Evaluating the impact of intraoperative neuromonitoring on neurological outcomes and extent of resection in pediatric supratentorial brain tumor surgery: a systematic review and meta-analysis.
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BACKGROUND: Surgical resection of pediatric supratentorial brain tumors requires balancing maximal tumor removal with preservation of neurological function. Intraoperative neuromonitoring (IONM) methodologies and indications are well-established in adults but remain understudied in children, whose developing brains pose unique challenges. This systematic review and meta-analysis evaluates the impact IONM on extent of tumor resection and postoperative neurological deficits in pediatric supratentorial brain tumor surgery. METHODS: A systematic review of studies was conducted according to PRISMA guidelines (PROSPERO ID: CRD420251101609). Studies published between January 1990, and June 2025 were included. Data were pooled using a random-effects model, and heterogeneity was assessed with I2 statistics. RESULTS: A total of 41 studies comprising 1,908 pediatric patients were included. The pooled gross total resection (GTR) rate was 76.9% (95% CI: 69.1-82.6) in the monitored group, compared with 52.8% (95% CI: 45.2-60.4) in the unmonitored group. The pooled incidence of postoperative neurological deficits was 15.1% (95% CI: 8.7-22.8) in the monitored group and 23.1% (95% CI: 12.4-38.8) in the unmonitored group. Stratified analyses showed that eloquent cortex involvement was associated with lower GTR rates and higher neurological deficits; however, these associations appeared less pronounced in monitored cohorts. CONCLUSIONS: These descriptive pooled estimates suggest that IONM may be associated with higher GTR rates and lower postoperative neurological deficit rates in pediatric supratentorial brain tumor surgery, particularly in eloquent brain regions. However, because the included studies did not directly compare monitored and unmonitored patients within the same cohorts, these findings should not be interpreted as evidence of a causal benefit of IONM. Rather, they provide a foundation for future prospective comparative studies to evaluate the potential impact of IONM and to develop pediatric-specific protocols aimed at preserving long-term neurological function.