MRI-guided laser interstitial thermal therapy for drug-resistant epilepsy

2.1 Epilepsy is a neurological condition characterised by episodes of abnormal electrical activity in the brain (recurrent seizures). The seizures can be focal or generalised.

2.2 The main treatment for epilepsy is antiepileptic drugs taken to prevent or reduce the occurrence of seizures. However, many people with epilepsy have drug-resistant epilepsy, which is refractory to drug treatment (estimates vary between 20% and 40% of people with epilepsy). They have frequent seizures and are at risk of status epilepticus and sudden unexpected death in epilepsy. If drug treatment fails to control the epilepsy adequately, surgery may be considered. Surgical options include open surgical resection (such as lesionectomy, anterior temporal lobectomy or hemispherectomy) or disconnection (such as multiple subpial transection or corpus callosotomy), neuroablation (for example, with stereotactic radiosurgery, radiofrequency thermocoagulation or MRI-guided focused ultrasound) or neuromodulation (such as cranial nerve stimulation, deep-brain stimulation or closed-loop stimulation).

2.3 Preoperatively, an MRI scan is done to identify the part of the brain causing the seizures and to identify the entry location for the laser catheter. The procedure is usually done under general anaesthesia with the patient lying on an MRI couch. A small burr hole is made in the skull and a fine fibreoptic laser catheter is inserted into the target area under stereotactic guidance. Continuous real-time MRI scanning is done to allow visualisation of the exact target area to be ablated and the surrounding tissue, and to monitor the temperature in the brain during the procedure. Under computer guidance, laser energy is applied to the target area. The laser is switched off and removed when temperatures have reached levels sufficient to cause coagulation necrosis (usually 46°C to 60°C) and the target tissue has been ablated. After the procedure, an MRI is done to verify the location and volume of the tissue ablated. The aim is to precisely ablate the target tissue and to minimise damage to the surrounding area. MRI-guided laser interstitial thermal therapy has most commonly been used for patients with a well-defined epileptogenic focus, especially in the temporal lobe, but it can be used elsewhere in the brain.