Magnetic resonance image-guided laser interstitial thermal therapy for intractable mesial temporal epilepsy


MRgLITT offers access to foci virtually anywhere in the brain with minimal disruption of the overlying cortex and white matter, promising fewer neurological side effects and less surgical morbidity and pain. Compared to other ablative techniques, MRgLITT offers immediate, discrete lesions with real-time monitoring of temperature beyond the fiber tip for damage estimates and off-target injury prevention. Applications of MRgLITT for epilepsy are growing rapidly and, although more evidence of safety and efficacy is needed, there are potential advantages for some patients 1).

It has been used for selective amygdalohippocampectomy ablation for the treatment of temporal lobe epilepsy.

see also Stereotactic laser amygdalohippocampotomy.

Magnetic resonance-guided laser-induced thermal therapy for epilepsy is an exciting new minimally invasive technique that finds potential new applications every day in the neurosurgical field. It certainly brings a new perspective on the way we practice epilepsy surgery even though long-term results should be properly collected and analyzed 2).

The report of Willie et al., demonstrates the technical feasibility and encouraging early results of stereotactic laser amygdalohippocampotomy (SLAH), a novel approach to eliminating seizures while minimizing collateral injury in patients with MTLE. Efficacy appears to approach that of open resection, especially in patients with MTS. Such minimally invasive techniques may be more desirable to patients and result in increased use of epilepsy surgery among the large number of medically intractable epilepsy patients. A larger, longer term multicenter study of seizure and cognitive outcomes after SLAH is currently under way 3).

Treatment of medication-resistant epilepsy that accomplishes ablation of the seizure focus with real-time magnetic resonance thermal mapping. Rates of seizure freedom in early series suggest that SLA approaches and perhaps surpasses the effectiveness of open resection. SLA minimizes the neurocognitive and endocrine adverse effects of open surgery. Secondary benefits of SLA include decreased length of stay, elimination of intensive care unit stay, reduced procedure-related discomfort, and improved access to surgical treatment for patients less likely to consider an open resective procedure 4).

Magnetic resonance image-guided laser interstitial thermal therapy (MRgLITT) is a tool in the neurosurgical armamentarium for the management of drug-resistant epilepsy. Given the introduction of this technology, the American Society for Stereotactic and Functional Neurosurgery (ASSFN), which acts as the joint section representing the field of stereotactic and functional neurosurgery on behalf of the Congress of Neurological Surgeons and the American Association of Neurological Surgeons, provides here the expert consensus opinion on evidence-based best practices for the use and implementation of this treatment modality. Indications for treatment are outlined, consisting of failure to respond to, or intolerance of, at least 2 appropriately chosen medications at appropriate doses for disabling, localization-related epilepsy in the setting of well-defined epileptogenic foci, or critical pathways of seizure propagation accessible by MRgLITT. Applications of MRgLITT in mesial temporal lobe epilepsy and hypothalamic hamartoma, along with its contraindications in the treatment of epilepsy, are discussed based on current evidence. To put this position statement in perspective, they detailed the evidence and authority on which this ASSFN position statement is based 5)

Youngerman BE, Save AV, McKhann GM. Magnetic Resonance Imaging-Guided Laser Interstitial Thermal Therapy for Epilepsy: Systematic Review of Technique, Indications, and Outcomes. Neurosurgery. 2020 Jan 24. pii: nyz556. doi: 10.1093/neuros/nyz556. [Epub ahead of print] PubMed PMID: 31980831.
Tovar-Spinoza Z, Carter D, Ferrone D, Eksioglu Y, Huckins S. The use of MRI-guided laser-induced thermal ablation for epilepsy. Childs Nerv Syst. 2013 Nov;29(11):2089-94. doi: 10.1007/s00381-013-2169-6. Epub 2013 Jun 4. Review. PubMed PMID: 23732793.
Willie JT, Laxpati NG, Drane DL, Gowda A, Appin C, Hao C, Brat DJ, Helmers SL, Saindane A, Nour SG, Gross RE. Real-time magnetic resonance-guided stereotactic laser amygdalohippocampotomy for mesial temporal lobe epilepsy. Neurosurgery. 2014 Jun;74(6):569-85. doi: 10.1227/NEU.0000000000000343. PubMed PMID: 24618797.
Rolston JD, Chang EF. Stereotactic Laser Ablation for Hypothalamic Hamartoma. Neurosurg Clin N Am. 2016 Jan;27(1):59-67. doi: 10.1016/ Epub 2015 Oct 24. Review. PubMed PMID: 26615108.
Wu C, Schwalb JM, Rosenow JM, McKhann GM 2nd, Neimat JS; American Society for Stereotactic and Functional Neurosurgeons. The American Society for Stereotactic and Functional Neurosurgery Position Statement on Laser Interstitial Thermal Therapy for the Treatment of Drug-Resistant Epilepsy. Neurosurgery. 2022 Feb 1;90(2):155-160. doi: 10.1227/NEU.0000000000001799. PMID: 34995216.
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