Neurosurgery society endorses laser therapy for drug-resistant epilepsy

The American Society for Stereotactic and Functional Neurosurgery released a position statement supporting the use of magnetic resonance-guided laser interstitial thermal therapy for patients with drug-resistant epilepsy.

“Over the last decade, magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has emerged as a less invasive option for stereotactic ablation rather than resection of the [epileptogenic zone],” Chengyuan Wu, MD, MSBmE, of the department of neurological surgery at Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Pennsylvania, and colleagues wrote in the statement. “MRgLITT offers access to foci virtually anywhere in the brain with minimal disruption of the overlying functional cortex and white matter, promising fewer neurological side effects and less surgical morbidity and pain.

“Compared to other ablative techniques such as radiofrequency ablation or stereotactic radiosurgery, MRgLITT produces immediate, discrete lesions with real-time monitoring of temperature and damage estimates that allows for quantification of the ablation and minimization of injury to surrounding brain tissue,” they added.

Indications for MRgLITT use in treating patients with drug-resistant epilepsy include failure to respond to, or intolerance of, two or more appropriately chosen medications at appropriate doses for disabling, localization-related epilepsy, as well as well-defined epileptogenic foci or critical pathways of seizure propagation that MRgLITT can access.

Contraindications include inability to pinpoint the epileptogenic focus/foci or critical pathways within epileptogenic networks and inability to receive MRI due to medical reasons. The authors also noted medical contraindications to surgery, such as unstable cardiac or respiratory conditions, anticoagulants that cannot be stopped and bleeding diatheses.

According to Wu and colleagues, results of multiple peer reviewed large case series showed MRgLITT was safe and efficacious for reducing seizure frequency among patients with drug-resistant epilepsy, with results similar to those obtained from cases series of open surgical procedures. Other literature suggested MRgLITT was a less invasive option for various focal drug-resistant epilepsies and led to shorter hospital stays and less surgical and neurologic morbidity compared with open surgical resection for common epilepsy etiologies.

Moreover, certain studies suggested MRgLITT may better preserve cognitive functions compared with open epilepsy surgery. The authors also highlighted data showing that patients increasingly prefer MRgLITT to open surgery when offered a choice between the two. Many epilepsy teams have come to use MRgLITT as the first-choice procedure for treating many focal epilepsies, with this treatment option having nearly completely supplanted open surgery for epilepsy due to hypothalamic hamartomas, according to the authors.

“While long-term outcomes must be compared against proven surgical resection techniques, MRgLITT serves as a minimally invasive option that clearly provides greater benefit in patients with [drug-resistant epilepsy] than medical management alone,” Wu and colleagues wrote.

Reference:

American Society for Stereotactic and Functional Neurosurgery position statement on laser interstitial thermal therapy for the treatment of drug-resistant epilepsy. https://www.assfn.org/Guidelines/american-society-for-stereotactic-and-functional-neurosurgery-position-statement-on-laser-interstitial-thermal-therapy-for-the-treatment-of-drug-resistant-epilepsy/. Accessed Oct. 13, 2021.