Gross Robert E, Sun Hai, Raghu Ashley L B, Abramyan Arevik
Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
Stereotact Funct Neurosurg. 2025 Aug 4:1-19. doi: 10.1159/000547794.
In the 15 years since the first patient with drug-resistant epilepsy was treated by MR-guided laser interstitial thermal therapy (LITT), it has revolutionized the surgical treatment of epilepsy. Therapeutic targets have ranged from every form of epileptogenic lesion, including mesial temporal sclerosis (MTS), hypothalamic hamartomas (HHs), malformations of cortical development, low-grade epilepsy-associated tumors, and cerebral cavernous malformations (CCM), to MRI-normal epileptogenic zones characterized by stereoelectroencephalography (SEEG), to disconnection surgeries such as corpus callosotomy and even functional hemispherotomy (FH). Many series now support the general effectiveness and safety of LITT for epilepsy, although we are still in the period where increasing experience and technical advances are driving refinement in the therapy. Here, we provide a broad survey of the landscape of LITT for epilepsy and a perspective on future developments.
The largest experience is with stereotactic laser amygdalohippocampotomy for mesial temporal lobe epilepsy (MTLE), leading to seizure freedom (Engel I) in 57% of patients (N = 554), less effective than anterior temporal lobectomy but with significantly improved cognitive outcomes. Seizure-free rates are about 10% higher for MTS, with lower rates in MRI-normal MTLE. The largest experience in epileptogenic lesions is with HH where a pooled analysis found 77% of patients became seizure-free (N = 374), with up to 93% of patients becoming free of gelastic seizures. Experience with other lesions is more limited, with seizure freedom in 59% of patients with focal cortical dysplasias (N = 37), 80% of patients with periventricular nodular heterotopias (N = 39), and 88% of patients with CCMs (N = 39); 54% of patients with cortical tubers achieved Engel I or II outcomes. Outcomes in patients undergoing stereotactic laser corpus callosotomy (N = 82) or FH (N = 6) are similar to the results of open surgery.
MR-guided LITT is becoming well established as a minimally invasive option for the treatment of drug-resistant epilepsy. While seizure freedom may in some circumstances be less than open resection, it offers improved therapeutic windows and, in some circumstances, provides surgical options where none existed previously. Moreover, it marries well with SEEG to offer a completely minimally invasive option. This combined with the increased therapeutic window and the lower level of surgical complications, pain, and even cost lowers the barrier to a potentially definitive surgical option for patients that have heretofore been reluctant. The future will see increased experience and technical advances in both laser technology and stereotactic delivery driving rapid global spread of LITT as a surgical tool in epilepsy.
自首例耐药性癫痫患者接受磁共振引导激光间质热疗（LITT）治疗后的15年里，它彻底改变了癫痫的外科治疗方式。治疗靶点范围广泛，涵盖各种形式的致痫性病变，包括内侧颞叶硬化（MTS）、下丘脑错构瘤（HHs）、皮质发育畸形、低度癫痫相关肿瘤以及脑海绵状血管畸形（CCM），还包括通过立体定向脑电图（SEEG）确定的MRI正常的致痫区，以及诸如胼胝体切开术甚至功能性大脑半球切除术（FH）等离断手术。尽管我们仍处于经验不断积累和技术不断进步推动治疗不断完善的阶段，但现在许多系列研究都支持LITT治疗癫痫的总体有效性和安全性。在此，我们对LITT治疗癫痫的情况进行广泛综述，并对未来发展进行展望。
立体定向激光杏仁核海马切除术治疗内侧颞叶癫痫（MTLE）的经验最为丰富，57%的患者（N = 554）实现无癫痫发作（Engel I级），效果虽不如前颞叶切除术，但认知结果有显著改善。MTS患者的无癫痫发作率高出约10%，MRI正常的MTLE患者无癫痫发作率较低。在致痫性病变方面，HH的经验最为丰富，一项汇总分析发现77%的患者（N = 374）实现无癫痫发作，高达93%的患者停止发作性笑。其他病变的经验较为有限，局灶性皮质发育不良患者中59%（N = 37）、室管膜下结节性异位患者中80%（N = 39）、CCM患者中88%（N = 39）实现无癫痫发作；皮质结节患者中54%达到Engel I级或II级结果。接受立体定向激光胼胝体切开术（N = 82）或FH（N = 6）的患者的结果与开放手术相似。
磁共振引导LITT已成为治疗耐药性癫痫的成熟微创选择。虽然在某些情况下无癫痫发作率可能低于开放切除术，但它提供了更好的治疗窗口，在某些情况下还提供了以前不存在的手术选择。此外，它与SEEG配合良好，提供了完全微创的选择。这与增加的治疗窗口、较低的手术并发症、疼痛甚至成本相结合，降低了那些此前不愿接受手术的患者接受潜在确定性手术选择的门槛。未来，激光技术和立体定向递送方面的经验增加和技术进步将推动LITT作为癫痫手术工具在全球迅速传播。
