AH, Rammo RA, Schultz LR, Sadry NS, Lee IY (2017) Complications of ventricular entry during craniotomy for brain tumor resection. J Neurosurg 127:426\u0026ndash;432\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Blank P, Bandopadhayay P, Haas-Kogan D, Fouladi M, Fangusaro J (2019) Management of pediatric low-grade glioma. Curr Opin Pediatr 31:21\u0026ndash;27\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Blank P, Fouladi M, Huse JT (2020) Molecular markers and targeted therapy in pediatric low-grade glioma. J Neurooncol 150:5\u0026ndash;15\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMirone G, Ruggiero C, Spennato P, Aliberti F, Trischitta V, Cinalli G (2015) Cortical gluing and Ringer lactate solution inflation to avoid cortical mantle collapse and subdural fluid collections in pediatric neurosurgery: safety and feasibility. Childs Nerv Syst 31:945\u0026ndash;951\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pediatric brain tumor, post-craniotomy complications, subdural effusion, overall survival, relapse free survival","lastPublishedDoi":"10.21203/rs.3.rs-4812313/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4812313/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eOver recent decades, survival rates in pediatric brain tumors (PBT) have been significantly improved due to technological advancements in surgical approaches and intensified chemotherapy. Although disease relapse rates have been reduced, these treatments still come with unavoidable complications. Subdural effusion (SDE) is a significant complication that can occur after craniotomy, with its incidence depending on the surgical approach and potentially affecting the prognosis of the disease. The objective of this study is to examine the impact of post-craniotomy SDE on survival outcomes in patients with PBT.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eOur study utilized a retrospective chart review to examine children diagnosed with PBT at Chang Gung Memorial Hospital between January 2013 and December 2023. Survival benefits were assessed using Kaplan-Meier analysis, while differences in continuous variables were examined using Student's t-tests. The statistical analyses were conducted using GraphPad Prism version 9.0 software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study included 178 children diagnosed with PBT, and their progress was tracked for a median duration of 3.8 years (IQR 1.6\u0026ndash;7.0). The diagnoses consisted of a variety of brain tumors. The incidence of post-craniotomy SDE was 21.3%. The majority of cases (66%) were managed through observation, while surgical intervention was necessary for 34% of cases. The study found that the presence of SDE was associated with slightly lower survival rates (18.4% vs. 15.0%) and slightly higher disease relapse rates (44.7% vs. 35.7%), although these differences did not reach statistical significance.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSDE is still a frequent complication that occurs after craniotomy in PBT patients. The presence of SDE can have a negative impact on both survival rates and the likelihood of disease relapse in PBT.\u003c/p\u003e","manuscriptTitle":"The Impact of Post-Craniotomy Subdural Effusion in Pediatric Brain Tumors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-04 21:27:14","doi":"10.21203/rs.3.rs-4812313/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c654f056-7cc4-4728-b020-28bf777044f5","owner":[],"postedDate":"September 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-04T21:27:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-04 21:27:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4812313","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4812313","identity":"rs-4812313","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}