Keyhole approach for total corpus callosotomy

Keyhole approach for total corpus callosotomy | 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 Keyhole approach for total corpus callosotomy Yutao Ren, Yong Liu, Bo Fang, Huanfa Li, Xiaorong Zhang, Hui Li, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9027303/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background and purpose To compare the surgical outcomes of corpus callosotomy (CC) performed using the keyhole approach (KA) and the traditional approach (TA) and demonstrate the efficacy and safety of total corpus callosotomy via the keyhole approach. Methods Patients with medically refractory epilepsy who underwent CC between February 2017 and September 2024 were retrospectively included. The CC keyhole surgical technique is described. Surgical outcomes, postoperative complications, and seizure controls were analyzed between patients who underwent CC via the KA and the TA. Results A total of 31 patients undergoing CC via the KA and 50 patients undergoing CC via the TA were enrolled. CC via the KA demonstrated statistically shorter surgical duration (109.84 ± 5.55 vs. 183.90 ± 13.55 minutes, p < 0.001), shorter incision length (6.0 vs. 15.0 cm, p < 0.001), smaller craniotomy size (3.53 vs. 20.00 cm², p < 0.001), less blood loss (34.35 ± 8.14 vs. 107.20 ± 28.88 mL, p < 0.001), shorter postoperative hospital stays (6.0 days vs. 7.5 days, p < 0.001), lower rates of postoperative fever (6.25% vs. 22.00%, p = 0.038), and a lower incidence of subcutaneous effusion compared with the TA (3.23% vs. 18.00%, p = 0.047). Conclusion CC conducted via the KA was shown to be an effective technique for treating medically refractory epilepsy with a shorter incision, smaller craniotomy, less blood loss, shorter operative times, shorter hospital stays, and a lower incidence of complications. corpus callosotomy keyhole approach traditional approach epilepsy Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Epilepsy is a neurological disorder, affecting approximately 0.7% of the general population. 1 Seizure freedom can be attained in the majority of patients by administering suitable antiseizure medicines (ASMs). Nevertheless, over one-third of patients continue to experience seizures despite using ASMs, and ultimately are found to have medically refractory epilepsy. 2 , 3 Focal resection, which is characterized by well-defined focal epileptogenic foci, is appropriate for patients with drug-resistant epilepsy (DRE). 4 However, patients with DRE who experience rapid secondary generalization, lack a single identifiable epileptic focus, have multifocal epilepsy or generalized seizures and are not candidates for focal resection. For these patients, palliative surgical options, including corpus callosotomy (CC) and neuromodulation, represent viable alternatives. 5 , 6 CC was first reported to be a palliative surgical treatment for patients with DRE by Van Wagenen and Herren in 1940. 7 The corpus callosum is recognized as the largest commissural structure in the forebrain and is hypothesized to serve as the primary pathway for the transmission of epileptic discharges between the two cerebral hemispheres. 8 The mechanism underlying CC entails transecting the fibers that link the two hemispheres of the brain, thereby inhibiting the interhemispheric propagation of epileptic discharges. 9 CC has demonstrated significant effectiveness in addressing drop attacks associated with tonic and atonic seizures, as well as in various syndromes characterized by epilepsy, including Lennox-Gastaut syndrome, West syndrome, and severe epilepsy characterized by multiple independent spike foci. 10 – 12 CC is usually conducted utilizing microsurgical techniques. The technique involves a complete callosotomy that extends from the splenium to the arachnoid membrane of the quadrigeminal cistern. Typically, a coronal incision accompanied by a craniotomy with an approximate diameter of 6 centimeters is used in CC. 13,14 The traditional approach (TA) is associated with relatively significant trauma and a relatively high risk of complications, causing many patients with DRE, particularly pediatric patients, to be reluctant to choose surgery. Belal et al (2022) reported a mini-craniotomy approach for CC using a frameless navigation probe, which involved an L-shaped incision along the midline, extending to the temporal line, with a 4 cm (anteroposterior) × 3 cm (lateral) craniotomy. 15 However, the L-shaped incision in this approach was still long and had a large skin flap. Hence, we propose a keyhole approach (KA) for CC, with a shorter straight skin incision, less damage to the galea, no skin flap, and a smaller semicircular craniotomy, resulting in reduced trauma. Thus, this study introduces a novel KA advancement for CC. Methods Participants We retrospectively included patients who underwent CC at our epilepsy center from February 2017 to September 2024. All CC procedures were conducted by a single surgeon (H.Z.). The inclusion criteria were 1) patients of all ages and genders, 2) generalized DRE defined by the International League Against Epilepsy, 16 3) non-localizing foci epilepsy, and 4) total CC conducted by the one-stage approach. The exclusion criteria included the presence of significant comorbidities and inadequate patient compliance. Patients diagnosed with DRE underwent a series of presurgical assessments before being considered candidates for CC, including: (1) long-term video electroencephalography (EEG) monitoring, (2) 3-Tesla magnetic resonance imaging (MRI) comprised of T1-weighted, T2-weighted, and fluid-attenuated inversion recovery sequences, and (3) positron emission tomography (PET) imaging. Surgical procedures After general anesthesia, the patient was placed in the supine position with their head aligned in a neutral position and fixed with a head frame. The skin incision and craniotomy were illustrated in Fig. 1 . In CC via the TA, a frontal L-shaped incision was made along the midline, extending to the temporal line, approximately 15 cm in length (Fig. 1 A and 2 A). Then, the myocutaneous flap was reflected in an anterolateral direction. As shown in Fig. 2 B, a rectangular craniotomy, approximately 5 × 4 cm in size, was milled open, not beyond the midline and the superior sagittal sinus was excluded (Fig. 2 E). In CC via the KA, a transverse straight incision was made on the frontal area, positioned 2 cm anterior to the coronal suture and approximately 6 cm long (Fig. 1 B and 2 C). The mastoid retractor was employed to facilitate flap separation. A semicircular craniotomy with a diameter of less than 3 cm was made, just in front of the coronal suture and close to the midline (Fig. 2 D). The dura mater was subsequently incised in a U-shaped manner and retracted toward the superior sagittal sinus, thereby revealing the interhemispheric fissure. Slowly releasing cerebrospinal fluid from the interhemispheric cistern and tilting the head toward the surgical approach side to leverage gravity for retracting the cerebral hemisphere away from the falx can facilitate the exposure of the deep corpus callosum. The optic axis of the microscope and the corresponding observed portion of the corpus callosum during CC are illustrated in Figs. 3 A and 3 B. Next, cerebrospinal fluid was slowly drained from the arachnoid space to reduce pressure and the interhemispheric fissure was gradually and carefully separated downward. Passing through the falx cerebri and cingulate gyrus, the pericallosal artery is visible, and the body of the corpus callosum is exposed and incised between the bilateral pericallosal arteries (Figs. 3 C and D). Subsequently, after repositioning the optical axis of the microscope in an anterior direction, the genu and rostrum of the corpus callosum were dissected (Fig. 3 E). Thereafter, the optical axis of the microscope was adjusted posteriorly to dissect the remaining body and splenium of the corpus callosum (Fig. 3 F). After completing the CC, hemostasis was achieved, the watertight dura mater was closed, the craniotomy was repositioned, and finally, the skin was cosmetically sutured. Outcome evaluation Outcome evaluation The incision length, surgery duration, craniotomy size, intraoperative blood loss, postoperative complications, and length of the postoperative hospital stay were recorded. Acute postoperative seizures are characterized as seizures occurring within the initial 2 weeks after surgery. 17 Acute disconnection syndrome is defined as transient alterations in visual, motor, sensory, and language functions after CC, and usually resolves within days to months. 18 Given the constraints of the sample size and as a palliative treatment, we adopted a simplified definition of seizure outcomes after CC. This included (1) being seizure free (complete seizure freedom), (2) improvement (any reduction in seizure frequency > 50%), and (3) ineffectiveness (any reduction in seizure frequency < 50%). 19 Statistical analysis Continuous variables are expressed as median (range) or mean ± standard deviation, depending on distribution normality. Continuous variables not normally distributed were analyzed using the Mann–Whitney U test. Normally distributed continuous variables exhibiting homogeneity of variance were analyzed using an independent samples t-test. Categorical data were analyzed using the Chi-squared test or Fisher's precision probability test. All analyses were performed using SPSS statistical software (PASW Statistics 27.0, version 27.0.1, SPSS Inc., Chicago, IL, USA). A p-value of less than 0.05 was deemed to indicate statistical significance. Results Patient characteristics A total of 81 patients who underwent CC were included in the study. The detailed characteristics of all participants are presented in Table 1 . Twenty-two males and nine females, with a median age of 18 years (range, 4–60 years), underwent surgery via the KA, and 35 males and 15 females, with a median age of 18 years (range, 4–54 years) at surgery, underwent surgery utilizing the TA. No statistically significant difference in gender composition or age at surgery was seen between the two groups. No statistically significant differences were observed in epilepsy duration (median, 11.00 vs. 13.50 years). The majority of the patients in both groups experienced seizures daily and weekly. The seizure types were mainly tonic seizures, atonic seizures, generalized tonic-clonic seizures (GTC) and other generalized seizures. In presurgical evaluations, MRI revealed positive findings in 15 (48.39%) patients in the KA group and 23 (46.00%) patients in the TA group. PET revealed positive findings in 47 (22.58%) patients in the KA group, compared to 13 (26.00%) patients in the TA group. Presurgical long-term video EEG demonstrated generalized discharges in 28 (90.32%) patients in the KA group and 46 (92.00%) in the TA group. Fourteen (45.16%) patients in the KA group had a previous medical history, compared to 21 (42.00%) in the TA group. No statistically significant differences were found in presurgical findings (MRI, PET, and EEG) or previous medical history between the KA and TA groups. Table 1 Characteristics of patients with CC via keyhole approach and traditional approach male, n (%) Keyhole approach (n = 31) Traditional approach (n = 50) p 22 (70.97) 35 (70.00) 0.93 Age at surgery, y (mean, range) 18 (4–60) 18 (4–54) 0.87 Epilepsy duration, y 11.00 (2–40) 13.50 (1.5–40) 0.58 Seizure types, n (%) Tonic/Atonic seizures 21 (67.74) 28 (56.00) GTC 26 (83.87) 37 (74.00) Other generalized seizures 19 (61.29) 24(48.00) Seizure frequency, n (%) Daily 18 (58.06) 33 (66.00) Weekly 10 (32.26) 16 (32.00) Monthly 13 (41.94) 19 (38.00) Cluster attack 5 (16.13) 11 (22.00) Status epilepticus 3 (9.68) 7 (14.00) MRI positive, n (%) 15 (48.39) 23 (46.00) 0.83 PET positive, n (%) 7 (22.58) 13 (26.00) 0.73 Generalized discharges, n (%) 28 (90.32) 46 (92.00) 0.70 previous medical history, n (%) 14 (45.16) 21 (42.00) 0.78 CC = corpus callosotomy; GTC = generalized tonic-clonic seizures. Surgical outcomes Table 2 shows the surgical outcomes of CC by the KA and the TA. CC via the KA (109.84 ± 5.55 minutes) demonstrated statistically shorter surgical durations compared to the TA (183.90 ± 13.55 minutes, p < 0.001). The median CC incision length via the KA was 6.0 cm, significantly shorter than that of CC via the TA (15.0 cm, p < 0.001). The median CC craniotomy size via the KA was significantly smaller than that of CC via the TA (3.53 vs. 20.00 cm 2 , p < 0.001). Blood loss in CC via the KA was 34.35 ± 8.14 mL, which was significantly less than that of CC via the TA (107.20 ± 28.88 mL, p < 0.001). The median postoperative hospital stay for patients undergoing CC via the KA was significantly shorter than that of CC via the TA (6.0 vs. 7.5 days, p < 0.001). Patients in the KA group exhibited a significantly lower proportion of postoperative fevers compared to those in the TA group (6.25% vs .22.00%, p = 0.038). The incidence of subcutaneous effusion following CC via the KA was significantly lower than that following CC via the TA (3.23% vs 18.00%, p = 0.047). All patients exhibited complete disconnection of the entire corpus callosum (Fig. 4 A). No deaths or permanent complications occurred after CC. The aesthetic appearance of the wound was assessed in all participants (Fig. 4 B). Table 2 Surgical outcomes of CC via keyhole approach and traditional approach Surgery duration, min Keyhole approach (n = 31) Traditional approach (n = 50) p 109.84 ± 5.55 183.90 ± 13.55 < 0.001 Incision length, cm 6.0 (5.5-7.0) 15.0 (13.0–15.0) < 0.001 Craniotomy area, cm 2 3.53 (2.45–4.53) 20.00 (16.00–27.00) < 0.001 Blood loss, ml 34.35 ± 8.14 107.20 ± 28.88 < 0.001 Postoperative hospital stay, d 6.0 (5–9) 7.5 (6–15) < 0.001 Postoperative fever, n (%) 2 (6.45) 11 (22.00) 0.038 Subcutaneous effusion, n (%) 1(3.23) 9 (18.00) 0.047 Follow up, mo 28 (13–46) 26 (14–59) 0.92 Acute postoperative seizures, n (%) 9 (29.03) 22 (44.00) 0.18 Acute disconnection syndrome, n (%) 4 (12.90) 7 (14.00) 0.58 Seizure outcomes, n (%) 0.98 Seizure free 6 (19.35) 9 (18.00) Improvement 18 (58.07) 29 (58.00) Ineffectiveness 7 (22.58) 12 (24.00) CC = corpus callosotomy. Seizure outcomes The median follow-up duration of CC via the KA was 28 months (range, 13–46 months), and 26 months via the TA (range, 14–59 months). The incidence of acute postoperative seizures in patients who underwent CC via the KA was much lower than that in patients who underwent CC via the TA (29.03% vs. 44.0%), although the difference was not statistically significant (p = 0.18). The incidence of acute disconnection syndrome was similar between the two groups of patients (12.90% vs. 14.00%, p = 0.58). Patients experiencing acute disconnection syndrome demonstrated total resolution within 1 month. Among the patients who underwent CC via the KA, six (19.35%) were seizure-free at the last follow-up, 18 (58.07%) were classified as improved, and seven (22.58%) patients were classified as having ineffective outcomes. Among the patients who underwent CC via the TA, nine (18.00%) patients were seizure-free, 29 (58.00%) were classified as improved, and 12 (24.00%) patients were classified as having ineffective outcomes. The seizure outcomes between patients who underwent CC via the KA or the TA were not statistically significantly different (p = 0.98). Discussion CC was one of the earliest surgical procedures conducted for treating DRE, and numerous studies have evaluated its outcomes in diverse patient populations. The most effective target seizure for CC is the drop attack, which can result in disabling falls. This is a form of seizure semiology associated with absence seizures, atypical absence seizures, atonic seizures, tonic seizures, epileptic spasms, and myoclonic seizures. CC can also be utilized for GTC, as well as complex partial seizures with or without secondary generalization. 20 – 22 Patients with a variety of epilepsy syndromes, such as Lennox-Gastaut syndrome, Sturge-Weber syndrome, and West syndrome, are also considered appropriate candidates for CC. 11,23 CC not only contributes to the alleviation of seizures but also facilitates the lateralization of EEG abnormalities and metabolic investigations. 24 , 25 However, the TA for CC is performed using a sigmoid or curvilinear bi-coronal incision and a large frontal craniotomy, resulting in significant surgical trauma and prolonged recovery times. 13 , 14 The CC technique is relatively fixed, and a large craniotomy is not necessarily required. A renewed focus has been on developing minimally invasive techniques for CC. Belal et al (2022) reported complete CC through a minicraniotomy with an L-shape incision, using a frameless navigation probe to ensure completeness of the disconnection. This approach represented a great step in improving the minimally invasive surgical technique. 15 With advancements in endoscopic techniques, CC via an endoscopic approach has enabled shorter skin incisions and smaller craniotomies. 14 , 26 However, the limited operative space under endoscopic vision necessitates resecting the cingulate gyrus to facilitate CC. MR-guided laser interstitial thermal therapy (LITT) offers several advantages over traditional open surgery and firstly used for the CC was reported by Ho et al in 2016. 27 , 28 Numerous studies have reported on the use of LITT for CC and demonstrated its effectiveness in decreasing seizure frequency, comparable to that achieved with traditional open CC. 29–31 LITT involves less trauma than open CC, but it is associated with longer surgical duration and prolonged postoperative steroid use. 29 Nonetheless, LITT presents surgical risks, such as neurological deficits due to thermal injury, catheter displacement, and intracranial hematoma. 32 Moreover, LITT cannot be used for complete CC. Radiosurgery for anterior one-third CC was first reported in 1999. 33 In addition to yielding results comparable to traditional surgery, radiosurgery may lead to complications such as radionecrosis that extends beyond the targeted area and cerebral edema. 34 , 35 Despite the minimally invasive characteristics of radiosurgery, a minimum evaluation period of 2 years is required to assess its clinical outcomes, and the procedure may need to be performed more than once. 36 However, our center's experience indicates that CC can be totally resected based on the intraoperative anatomical relationships. The objective of this study was to conduct a comparative analysis of CC performed via the TA and the KA. CC via the KA utilizes a transverse straight incision located just before 2 cm anterior to the coronal suture. The craniotomy is positioned anterior to the coronal suture to prevent intraoperative damage to the supplementary motor area and avoid postoperative limb dysfunction. The KA involves a shorter straight surgical incision, a smaller craniotomy area, reduced intraoperative blood loss, shorter operative times, shorter postoperative hospital stay duration, and a lower incidence of postoperative fever and subcutaneous effusion compared to the TA for CC. The advantage of the large craniotomy is that dissection of the venous drainage in the longitudinal fissure can be avoided. It is feasible to accomplish CC via the KA with a relatively small-sized craniotomy. This is done by selecting the cerebral hemisphere with the least or no cortical veins as the surgical approach side based on preoperative MRI T2-weighted images. Thus, no injury to any cortical veins draining into the superior sagittal sinus is incurred. The right side was chosen in the majority of the cases in this study. The essential surgical considerations for CC by the KA include the meticulous and progressive evacuation of cerebrospinal fluid within several minutes following craniotomy to facilitate creating an operative space. Identifying critical anatomical structures, such as the septum pellucidum, is crucial for ensuring that the surgery is performed on midline structures. Although the craniotomy size is much smaller, one-stage total CC was performed in our case series. The primary aims of CC are to restrict the spread of epileptic discharges and reduce both the severity and frequency of seizures. Total CC was found to be significantly more effective in decreasing seizure frequency compared to partial CC. 21,37–39 Additionally, one-stage total CC showed greater effectiveness in alleviating a wide range of seizure types than anterior two-thirds callosotomy or two-stage complete callosotomy. 10 Patients undergoing complete CC may also experience benefits without developing clinically significant disconnection syndromes. 39 Shim et al. proposed that one-stage total CC should be the preferred approach for managing generalized seizures. 38 Although complete resection of the corpus callosum in one stage presents challenges, our familiarity with its anatomy, extensive experience, and advanced techniques enabled us to achieve total callosotomy using the KA. The advantages of the KA for CC encompass several key factors, including the utilization of short, linear incisions with a small craniotomy, which contribute to a swift postoperative recovery. Furthermore, the craniotomy does not cross the midline, thereby diminishing the likelihood of damage to the superior sagittal sinus and its associated draining veins. The incidence of acute disconnection syndrome following CC via the KA and the TA was essentially the same. No statistically significant difference in seizure outcomes was found between CC via the KA and the TA, consistent with previous findings. 19 , 40 Small incisions also result in minimal scarring, superior cosmetic appearance, reduced hair loss, unperceived wounds, and higher patient satisfaction. Limitations However, given the retrospective nature of the study and the limited sample size, further prospective studies are required to validate the safety and efficacy of the KA for CC. Conclusion CC by the KA is an effective technique for treating patients with medically refractory epilepsy with good surgical outcomes and seizure control, a shorter incision, smaller craniotomy, minimal blood loss, shorter operative times, shorter postoperative hospital stays, and a lower incidence of postoperative fever and subcutaneous effusion compared with the TA. Future research should include a larger patient population to assess the efficacy of this novel technique more comprehensively. Declarations Acknowledgements None Author contributions Yutao Ren, Yong Liu, Qiang Meng and Hua Zhang conceived the study concept. Yutao Ren, Yong Liu, Qiang Meng, Bo Fang, Huanfa Li and Hao Wu participated in the design of the study. Xiaorong Zhang, Hui Li, Shan Dong, and Xiaofang Liu collected data. Yutao Ren, Yong Liu, Haohao Cui and Xiaobo Ye analyzed and interpreted the data drafted and edited the manuscript. Yutao Ren, Yong Liu, Qiang Meng and Hua Zhang had full access to all the data in the study and takes responsibility for the data and the accuracy of the data analysis. All the authors approved the final manuscript. Funding This research was supported by the Key Research and Development Program of Shaanxi (Program No. 2024SF-YBXM-216), National Natural Science Foundation of China (Program No. 82371459), and Innovation Capability Support Program of Shaanxi (Program No. 2021LCZX-01). Data availability AllData generated in the current study are available from the corresponding author on reasonable request. Human ethics and consent to participate declarations This study received approval from the Clinical Research Review Committee of the First Affiliated Hospital of Xi’an Jiaotong University (NO: XJTU1AF2025LSYY-480). The patients were recruited retrospectively and the informed consent was waived Disclosures None. Clinical Trial Number Not applicable. Competing interests The authors declare no competing interests References Duncan JS, Sander JW, Sisodiya SM et al (2006) Adult epilepsy. 10.1016/s0140-6736(06)68477-8 Kwan P, Brodie MJ (2000) Early identification of refractory epilepsy. 10.1056/nejm200002033420503 Wiebe S, Jette N (2012) Pharmacoresistance and the role of surgery in difficult to treat epilepsy. 10.1038/nrneurol.2012.181 Englot DJ, Chang EF (2014) Rates and predictors of seizure freedom in resective epilepsy surgery: an update. 10.1007/s10143-014-0527-9 Englot DJ, Birk H, Chang EF (2017) Seizure outcomes in nonresective epilepsy surgery: an update. 10.1007/s10143-016-0725-8 Tanriverdi T, Olivier A, Poulin N (2009) et a l Long-term seizure outcome after corpus callosotomy: a retrospective analysis of 95 patients. 10.3171/2008.3.17570 WP VW (1940) Surgical division of commissural pathways in the corpus callosum: relation to spread of an epileptic attack Unterberger I, Walser BauerR G, et al (2016) Corpus callosum and epilepsies. 10.1016/j.seizure.2016.02.012 Passamonti C, Zamponi N, Foschi N et al (2014) Long-term seizure and behavioral outcomes after corpus callosotomy. 10.1016/j.yebeh.2014.08.130 Kasasbeh AS, Smyth MD, Steger-May K et al (2014) Outcomes after anterior or complete corpus callosotomy in children. 10.1227/neu.0000000000000197 Markosian C, Patel S, Kosach S et al (2022) Corpus Callosotomy in the Modern Era: Origins, Efficacy, Technical Variations, Complications, and Indications. 10.1016/j.wneu.2022.01.037 Vaddiparti A, Huang R, Blihar D et al (2021) The Evolution of Corpus Callosotomy for Epilepsy Management. 10.1016/j.wneu.2020.08.178 Uda T, Kunihiro N, Umaba R et al (2021) Surgical Aspects of Corpus Callosotomy. 10.3390/brainsci11121608 Smyth MD, Vellimana AK, Asano E et al (2017) Corpus callosotomy-Open and endoscopic surgical techniques. 10.1111/epi.13681 Belal A, Allmen GV, Kommuru I et al (2022) Complete corpus callosotomy using a frameless navigation probe through a minicraniotomy in children with medically refractory epilepsy: A case series and technical note. 10.25259/SNI_1188_2021 Kwan P, Arzimanoglou A, Berg AT et al (2010) Definition of drug resistant epilepsy: consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies. 10.1111/j.1528-1167.2009.02397.x Mani J, Gupta A, Mascha E et al (2006) Postoperative seizures after extratemporal resections and hemispherectomy in pediatric epilepsy. 10.1212/01.wnl.0000204236.96232.1c Jea A, Vachhrajani S, Widjaja E et al (2008) Corpus callosotomy in children and the disconnection syndromes: a review. 10.1007/s00381-008-0626-4 Liu Y, Zhang J, Ren Y et al (2023) The clinical features of patients with seizure freedom and failure after total corpus callosotomy for childhood-onset refractory epilepsy. 10.1080/02688697.2023.2273840 Chan AY, Rolston JD, Lee B et al (2019) Rates and predictors of seizure outcome after corpus callosotomy for drug-resistant epilepsy: a meta-analysis. 10.3171/2017.12.jns172331 Sunaga S, Shimizu H, Sugano H (2009) Long-term follow-up of seizure outcomes after corpus callosotomy. 10.1016/j.seizure.2008.08.001 Graham D, Tisdall MM, Gill D (2016) Corpus callosotomy outcomes in pediatric patients: A systematic review. 10.1111/epi.13408 Asadi-Pooya AA, Sharan A, Nei M et al (2008) Corpus callosotomy. 10.1016/j.yebeh.2008.04.020 Okanishi T, Fujimoto A (2021) Corpus Callosotomy for Controlling Epileptic Spasms: A Proposal for Surgical Selection. 10.3390/brainsci11121601 Iwasaki M, Nakasato N, Kakisaka Y et al (2011) Lateralization of interictal spikes after corpus callosotomy. 10.1016/j.clinph.2011.04.013 Chandra SP, Kurwale NS, Chibber SS et al (2016) Endoscopic-Assisted (Through a Mini Craniotomy) Corpus Callosotomy Combined With Anterior, Hippocampal, and Posterior Commissurotomy in Lennox-Gastaut Syndrome: A Pilot Study to Establish Its Safety and Efficacy. 10.1227/neu.0000000000001060 Ho AL, Miller KJ, Cartmell S et al (2016) Stereotactic laser ablation of the splenium for intractable epilepsy. 10.1016/j.ebcr.2015.12.003 Mo J, Guo Z, Wang X et al (2024) Magnetic resonance-guided laser interstitial thermal therapy vs. open surgery for drug-resistant mesial temporal lobe epilepsy: a propensity score matched retrospective cohort study. 10.1097/JS9.0000000000000811 Caruso JP, Janjua MB, Dolce A et al (2021) Retrospective analysis of open surgical versus laser interstitial thermal therapy callosotomy in pediatric patients with refractory epilepsy. 10.3171/2020.7.peds20167 Badger CA, Lopez AJ, Heuer G et al (2020) Systematic review of corpus callosotomy utilizing MRI guided laser interstitial thermal therapy. 10.1016/j.jocn.2020.04.046 Palma AE, Wicks RT, Popli G et al (2019) Corpus callosotomy via laser interstitial thermal therapy: a case series. 10.3171/2018.10.peds18368 Pruitt R, Gamble A, Black K et al (2017) Complication avoidance in laser interstitial thermal therapy: lessons learned. 10.3171/2016.3.jns152147 Pendl G, Eder HG, Schroettner O et al (1999) Corpus callosotomy with radiosurgery. 10.1097/00006123-199908000-00021 Feichtinger M, Schröttner O, Eder H (2006) Efficacy and safety of radiosurgical callosotomy: a retrospective analysis. 10.1111/j.1528-1167.2006.00592.x Celis MA, Moreno-Jiménez S, Lárraga-Gutiérrez JM et al (2007) Corpus callosotomy using conformal stereotactic radiosurgery. 10.1007/s00381-007-0356-z Romanelli P, Anschel DJ (2006) Radiosurgery for epilepsy. 10.1016/s1474-4422(06)70496-3 Thohar Arifin M, Muttaqin Z, Bakhtiar Y et al (2020) Seizure Outcomes in Patients with Complete versus Anterior Corpus Callosotomy: Analysis of Outcome. 10.2147/ijgm.s247438 Shim KW, Lee YM, Kim HD et al (2008) Changing the paradigm of 1-stage total callosotomy for the treatment of pediatric generalized epilepsy. 10.3171/ped/2008/2/7/029 Jalilian L, Limbrick DD, Steger-May K et al (2010) Complete versus anterior two-thirds corpus callosotomy in children: analysis of outcome. 10.3171/2010.5.peds1029 Wu X, Ou S, Zhang H et al (2023) Long-term follow-up seizure outcomes after corpus callosotomy: A systematic review with meta-analysis. 10.1002/brb3.2964 Additional Declarations No competing interests reported. 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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-9027303","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":604833327,"identity":"ed004a0a-c87e-405e-a2f4-9c781c1c3dd1","order_by":0,"name":"Yutao Ren","email":"","orcid":"","institution":"The First Affiliated Hospital of Xi'an Jiaotong University Department of Neurosurgery","correspondingAuthor":false,"prefix":"","firstName":"Yutao","middleName":"","lastName":"Ren","suffix":""},{"id":604833328,"identity":"47f0d2b8-8b46-4384-90cf-eef014cbf958","order_by":1,"name":"Yong Liu","email":"","orcid":"","institution":"The First Affiliated Hospital of Xi'an Jiaotong University Department of Neurosurgery","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Liu","suffix":""},{"id":604833330,"identity":"7b835b1b-1002-4490-af67-2548ed266c36","order_by":2,"name":"Bo Fang","email":"","orcid":"","institution":"Northwest Women and Children's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Fang","suffix":""},{"id":604833332,"identity":"4fda88e6-748a-4d3f-a3eb-e377fda16d9d","order_by":3,"name":"Huanfa Li","email":"","orcid":"","institution":"The First Affiliated Hospital of Xi'an Jiaotong University Department of Neurosurgery","correspondingAuthor":false,"prefix":"","firstName":"Huanfa","middleName":"","lastName":"Li","suffix":""},{"id":604833333,"identity":"bae62b5f-6ae4-49ee-ad39-069276de4b67","order_by":4,"name":"Xiaorong Zhang","email":"","orcid":"","institution":"The First Affiliated Hospital of Xi'an Jiaotong University Department of Neurosurgery","correspondingAuthor":false,"prefix":"","firstName":"Xiaorong","middleName":"","lastName":"Zhang","suffix":""},{"id":604833334,"identity":"60449e6d-45e0-4eba-ad42-b360e866c797","order_by":5,"name":"Hui Li","email":"","orcid":"","institution":"The First Affiliated Hospital of Xi'an Jiaotong University Department of Neurosurgery","correspondingAuthor":false,"prefix":"","firstName":"Hui","middleName":"","lastName":"Li","suffix":""},{"id":604833335,"identity":"fb9494b2-9ff2-4df9-bb31-d4af9ea563bb","order_by":6,"name":"Hao Wu","email":"","orcid":"","institution":"The First Affiliated Hospital of Xi'an Jiaotong University Department of Neurosurgery","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Wu","suffix":""},{"id":604833336,"identity":"6548850f-5d19-4c1d-a852-3e5fc9d95c7a","order_by":7,"name":"Shan Dong","email":"","orcid":"","institution":"The First Affiliated Hospital of Xi'an Jiaotong University Department of Neurosurgery","correspondingAuthor":false,"prefix":"","firstName":"Shan","middleName":"","lastName":"Dong","suffix":""},{"id":604833337,"identity":"4093afec-394f-497b-b551-bc439d3729dd","order_by":8,"name":"Xiaofang Liu","email":"","orcid":"","institution":"The First Affiliated Hospital of Xi'an Jiaotong University Department of Neurosurgery","correspondingAuthor":false,"prefix":"","firstName":"Xiaofang","middleName":"","lastName":"Liu","suffix":""},{"id":604833338,"identity":"8571be4f-1e4e-4b71-953b-a2de08c9e6ee","order_by":9,"name":"Haohao Cui","email":"","orcid":"","institution":"The First Affiliated Hospital of Xi'an Jiaotong University Department of Neurosurgery","correspondingAuthor":false,"prefix":"","firstName":"Haohao","middleName":"","lastName":"Cui","suffix":""},{"id":604833339,"identity":"039e41ad-b6df-4b07-84d1-9b53d38fd370","order_by":10,"name":"Xiaobo Ye","email":"","orcid":"","institution":"The First Affiliated Hospital of Xi'an Jiaotong University Department of Neurosurgery","correspondingAuthor":false,"prefix":"","firstName":"Xiaobo","middleName":"","lastName":"Ye","suffix":""},{"id":604833342,"identity":"32e0fe29-de70-4e38-8412-ac16bec912f0","order_by":11,"name":"Qiang Meng","email":"","orcid":"","institution":"The First Affiliated Hospital of Xi'an Jiaotong University Department of Neurosurgery","correspondingAuthor":false,"prefix":"","firstName":"Qiang","middleName":"","lastName":"Meng","suffix":""},{"id":604833343,"identity":"dfd05d80-d009-403c-8ff6-c7d75a466302","order_by":12,"name":"Hua Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYDACCSBmbGBg4GdgSGCAsonUItnAkNhAmhaDAxDVhLXIz25+9vDrjsPyxjcSnj/mYbCR3XCA+dkDfFoY5xwzN5Y9c9hw25kDic08DGnGGw6wmRvg08IskWAmLdl2mHHb8QaQlsOJGw7wsEng08Imkf4NpMV+czMDSMt/wlp4JHLMJD+2AQ1nB9tygLAWCYmcMmnGtvTkGUC/zJxjkGw88zCbGV4t8jPSt0n+bLO27Z+Rk/DhTYWdbN/x5md4tYAAMw/EjQnA2AFxCakHAsYfYIr9ABFqR8EoGAWjYCQCAOAkS2bg+sjZAAAAAElFTkSuQmCC","orcid":"","institution":"The First Affiliated Hospital of Xi'an Jiaotong University Department of Neurosurgery","correspondingAuthor":true,"prefix":"","firstName":"Hua","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2026-03-04 07:53:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9027303/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9027303/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104668225,"identity":"b669e523-c493-42e0-a1fc-81a5e0bf0dde","added_by":"auto","created_at":"2026-03-15 16:52:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":181624,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the skin incision and craniotomy for CC. A: a right frontal L-shape skin incision and a craniotomy of approximately 4.0 x 4.0 cm for CC via the traditional approach. B: a transverse straight skin incision and a craniotomy with a diameter of approximately 2.5 cm for CC via the keyhole approach.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9027303/v1/463f5b6a100526d841c69c81.png"},{"id":104808619,"identity":"099c7277-529f-400b-88c2-787e65e668bd","added_by":"auto","created_at":"2026-03-17 12:39:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":641066,"visible":true,"origin":"","legend":"\u003cp\u003ePatient position, skin incision, and craniotomy for CC. A: Supine position with a right frontal L-shape skin incision for CC via the traditional approach. B: 3D reconstruction of the skull showing a craniotomy of approximately 4.0 x 4.0 cm following CC via the traditional approach. C: Supine position with a transverse straight skin incision for CC via the keyhole approach. D: 3D reconstruction of the skull showing the craniotomy with a diameter of approximately 2.5 cm following CC via the keyhole approach. CC, corpus callosotomy.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9027303/v1/77d5aac3602320b2986850a0.png"},{"id":104668227,"identity":"84052f94-f63b-4009-a9cc-3208ce644791","added_by":"auto","created_at":"2026-03-15 16:52:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":737969,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical CC technique via keyhole approach. A: Merged diagram of the MRI sagittal view and 3D reconstruction of the skull and corpus callosum demonstrates three different optic axes of the microscope utilized during the CC. B: The body (a), genu (b), and splenium (c) of the corpus callosum observed through three distinct microscope axes in diagram A. C: Following exposure of the interhemispheric fissure, the corpus callosum body is observed to be situated between the bilateral pericallosal arteries. D: Section of the corpus callosum body. E: Section of the genu of the corpus callosum and exposure of the cavum of the septum pellucidum. F: Callosal section of the splenium of the corpus callosum. Abbreviations: MRI: magnetic resonance imaging; Bo: body of the corpus callosum; CSP: cavum of the septum pellucidum; Ge: genu of the corpus callosum; pca: pericallosal artery; Sp: splenium of the corpus callosum.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9027303/v1/e24b477c07002cf1e67ee8aa.png"},{"id":104668229,"identity":"744436c6-9648-4fcc-8473-3a770d5886f6","added_by":"auto","created_at":"2026-03-15 16:52:41","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":288897,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative MRI and incision. A: Postoperative MRI in sagittal view demonstrates complete sectioning of the corpus callosum. B: Cosmetic appearance of the wound at 1 week after CC via keyhole approach.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9027303/v1/10a78c7bcb42ce6612a487bf.png"},{"id":104809741,"identity":"e2653072-cb0f-4fb4-968f-f68602834409","added_by":"auto","created_at":"2026-03-17 12:52:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3172396,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9027303/v1/5102af1a-c411-445c-9e53-9666af59ce27.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Keyhole approach for total corpus callosotomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEpilepsy is a neurological disorder, affecting approximately 0.7% of the general population.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Seizure freedom can be attained in the majority of patients by administering suitable antiseizure medicines (ASMs). Nevertheless, over one-third of patients continue to experience seizures despite using ASMs, and ultimately are found to have medically refractory epilepsy.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Focal resection, which is characterized by well-defined focal epileptogenic foci, is appropriate for patients with drug-resistant epilepsy (DRE).\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, patients with DRE who experience rapid secondary generalization, lack a single identifiable epileptic focus, have multifocal epilepsy or generalized seizures and are not candidates for focal resection. For these patients, palliative surgical options, including corpus callosotomy (CC) and neuromodulation, represent viable alternatives.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCC was first reported to be a palliative surgical treatment for patients with DRE by Van Wagenen and Herren in 1940.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The corpus callosum is recognized as the largest commissural structure in the forebrain and is hypothesized to serve as the primary pathway for the transmission of epileptic discharges between the two cerebral hemispheres.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The mechanism underlying CC entails transecting the fibers that link the two hemispheres of the brain, thereby inhibiting the interhemispheric propagation of epileptic discharges.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e CC has demonstrated significant effectiveness in addressing drop attacks associated with tonic and atonic seizures, as well as in various syndromes characterized by epilepsy, including Lennox-Gastaut syndrome, West syndrome, and severe epilepsy characterized by multiple independent spike foci.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCC is usually conducted utilizing microsurgical techniques. The technique involves a complete callosotomy that extends from the splenium to the arachnoid membrane of the quadrigeminal cistern. Typically, a coronal incision accompanied by a craniotomy with an approximate diameter of 6 centimeters is used in CC.\u003csup\u003e13,14\u003c/sup\u003e The traditional approach (TA) is associated with relatively significant trauma and a relatively high risk of complications, causing many patients with DRE, particularly pediatric patients, to be reluctant to choose surgery. Belal \u003cem\u003eet al\u003c/em\u003e (2022) reported a mini-craniotomy approach for CC using a frameless navigation probe, which involved an L-shaped incision along the midline, extending to the temporal line, with a 4 cm (anteroposterior) \u0026times; 3 cm (lateral) craniotomy.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e However, the L-shaped incision in this approach was still long and had a large skin flap. Hence, we propose a keyhole approach (KA) for CC, with a shorter straight skin incision, less damage to the galea, no skin flap, and a smaller semicircular craniotomy, resulting in reduced trauma. Thus, this study introduces a novel KA advancement for CC.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eWe retrospectively included patients who underwent CC at our epilepsy center from February 2017 to September 2024. All CC procedures were conducted by a single surgeon (H.Z.). The inclusion criteria were 1) patients of all ages and genders, 2) generalized DRE defined by the International League Against Epilepsy,\u003csup\u003e16\u003c/sup\u003e 3) non-localizing foci epilepsy, and 4) total CC conducted by the one-stage approach. The exclusion criteria included the presence of significant comorbidities and inadequate patient compliance.\u003c/p\u003e \u003cp\u003ePatients diagnosed with DRE underwent a series of presurgical assessments before being considered candidates for CC, including: (1) long-term video electroencephalography (EEG) monitoring, (2) 3-Tesla magnetic resonance imaging (MRI) comprised of T1-weighted, T2-weighted, and fluid-attenuated inversion recovery sequences, and (3) positron emission tomography (PET) imaging.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical procedures\u003c/h3\u003e\n\u003cp\u003eAfter general anesthesia, the patient was placed in the supine position with their head aligned in a neutral position and fixed with a head frame. The skin incision and craniotomy were illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. In CC via the TA, a frontal L-shaped incision was made along the midline, extending to the temporal line, approximately 15 cm in length (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Then, the myocutaneous flap was reflected in an anterolateral direction. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB, a rectangular craniotomy, approximately 5 \u0026times; 4 cm in size, was milled open, not beyond the midline and the superior sagittal sinus was excluded (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn CC via the KA, a transverse straight incision was made on the frontal area, positioned 2 cm anterior to the coronal suture and approximately 6 cm long (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). The mastoid retractor was employed to facilitate flap separation. A semicircular craniotomy with a diameter of less than 3 cm was made, just in front of the coronal suture and close to the midline (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD).\u003c/p\u003e \u003cp\u003eThe dura mater was subsequently incised in a U-shaped manner and retracted toward the superior sagittal sinus, thereby revealing the interhemispheric fissure. Slowly releasing cerebrospinal fluid from the interhemispheric cistern and tilting the head toward the surgical approach side to leverage gravity for retracting the cerebral hemisphere away from the falx can facilitate the exposure of the deep corpus callosum. The optic axis of the microscope and the corresponding observed portion of the corpus callosum during CC are illustrated in Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB. Next, cerebrospinal fluid was slowly drained from the arachnoid space to reduce pressure and the interhemispheric fissure was gradually and carefully separated downward. Passing through the falx cerebri and cingulate gyrus, the pericallosal artery is visible, and the body of the corpus callosum is exposed and incised between the bilateral pericallosal arteries (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC and D). Subsequently, after repositioning the optical axis of the microscope in an anterior direction, the genu and rostrum of the corpus callosum were dissected (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eE). Thereafter, the optical axis of the microscope was adjusted posteriorly to dissect the remaining body and splenium of the corpus callosum (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eF).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter completing the CC, hemostasis was achieved, the watertight dura mater was closed, the craniotomy was repositioned, and finally, the skin was cosmetically sutured.\u003c/p\u003e\n\u003ch3\u003eOutcome evaluation\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eOutcome evaluation\u003c/div\u003e \u003cp\u003eThe incision length, surgery duration, craniotomy size, intraoperative blood loss, postoperative complications, and length of the postoperative hospital stay were recorded. Acute postoperative seizures are characterized as seizures occurring within the initial 2 weeks after surgery.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Acute disconnection syndrome is defined as transient alterations in visual, motor, sensory, and language functions after CC, and usually resolves within days to months.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Given the constraints of the sample size and as a palliative treatment, we adopted a simplified definition of seizure outcomes after CC. This included (1) being seizure free (complete seizure freedom), (2) improvement (any reduction in seizure frequency\u0026thinsp;\u0026gt;\u0026thinsp;50%), and (3) ineffectiveness (any reduction in seizure frequency\u0026thinsp;\u0026lt;\u0026thinsp;50%).\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables are expressed as median (range) or mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, depending on distribution normality. Continuous variables not normally distributed were analyzed using the Mann\u0026ndash;Whitney U test. Normally distributed continuous variables exhibiting homogeneity of variance were analyzed using an independent samples t-test. Categorical data were analyzed using the Chi-squared test or Fisher's precision probability test. All analyses were performed using SPSS statistical software (PASW Statistics 27.0, version 27.0.1, SPSS Inc., Chicago, IL, USA). A p-value of less than 0.05 was deemed to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eA total of 81 patients who underwent CC were included in the study. The detailed characteristics of all participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Twenty-two males and nine females, with a median age of 18 years (range, 4\u0026ndash;60 years), underwent surgery via the KA, and 35 males and 15 females, with a median age of 18 years (range, 4\u0026ndash;54 years) at surgery, underwent surgery utilizing the TA. No statistically significant difference in gender composition or age at surgery was seen between the two groups. No statistically significant differences were observed in epilepsy duration (median, 11.00 vs. 13.50 years). The majority of the patients in both groups experienced seizures daily and weekly. The seizure types were mainly tonic seizures, atonic seizures, generalized tonic-clonic seizures (GTC) and other generalized seizures. In presurgical evaluations, MRI revealed positive findings in 15 (48.39%) patients in the KA group and 23 (46.00%) patients in the TA group. PET revealed positive findings in 47 (22.58%) patients in the KA group, compared to 13 (26.00%) patients in the TA group. Presurgical long-term video EEG demonstrated generalized discharges in 28 (90.32%) patients in the KA group and 46 (92.00%) in the TA group. Fourteen (45.16%) patients in the KA group had a previous medical history, compared to 21 (42.00%) in the TA group. No statistically significant differences were found in presurgical findings (MRI, PET, and EEG) or previous medical history between the KA and TA groups.\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\u003eCharacteristics of patients with CC via keyhole approach and traditional approach\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=\"left\" 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\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003emale, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKeyhole approach (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTraditional approach\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (70.97)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (70.00)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.93\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 surgery, y (mean, range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (4\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (4\u0026ndash;54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpilepsy duration, y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.00 (2\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.50 (1.5\u0026ndash;40)\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\u003eSeizure types, n (%)\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTonic/Atonic seizures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (67.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (56.00)\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\u003eGTC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (83.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (74.00)\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\u003eOther generalized seizures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (61.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(48.00)\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\u003eSeizure frequency, n (%)\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=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (58.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (66.00)\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\u003eWeekly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (32.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (32.00)\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\u003eMonthly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (41.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (38.00)\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\u003eCluster attack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (16.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (22.00)\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\u003eStatus epilepticus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (14.00)\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\u003eMRI positive, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (48.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (46.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePET positive, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (22.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (26.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneralized discharges, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (90.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (92.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eprevious medical history, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (45.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (42.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCC\u0026thinsp;=\u0026thinsp;corpus callosotomy; GTC\u0026thinsp;=\u0026thinsp;generalized tonic-clonic seizures.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical outcomes\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the surgical outcomes of CC by the KA and the TA. CC via the KA (109.84\u0026thinsp;\u0026plusmn;\u0026thinsp;5.55 minutes) demonstrated statistically shorter surgical durations compared to the TA (183.90\u0026thinsp;\u0026plusmn;\u0026thinsp;13.55 minutes, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The median CC incision length via the KA was 6.0 cm, significantly shorter than that of CC via the TA (15.0 cm, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The median CC craniotomy size via the KA was significantly smaller than that of CC via the TA (3.53 vs. 20.00 cm\u003csup\u003e2\u003c/sup\u003e, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Blood loss in CC via the KA was 34.35\u0026thinsp;\u0026plusmn;\u0026thinsp;8.14 mL, which was significantly less than that of CC via the TA (107.20\u0026thinsp;\u0026plusmn;\u0026thinsp;28.88 mL, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The median postoperative hospital stay for patients undergoing CC via the KA was significantly shorter than that of CC via the TA (6.0 vs. 7.5 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients in the KA group exhibited a significantly lower proportion of postoperative fevers compared to those in the TA group (6.25% vs .22.00%, p\u0026thinsp;=\u0026thinsp;0.038). The incidence of subcutaneous effusion following CC via the KA was significantly lower than that following CC via the TA (3.23% vs 18.00%, p\u0026thinsp;=\u0026thinsp;0.047). All patients exhibited complete disconnection of the entire corpus callosum (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA). No deaths or permanent complications occurred after CC. The aesthetic appearance of the wound was assessed in all participants (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB).\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\u003eSurgical outcomes of CC via keyhole approach and traditional approach\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=\"left\" 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\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSurgery duration, min\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKeyhole approach (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTraditional approach\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109.84\u0026thinsp;\u0026plusmn;\u0026thinsp;5.55\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e183.90\u0026thinsp;\u0026plusmn;\u0026thinsp;13.55\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncision length, cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (5.5-7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0 (13.0\u0026ndash;15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCraniotomy area, cm\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.53 (2.45\u0026ndash;4.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.00 (16.00\u0026ndash;27.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss, ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.35\u0026thinsp;\u0026plusmn;\u0026thinsp;8.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107.20\u0026thinsp;\u0026plusmn;\u0026thinsp;28.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospital stay, d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0 (5\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5 (6\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative fever, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (22.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubcutaneous effusion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(3.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (18.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow up, mo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (13\u0026ndash;46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (14\u0026ndash;59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute postoperative seizures, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (29.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (44.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute disconnection syndrome, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (12.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (14.00)\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\u003eSeizure outcomes, n (%)\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\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeizure free\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (19.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (18.00)\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\u003eImprovement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (58.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (58.00)\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\u003eIneffectiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (22.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (24.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCC\u0026thinsp;=\u0026thinsp;corpus callosotomy.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eSeizure outcomes\u003c/h3\u003e\n\u003cp\u003eThe median follow-up duration of CC via the KA was 28 months (range, 13\u0026ndash;46 months), and 26 months via the TA (range, 14\u0026ndash;59 months). The incidence of acute postoperative seizures in patients who underwent CC via the KA was much lower than that in patients who underwent CC via the TA (29.03% vs. 44.0%), although the difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.18). The incidence of acute disconnection syndrome was similar between the two groups of patients (12.90% vs. 14.00%, p\u0026thinsp;=\u0026thinsp;0.58). Patients experiencing acute disconnection syndrome demonstrated total resolution within 1 month. Among the patients who underwent CC via the KA, six (19.35%) were seizure-free at the last follow-up, 18 (58.07%) were classified as improved, and seven (22.58%) patients were classified as having ineffective outcomes. Among the patients who underwent CC via the TA, nine (18.00%) patients were seizure-free, 29 (58.00%) were classified as improved, and 12 (24.00%) patients were classified as having ineffective outcomes. The seizure outcomes between patients who underwent CC via the KA or the TA were not statistically significantly different (p\u0026thinsp;=\u0026thinsp;0.98).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCC was one of the earliest surgical procedures conducted for treating DRE, and numerous studies have evaluated its outcomes in diverse patient populations. The most effective target seizure for CC is the drop attack, which can result in disabling falls. This is a form of seizure semiology associated with absence seizures, atypical absence seizures, atonic seizures, tonic seizures, epileptic spasms, and myoclonic seizures. CC can also be utilized for GTC, as well as complex partial seizures with or without secondary generalization.\u003csup\u003e\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Patients with a variety of epilepsy syndromes, such as Lennox-Gastaut syndrome, Sturge-Weber syndrome, and West syndrome, are also considered appropriate candidates for CC.\u003csup\u003e11,23\u003c/sup\u003e CC not only contributes to the alleviation of seizures but also facilitates the lateralization of EEG abnormalities and metabolic investigations.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHowever, the TA for CC is performed using a sigmoid or curvilinear bi-coronal incision and a large frontal craniotomy, resulting in significant surgical trauma and prolonged recovery times.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The CC technique is relatively fixed, and a large craniotomy is not necessarily required. A renewed focus has been on developing minimally invasive techniques for CC. Belal \u003cem\u003eet al\u003c/em\u003e (2022) reported complete CC through a minicraniotomy with an L-shape incision, using a frameless navigation probe to ensure completeness of the disconnection. This approach represented a great step in improving the minimally invasive surgical technique.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e With advancements in endoscopic techniques, CC via an endoscopic approach has enabled shorter skin incisions and smaller craniotomies.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e However, the limited operative space under endoscopic vision necessitates resecting the cingulate gyrus to facilitate CC. MR-guided laser interstitial thermal therapy (LITT) offers several advantages over traditional open surgery and firstly used for the CC was reported by Ho \u003cem\u003eet al\u003c/em\u003e in 2016.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Numerous studies have reported on the use of LITT for CC and demonstrated its effectiveness in decreasing seizure frequency, comparable to that achieved with traditional open CC.\u003csup\u003e29\u0026ndash;31\u003c/sup\u003e LITT involves less trauma than open CC, but it is associated with longer surgical duration and prolonged postoperative steroid use.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Nonetheless, LITT presents surgical risks, such as neurological deficits due to thermal injury, catheter displacement, and intracranial hematoma.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Moreover, LITT cannot be used for complete CC. Radiosurgery for anterior one-third CC was first reported in 1999.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e In addition to yielding results comparable to traditional surgery, radiosurgery may lead to complications such as radionecrosis that extends beyond the targeted area and cerebral edema.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e Despite the minimally invasive characteristics of radiosurgery, a minimum evaluation period of 2 years is required to assess its clinical outcomes, and the procedure may need to be performed more than once.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHowever, our center's experience indicates that CC can be totally resected based on the intraoperative anatomical relationships. The objective of this study was to conduct a comparative analysis of CC performed via the TA and the KA. CC via the KA utilizes a transverse straight incision located just before 2 cm anterior to the coronal suture. The craniotomy is positioned anterior to the coronal suture to prevent intraoperative damage to the supplementary motor area and avoid postoperative limb dysfunction. The KA involves a shorter straight surgical incision, a smaller craniotomy area, reduced intraoperative blood loss, shorter operative times, shorter postoperative hospital stay duration, and a lower incidence of postoperative fever and subcutaneous effusion compared to the TA for CC. The advantage of the large craniotomy is that dissection of the venous drainage in the longitudinal fissure can be avoided. It is feasible to accomplish CC via the KA with a relatively small-sized craniotomy. This is done by selecting the cerebral hemisphere with the least or no cortical veins as the surgical approach side based on preoperative MRI T2-weighted images. Thus, no injury to any cortical veins draining into the superior sagittal sinus is incurred. The right side was chosen in the majority of the cases in this study. The essential surgical considerations for CC by the KA include the meticulous and progressive evacuation of cerebrospinal fluid within several minutes following craniotomy to facilitate creating an operative space. Identifying critical anatomical structures, such as the septum pellucidum, is crucial for ensuring that the surgery is performed on midline structures.\u003c/p\u003e \u003cp\u003eAlthough the craniotomy size is much smaller, one-stage total CC was performed in our case series. The primary aims of CC are to restrict the spread of epileptic discharges and reduce both the severity and frequency of seizures. Total CC was found to be significantly more effective in decreasing seizure frequency compared to partial CC.\u003csup\u003e21,37\u0026ndash;39\u003c/sup\u003e Additionally, one-stage total CC showed greater effectiveness in alleviating a wide range of seizure types than anterior two-thirds callosotomy or two-stage complete callosotomy.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Patients undergoing complete CC may also experience benefits without developing clinically significant disconnection syndromes.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Shim et al. proposed that one-stage total CC should be the preferred approach for managing generalized seizures.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e Although complete resection of the corpus callosum in one stage presents challenges, our familiarity with its anatomy, extensive experience, and advanced techniques enabled us to achieve total callosotomy using the KA.\u003c/p\u003e \u003cp\u003eThe advantages of the KA for CC encompass several key factors, including the utilization of short, linear incisions with a small craniotomy, which contribute to a swift postoperative recovery. Furthermore, the craniotomy does not cross the midline, thereby diminishing the likelihood of damage to the superior sagittal sinus and its associated draining veins. The incidence of acute disconnection syndrome following CC via the KA and the TA was essentially the same. No statistically significant difference in seizure outcomes was found between CC via the KA and the TA, consistent with previous findings.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e Small incisions also result in minimal scarring, superior cosmetic appearance, reduced hair loss, unperceived wounds, and higher patient satisfaction.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eHowever, given the retrospective nature of the study and the limited sample size, further prospective studies are required to validate the safety and efficacy of the KA for CC.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCC by the KA is an effective technique for treating patients with medically refractory epilepsy with good surgical outcomes and seizure control, a shorter incision, smaller craniotomy, minimal blood loss, shorter operative times, shorter postoperative hospital stays, and a lower incidence of postoperative fever and subcutaneous effusion compared with the TA. Future research should include a larger patient population to assess the efficacy of this novel technique more comprehensively.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003eYutao Ren,\u0026nbsp;Yong Liu,\u0026nbsp;Qiang Meng\u0026nbsp;and Hua Zhang conceived the study concept.\u0026nbsp;Yutao Ren,\u0026nbsp;Yong Liu,\u0026nbsp;Qiang Meng, Bo Fang, Huanfa Li and Hao Wu participated in the design of the study.\u0026nbsp;Xiaorong Zhang, Hui Li, Shan Dong, and Xiaofang Liu\u0026nbsp;collected data.\u0026nbsp;Yutao Ren,\u0026nbsp;Yong Liu, Haohao Cui and Xiaobo Ye\u0026nbsp;analyzed and interpreted the data drafted and edited the manuscript.\u0026nbsp;Yutao Ren,\u0026nbsp;Yong Liu,\u0026nbsp;Qiang Meng\u0026nbsp;and Hua Zhang\u0026nbsp;had full access to all the data in the study and takes responsibility for the data and the accuracy of the data analysis. All the authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eThis research was supported by the Key Research and Development Program of Shaanxi (Program No. 2024SF-YBXM-216), National Natural Science Foundation of China (Program No. 82371459), and Innovation Capability Support Program of Shaanxi (Program No. 2021LCZX-01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003eAllData generated in the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman ethics and consent to participate declarations\u0026nbsp;\u003c/strong\u003eThis study received approval from the Clinical Research Review Committee of\u0026nbsp;the First Affiliated Hospital of Xi’an Jiaotong University (NO: XJTU1AF2025LSYY-480). The patients were recruited retrospectively and the informed consent was waived\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosures\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e The authors declare no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDuncan JS, Sander JW, Sisodiya SM et al (2006) Adult epilepsy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0140-6736(06)68477-8\u003c/span\u003e\u003cspan address=\"10.1016/s0140-6736(06)68477-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwan P, Brodie MJ (2000) Early identification of refractory epilepsy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/nejm200002033420503\u003c/span\u003e\u003cspan address=\"10.1056/nejm200002033420503\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiebe S, Jette N (2012) Pharmacoresistance and the role of surgery in difficult to treat epilepsy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/nrneurol.2012.181\u003c/span\u003e\u003cspan address=\"10.1038/nrneurol.2012.181\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnglot DJ, Chang EF (2014) Rates and predictors of seizure freedom in resective epilepsy surgery: an update. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10143-014-0527-9\u003c/span\u003e\u003cspan address=\"10.1007/s10143-014-0527-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnglot DJ, Birk H, Chang EF (2017) Seizure outcomes in nonresective epilepsy surgery: an update. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10143-016-0725-8\u003c/span\u003e\u003cspan address=\"10.1007/s10143-016-0725-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanriverdi T, Olivier A, Poulin N (2009) et a\u003cem\u003el\u003c/em\u003e Long-term seizure outcome after corpus callosotomy: a retrospective analysis of 95 patients. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/2008.3.17570\u003c/span\u003e\u003cspan address=\"10.3171/2008.3.17570\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWP VW (1940) Surgical division of commissural pathways in the corpus callosum: relation to spread of an epileptic attack\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnterberger I, Walser BauerR G, et al (2016) Corpus callosum and epilepsies. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.seizure.2016.02.012\u003c/span\u003e\u003cspan address=\"10.1016/j.seizure.2016.02.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePassamonti C, Zamponi N, Foschi N et al (2014) Long-term seizure and behavioral outcomes after corpus callosotomy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.yebeh.2014.08.130\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2014.08.130\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKasasbeh AS, Smyth MD, Steger-May K et al (2014) Outcomes after anterior or complete corpus callosotomy in children. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1227/neu.0000000000000197\u003c/span\u003e\u003cspan address=\"10.1227/neu.0000000000000197\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarkosian C, Patel S, Kosach S et al (2022) Corpus Callosotomy in the Modern Era: Origins, Efficacy, Technical Variations, Complications, and Indications. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wneu.2022.01.037\u003c/span\u003e\u003cspan address=\"10.1016/j.wneu.2022.01.037\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaddiparti A, Huang R, Blihar D et al (2021) The Evolution of Corpus Callosotomy for Epilepsy Management. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wneu.2020.08.178\u003c/span\u003e\u003cspan address=\"10.1016/j.wneu.2020.08.178\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUda T, Kunihiro N, Umaba R et al (2021) Surgical Aspects of Corpus Callosotomy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/brainsci11121608\u003c/span\u003e\u003cspan address=\"10.3390/brainsci11121608\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmyth MD, Vellimana AK, Asano E et al (2017) Corpus callosotomy-Open and endoscopic surgical techniques. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/epi.13681\u003c/span\u003e\u003cspan address=\"10.1111/epi.13681\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBelal A, Allmen GV, Kommuru I et al (2022) Complete corpus callosotomy using a frameless navigation probe through a minicraniotomy in children with medically refractory epilepsy: A case series and technical note. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.25259/SNI_1188_2021\u003c/span\u003e\u003cspan address=\"10.25259/SNI_1188_2021\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwan P, Arzimanoglou A, Berg AT et al (2010) Definition of drug resistant epilepsy: consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1528-1167.2009.02397.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1528-1167.2009.02397.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMani J, Gupta A, Mascha E et al (2006) Postoperative seizures after extratemporal resections and hemispherectomy in pediatric epilepsy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1212/01.wnl.0000204236.96232.1c\u003c/span\u003e\u003cspan address=\"10.1212/01.wnl.0000204236.96232.1c\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJea A, Vachhrajani S, Widjaja E et al (2008) Corpus callosotomy in children and the disconnection syndromes: a review. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00381-008-0626-4\u003c/span\u003e\u003cspan address=\"10.1007/s00381-008-0626-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Y, Zhang J, Ren Y et al (2023) The clinical features of patients with seizure freedom and failure after total corpus callosotomy for childhood-onset refractory epilepsy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/02688697.2023.2273840\u003c/span\u003e\u003cspan address=\"10.1080/02688697.2023.2273840\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan AY, Rolston JD, Lee B et al (2019) Rates and predictors of seizure outcome after corpus callosotomy for drug-resistant epilepsy: a meta-analysis. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/2017.12.jns172331\u003c/span\u003e\u003cspan address=\"10.3171/2017.12.jns172331\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSunaga S, Shimizu H, Sugano H (2009) Long-term follow-up of seizure outcomes after corpus callosotomy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.seizure.2008.08.001\u003c/span\u003e\u003cspan address=\"10.1016/j.seizure.2008.08.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraham D, Tisdall MM, Gill D (2016) Corpus callosotomy outcomes in pediatric patients: A systematic review. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/epi.13408\u003c/span\u003e\u003cspan address=\"10.1111/epi.13408\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsadi-Pooya AA, Sharan A, Nei M et al (2008) Corpus callosotomy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.yebeh.2008.04.020\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2008.04.020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkanishi T, Fujimoto A (2021) Corpus Callosotomy for Controlling Epileptic Spasms: A Proposal for Surgical Selection. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/brainsci11121601\u003c/span\u003e\u003cspan address=\"10.3390/brainsci11121601\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIwasaki M, Nakasato N, Kakisaka Y et al (2011) Lateralization of interictal spikes after corpus callosotomy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.clinph.2011.04.013\u003c/span\u003e\u003cspan address=\"10.1016/j.clinph.2011.04.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChandra SP, Kurwale NS, Chibber SS et al (2016) Endoscopic-Assisted (Through a Mini Craniotomy) Corpus Callosotomy Combined With Anterior, Hippocampal, and Posterior Commissurotomy in Lennox-Gastaut Syndrome: A Pilot Study to Establish Its Safety and Efficacy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1227/neu.0000000000001060\u003c/span\u003e\u003cspan address=\"10.1227/neu.0000000000001060\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHo AL, Miller KJ, Cartmell S et al (2016) Stereotactic laser ablation of the splenium for intractable epilepsy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ebcr.2015.12.003\u003c/span\u003e\u003cspan address=\"10.1016/j.ebcr.2015.12.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMo J, Guo Z, Wang X et al (2024) Magnetic resonance-guided laser interstitial thermal therapy vs. open surgery for drug-resistant mesial temporal lobe epilepsy: a propensity score matched retrospective cohort study. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/JS9.0000000000000811\u003c/span\u003e\u003cspan address=\"10.1097/JS9.0000000000000811\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaruso JP, Janjua MB, Dolce A et al (2021) Retrospective analysis of open surgical versus laser interstitial thermal therapy callosotomy in pediatric patients with refractory epilepsy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/2020.7.peds20167\u003c/span\u003e\u003cspan address=\"10.3171/2020.7.peds20167\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBadger CA, Lopez AJ, Heuer G et al (2020) Systematic review of corpus callosotomy utilizing MRI guided laser interstitial thermal therapy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jocn.2020.04.046\u003c/span\u003e\u003cspan address=\"10.1016/j.jocn.2020.04.046\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalma AE, Wicks RT, Popli G et al (2019) Corpus callosotomy via laser interstitial thermal therapy: a case series. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/2018.10.peds18368\u003c/span\u003e\u003cspan address=\"10.3171/2018.10.peds18368\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePruitt R, Gamble A, Black K et al (2017) Complication avoidance in laser interstitial thermal therapy: lessons learned. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/2016.3.jns152147\u003c/span\u003e\u003cspan address=\"10.3171/2016.3.jns152147\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePendl G, Eder HG, Schroettner O et al (1999) Corpus callosotomy with radiosurgery. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00006123-199908000-00021\u003c/span\u003e\u003cspan address=\"10.1097/00006123-199908000-00021\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeichtinger M, Schr\u0026ouml;ttner O, Eder H (2006) Efficacy and safety of radiosurgical callosotomy: a retrospective analysis. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1528-1167.2006.00592.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1528-1167.2006.00592.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCelis MA, Moreno-Jim\u0026eacute;nez S, L\u0026aacute;rraga-Guti\u0026eacute;rrez JM et al (2007) Corpus callosotomy using conformal stereotactic radiosurgery. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00381-007-0356-z\u003c/span\u003e\u003cspan address=\"10.1007/s00381-007-0356-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRomanelli P, Anschel DJ (2006) Radiosurgery for epilepsy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s1474-4422(06)70496-3\u003c/span\u003e\u003cspan address=\"10.1016/s1474-4422(06)70496-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThohar Arifin M, Muttaqin Z, Bakhtiar Y et al (2020) Seizure Outcomes in Patients with Complete versus Anterior Corpus Callosotomy: Analysis of Outcome. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2147/ijgm.s247438\u003c/span\u003e\u003cspan address=\"10.2147/ijgm.s247438\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShim KW, Lee YM, Kim HD et al (2008) Changing the paradigm of 1-stage total callosotomy for the treatment of pediatric generalized epilepsy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/ped/2008/2/7/029\u003c/span\u003e\u003cspan address=\"10.3171/ped/2008/2/7/029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJalilian L, Limbrick DD, Steger-May K et al (2010) Complete versus anterior two-thirds corpus callosotomy in children: analysis of outcome. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/2010.5.peds1029\u003c/span\u003e\u003cspan address=\"10.3171/2010.5.peds1029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu X, Ou S, Zhang H et al (2023) Long-term follow-up seizure outcomes after corpus callosotomy: A systematic review with meta-analysis. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/brb3.2964\u003c/span\u003e\u003cspan address=\"10.1002/brb3.2964\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"corpus callosotomy, keyhole approach, traditional approach, epilepsy","lastPublishedDoi":"10.21203/rs.3.rs-9027303/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9027303/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground and purpose\u003c/h2\u003e \u003cp\u003eTo compare the surgical outcomes of corpus callosotomy (CC) performed using the keyhole approach (KA) and the traditional approach (TA) and demonstrate the efficacy and safety of total corpus callosotomy via the keyhole approach.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients with medically refractory epilepsy who underwent CC between February 2017 and September 2024 were retrospectively included. The CC keyhole surgical technique is described. Surgical outcomes, postoperative complications, and seizure controls were analyzed between patients who underwent CC via the KA and the TA.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 31 patients undergoing CC via the KA and 50 patients undergoing CC via the TA were enrolled. CC via the KA demonstrated statistically shorter surgical duration (109.84\u0026thinsp;\u0026plusmn;\u0026thinsp;5.55 vs. 183.90\u0026thinsp;\u0026plusmn;\u0026thinsp;13.55 minutes, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), shorter incision length (6.0 vs. 15.0 cm, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), smaller craniotomy size (3.53 vs. 20.00 cm\u0026sup2;, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), less blood loss (34.35\u0026thinsp;\u0026plusmn;\u0026thinsp;8.14 vs. 107.20\u0026thinsp;\u0026plusmn;\u0026thinsp;28.88 mL, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), shorter postoperative hospital stays (6.0 days vs. 7.5 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), lower rates of postoperative fever (6.25% vs. 22.00%, p\u0026thinsp;=\u0026thinsp;0.038), and a lower incidence of subcutaneous effusion compared with the TA (3.23% vs. 18.00%, p\u0026thinsp;=\u0026thinsp;0.047).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCC conducted via the KA was shown to be an effective technique for treating medically refractory epilepsy with a shorter incision, smaller craniotomy, less blood loss, shorter operative times, shorter hospital stays, and a lower incidence of complications.\u003c/p\u003e","manuscriptTitle":"Keyhole approach for total corpus callosotomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-15 16:52:36","doi":"10.21203/rs.3.rs-9027303/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-19T02:31:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T23:13:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T10:42:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141196852809443840904840342661219269925","date":"2026-03-14T10:36:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"238984265401070567872099503819691295210","date":"2026-03-12T05:47:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-11T04:08:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-11T04:06:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-09T19:07:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurosurgical Review","date":"2026-03-04T07:45:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f932d2c7-5686-4533-9565-4e0a4c3d14d2","owner":[],"postedDate":"March 15th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T20:23:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-15 16:52:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9027303","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9027303","identity":"rs-9027303","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}