COMMENTARY

Laser Ablation's Role in Drug-Resistant Epilepsy

Andrew N. Wilner, MD

Disclosures

October 06, 2016

A Bright Light for Epilepsy Treatment?

Epilepsy surgery offers freedom from seizures to many patients with drug-resistant epilepsy.[1] Although complications rates are low, traditional epilepsy surgery requires craniotomy and is a daunting prospect for many patients. Only approximately 2% of potential candidates with drug-resistant epilepsy undergo surgery each year.[2] A more attractive alternative for certain patients may be less invasive laser therapy.

The first five cases of drug-resistant epilepsy treated with magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) were reported in 2012.[3] This new technology (Visualase® [Medtronic, Inc; Minneapolis, Minnesota]) combines real-time MRI thermal imaging with a laser probe. After precise stereotactic targeting of epileptic tissue, a surgeon inserts the laser through a burr hole until it reaches its target, then destroys selected tissue with controlled bursts of heat. MRgLITT obviates the need for craniotomy, as well as its associated discomfort and potential complications, resulting in shorter hospital stays.[2]

A prospective series of 20 patients with mesial temporal sclerosis who underwent MRgLITT revealed lower seizure-free rates than the expected 60%-80% with conventional anterior temporal lobectomy.[2] Freedom from seizures impairing consciousness was achieved in only eight of 15 patients (53%) at 6 months, four of 11 patients (26.4%) after 1 year, and three of five patients (60%) at 2 years. No difference in total ablated lesion volume was found between responders and nonresponders. Four patients in whom MRgLITT failed had subsequent anterior temporal lobectomy, and three became seizure-free.

Although less invasive, MRgLITT is not without adverse events. Complications may occur when the laser is inserted, as well as from ablation.[4] In the five-case study noted above,[3] noncontextual memory task scores declined, but contextual verbal memory was preserved. One patient had a small intracranial hemorrhage at the ablation site, and another had transient vertical diplopia. A patient who had preexisting suicidal ideation committed suicide 4 months after the procedure.

The largest series to date, a single-center report of 102 cases of laser ablation in patients with primary brain tumors, metastatic disease/radiation necrosis, chronic pain, and epilepsy reported new neurologic deficits in 14 cases (13.7%).[4] Deficits completely resolved in nine of 14 patients (64.3%), but partial deficits remained in two patients (14.3%), and two (14.3%) died. However, none of these complications occurred in the 10 patients who underwent the procedure for epilepsy.

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