REVIEW

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Magnetic Resonance Imaging-Guided Laser
Interstitial Thermal Therapy for Epilepsy: Systematic
Review of Technique, Indications, and Outcomes
Brett E. Youngerman, MD, MS BACKGROUND: For patients with focal drug-resistant epilepsy (DRE), surgical resection
Akshay V. Save, BS of the epileptogenic zone (EZ) may offer seizure freedom and benefits for quality of life.
Guy M. McKhann, MD Yet, concerns remain regarding invasiveness, morbidity, and neurocognitive side effects.
Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has emerged as a
Department of Neurological Surgery, less invasive option for stereotactic ablation rather than resection of the EZ.
Columbia University Medical Center, New
York, New York
OBJECTIVE: To provide an introduction to MRgLITT for epilepsy, including historical devel-
opment, surgical technique, and role in therapy.
Correspondence: METHODS: The development of MRgLITT is briefly recounted. A systematic review
Guy M. McKhann, MD, identified reported techniques and indication-specific outcomes of MRgLITT for DRE in
Department of Neurological Surgery,
Columbia University Medical Center, human studies regardless of sample size or follow-up duration. Potential advantages and
710 West 168th St, disadvantages compared to available alternatives for each indication are assessed in an
New York, NY 10032, USA. unstructured review.
Email: gm317@cumc.columbia.edu
RESULTS: Techniques and outcomes are reported for mesial temporal lobe epilepsy,
Received, June 6, 2019. hypothalamic hamartoma, focal cortical dysplasia, nonlesional epilepsy, tuberous
Accepted, November 20, 2019. sclerosis, periventricular nodular heterotopia, cerebral cavernous malformations,
poststroke epilepsy, temporal encephalocele, and corpus callosotomy.
Copyright 
C 2020 by the

Congress of Neurological Surgeons

CONCLUSION: 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.
KEY WORDS: MRI-guided laser interstitial thermal therapy (MRgLITT), Epilepsy, Mesial temporal lobe epilepsy,
Mesial temporal sclerosis, Focal cortical dysplasia, Hypothalamic hamartoma, Stereoelectroencephalography
(SEEG)

Neurosurgery 0:1–17, 2020 DOI:10.1093/neuros/nyz556 www.neurosurgery-online.com

refractory to medical therapy2,3 and suffer

E
pilepsy is a debilitating disease, affecting
more than 68 million people worldwide.1 progressive, negative impact on cognition,
Up to a third of patients have seizures productivity, quality of life, and mortality.1,4

ABBREVIATIONS: ATL, anterior temporal lobectomy; CC, corpus callosotomy; CCM, cerebral cavernous malfor-
mation; CT, computed tomography; DRE, drug-resistant epilepsy; EZ, epileptogenic zone; FCD, focal cortical
dysplasia; FDA, Food and Drug Administration; HH, hypothalamic hamartoma; LITT, laser interstitial thermal
therapy; MR, magnetic resonance; MRgLITT, magnetic resonance-guided laser interstitial thermal therapy;
MRI, magnetic resonance imaging; MTLE, mesial temporal lobe epilepsy; MTS, mesial temporal sclerosis; NL,
nonlesional; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PVNH, periven-
tricular nodular heterotopia; RF-TC, radiofrequency thermocoagulation; RNS, Responsive Neurostimulation; SAH,
selective amygdalohippocampectomy; SEEG, stereoelectroencephalography; SLAH, selective laser amygdalohip-
pocampotomy; SRS, stereotactic radiosurgery; TS, tuberous sclerosis

Supplemental digital content is available for this article at www.neurosurgery-online.com.

NEUROSURGERY VOLUME 0 | NUMBER 0 | 2020 | 1

YOUNGERMAN ET AL
In patients with well-localized drug-resistant epilepsy (DRE),
surgical resection of the epileptogenic zone (EZ) is highly effective
and has significant overall quality-of-life benefits. Yet, surgery
remains underutilized,5,6 at least in part, because of concerns
regarding its invasiveness, procedural morbidity, and neurocog-
nitive side effects.7
Stereotactic ablation offers less invasive access to the EZ,
especially for targets that are deep to uninvolved brain. Stereo-
tactic chemical lesioning, cryoablation, and radiofrequency
thermocoagulation (RF-TC) of the amygdala and hippocampus
for epilepsy were first reported in the 1960s and 1970s with
variable results.8,9 Computed tomography (CT)- and magnetic
resonance imaging (MRI)-guided RF-TC in the 1990s brought
improved targeting and safety, and it is still practiced at select
centers,10-13 but open resection remained the preferred approach
for most surgeons and indications.
Laser interstitial thermal therapy (LITT) allowed larger yet
more discrete lesions.14-16 In the 1980s, animal models demon-
strated that interstitial ablation yielded reproducible volumes of
coagulative necrosis followed by granulation and fibrosis.17-19
Human LITT was first performed for liver metastases20 and,
in the brain, for gliomas and cerebral metastases in the early
1990s.21,22 In parallel, magnetic resonance (MR) thermometry
demonstrated that time-dependent tissue damage occurs between
certain temperature thresholds.23 Improvements in imaging24
paved the way for modern systems that, in near real time,
accurately monitor temperature, track cumulative dose delivery,
and estimate tissue damage on and off target.25 Commercial
MR-guided LITT (MRgLITT) was Food and Drug Adminis-
tration (FDA) cleared in 2007 for use in neurosurgery and
first reported for treatment of DRE in 2012.26 See the work of
LaRiviere27 or Wicks28 for extensive historical reviews.
Applications of MRgLITT for epilepsy are growing rapidly
with purported advantages for a wide variety of targets. However,
reported techniques, indications, and outcomes are variable and
there are multiple, in some cases far more well established, alter-
native approaches available.
SYSTEMATIC REVIEW METHODOLOGY
This review covers reported techniques and safety and efficacy
of LITT for DRE in human clinical studies and was conducted
following Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) guidelines.29 Full methodology is
available in the Methods, Supplemental Digital Content and
results in Tables 1-4. In order to be inclusive of early reports
in the literature and the variety of applications of MRgLITT,
studies were not excluded based on the sample size, length of
follow-up, or the types of seizure outcomes reported, though
seizure freedom rates with minimum 1-yr follow-up are reported
separately when they could be abstracted to minimize bias. Given
heterogeneous patient cohorts, multiple outcomes of interest, and
the small, retrospective, uncontrolled design of most studies, a
quantitative meta-analysis was not pursued, and the potential
2 | VOLUME 0 | NUMBER 0 | 2020
advantages and disadvantages of MRgLITT compared to alter-
natives are discussed for each indication.
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MRgLITT TECHNIQUE
Once an ablation target is identified, one or more laser
fiber trajectories are planned based on the target, adjacent and
overlying anatomy, and estimates of thermal spread (Figure 1).
Many centers avoid surface vessels and sulci visible on preoper-
ative MRI.91-93 Some prefer not to cross the ventricles to avoid
ependymal or choroidal vessels or deflection of the trajectory,
but occasionally transgress the occipital horn or temporal horn,
for example, in occipital approaches to the mesial temporal lobe.
Cerebrospinal fluid and vessels tend to divert heat and ablations
conform, to some extent, to lesions, particularly if they are encap-
sulated.15,16
Stereotactic placement of the laser fiber assembly can be
performed in the operating room using any frame-based,
frameless, or robotic system (Tables 1-4) before proceeding to
MRI. After a small incision and a twist drill hole, some centers
coagulate the dura with an insulated probe, whereas others open
it sharply or during drilling. Many surgeons create a tract toward
the target using a blunt rigid stylet prior to implanting the
assembly through a skull-mounted anchor bolt. Intraoperative
CT can confirm placement before transfer to MRI, allowing for
immediate revision of a misplaced laser, whereas interventional
MRI offers confirmation with potentially improved operative
efficiency.94 In one unique case report,95 the skull-mounted
AXiiiS mini-frame (Monteris, Plymouth, Minnesota) was used in
a 6-mo-old to obviate the need for skull fixation or an anchor bolt.
Commercially available systems use an inner laser fiber with
variable diffusing tips and an outer cooling catheter to disperse
heat. The Visualase system (Medtronic Inc, Dublin, Ireland)
is more frequently reported in the epilepsy literature. It uses a
3- or 10-mm cylindrical diffusing tip and saline coolant circulated
through an outer 1.65-mm diameter catheter. The NeuroBlate
System (Monteris) uses CO2 coolant and offers a 6-mm cylin-
drical tip, as well as a “side-fire” tip that can distribute heat
asymmetrically, though both have larger catheter diameters (2.2
mm and 3.2 mm, respectively). MR thermometry is provided in
up to 3 planes orthogonal to the laser fiber. Time-dependent tissue
damage occurs at 45◦ C to 60◦ C, above which there is immediate
irreversible tissue coagulation.28,96 Low safety points, usually set
at 43◦ C to 50◦ C, above which the laser turns off, are placed to
protect adjacent tissue. High safety points are usually set at 90◦ C
and placed near the diffuser tip to prevent vaporization and gas
expansion, charring, or melting of the catheter. The “irreversible
damage zone” is estimated and displayed in near real time based
on the temperature history of each MRI voxel.28,97 The Visualase
inner fiber can be manually withdrawn in 5- to 10-mm incre-
ments to complete serial ablations in an ellipsoid shape. The
NeuroBlate System’s robotic drive advances and orients the side-
fire laser to define more complex shapes.
www.neurosurgery-online.com
 TABLE 1. MTLE With and Without MTS

Engel I outcomes, n (%)

Follow-up,
months, median All patients All patients MTS (≥1-yr Non-MTS

NEUROSURGERY
Study N Technique (range) (Last F/u) (≥1-yr F/u) F/u) (≥1-yr F/u) Adverse Events

Curry 201226 1 V + CRW 12 (12) 1/1 (100) 1/1 (100) 1/1 (100) None None
Kang 201630 20 V + CRW 13 (1-39) 11/20a (55) 4/11b (36) 4/10 (40) None 1 (5%) ICH with VFD; 1 (5%) 4th CN palsy
(transient); 2 worsened mood (1 suicide)
Waseem 201731 and 7 V + head frame NR (≥12) 4/7 (57) 4/7 (57) 4/5 (80) 0/2 (0) 2 (29%) VFD; 1 (14%) postop sz
201532
Cajigas 201933 (incl. 26 V + CRW NR (24-59) Mean 16/26 (62) 16/26 (62) 13/19 (68) 3/7 (43) 2 (8%) VFD (1 transient and 1 permanent
Jermakowicz 201734 ) 42.9 HH)
Youngerman 201835 30 V + CRW 17 (12-36) 17/30 (57) 17/30 (57) 10/18 (56) 7/12 (58) 1 (3%) VFD (transient); 1 (3%) ICH/IVH (no
deficit)
Brown 201836 10 NR 12 (NR) 5/10 (50) NR NR 0/1 2 (20%) VFD; 1 (10%) hemorrhage
Tao 201837 21 V + CRW 24 (7-43) 11/21 (52) 9/18 (50) 7/10 (70) 2/8 (25) 1 (5%) VFD (HH); 1 (5%) acute psychiatric
episode
Donos 201838 43 V + Leksell NR (NR) Mean 29/43 (67) NR NR NR 1 (2%) delayed onset optic neuritis
20.3 ± 13.8
Grewal 201839 (incl. 23 NR + Leksell/ 34 (12-70) 11/23 (48) 11/23 (48) 9/18 (50) 2/5 (40) 5 (22%) VFD (2 HH)c
Greenway 2017,40 Grewal Stealth/ClearPoint
2018,41 Tatum 201942 )
Gross 201843 (incl. Willie 58 V + CRW/ClearPoint NR (>12) d 31/38 (53) 31/58 (53) e 26/43 (61) 5/15 (33) 5 (9%) VFD (4 transient, 1 persistent HH);
201444 and Drane 201545 ) 1/58 (2%) ICH with VFD; 1 (2%) operative
SDH (no deficit); 4 (7%) transient CN III or
IV palsies
Le 201846 30 V + ClearPoint/OR 18 (6-44) 18/29 (62) NR NR NR 1 (3%) VFD (SQ); 2 (7%) transient CN
palsies
Sprissler 201947 16 V + NR 14.5 (12-32) 7/16 (44) 7/16 (44) f 4/11 (36) f 2/5 (40) NR
Wu 201948 g 234 NR (multi-center) NR (12-75) 134/234 (58) 134/234 (58) NR NR 3 (1.3%) hemorrhage; 12 (5.1%) VFD; 10
(4.3%) worsened affective disorder; 1
(0.4%) death (SUDEP at 12 months
postop)
CN – cranial nerve; CRW – Cosman-Robert-Wells head frame; f/u – follow-up; HH – homonymous hemianopsia; ICH – intracerebral hemorrhage; IVH – intraventricular hemorrhage; Leksell – Leksell head frame;
MTS – mesial temporal sclerosis; NR – not reported; OR – laser fiber placed in operating room, not otherwise specified; SDH – subdural hematoma; SUDEP – sudden unexpected death in epilepsy; V – Visualase;
VFD – visual field deficit; yr – year.
a
Includes 2 patients with low-grade glioma.
b
Includes 1 patients with low-grade glioma.
c
A total of 12 patients underwent formal visual field testing: 2 had clinically significant HH, 3 had noticeable superior quadrantanopsia, and 3 had “silent” quadrantanopsia.
d
Three patients underwent repeat ablation.
e
One patient underwent repeat ablation.
f
Note, the number of seizure free patients in the subgroups (4 + 2) does not sum to the total number of seizure free (7).
g
Multicenter series including patients from Jermakowicz 2017,34 Youngerman 2018,35 and Le 2018.46

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YOUNGERMAN ET AL

TABLE 2. Hypothalamic Hamartoma

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F/u, months, Seizure freedom
median
Study N Seizure types LITT technique (range) Last F/u ≥1-Yr F/u Adverse Events

Lewis 201549 1 NR V + Leksell 4.5 0/1 (0) - None

Zubkov 201550 1 CPS NR 8 NGS: 0/1 (0) - Disabling amnestic syndrome
from bilateral mammillary body
damage (in the context of
previous right ATL for FCD)
Burrows 201651 3 GS V + Leksell 30 (28-32) GS: 1/2 (50) GS: 1/2 (50) 1 (33%) hyponatremia, weight
gain; 1 (33%) small tract
hemorrhage (no deficit)
Brandmeir 201652 1 GS V + ROSA 6 GS: 1/1 (100) - 1 (17%) transient hemiparesis;
1 (17%) unintentional weight loss
Rolston 201653 2 GS/TCS/CPS V + Leksell 6 (5-7) GS: 1/1 (100) - 1 (50%) transient hyperphagia
NGS: 1/1 (100) and amnesia
Buckley 201654 6 GS ± SPS/CPS/SGS V + CRW 9.7 (2-18) GS: 4/6 (67) GS: 1/3 (33) 3 (50%)transient neurological
NGS: 3/5 (60) NGS: 1/3 (33) symptoms (hemiparesis,
dysphasia, blurred vision);
1 (17%) intralesional hemorrhage
(no deficit)
Du 201755 8 GS/CPS/TC/SPS/RA V + NR 23.5 (7-30) GS: 3/3 (100) GS: 2/2 (100) 1 (13%) operative EDH; 1 (13%)
NGS: 4/5 (80) NGS: 3/3 (100) short-term memory loss
Wright 201856 1 GS NB + AXiiiS 24 GS: 1/1 (100) GS: 1/1 (100) None
Southwell 201857 5 GS/TCS/CPS/AS/NS V + ClearPoint 21 (7-45) GS: 2/4 (50) GS: 1/3 (33) 1 (20%) precocious puberty
NGS: 3/5 (60) NGS: 2/4 (50)
Xu 201858 18 GS/TCS/CPS V + HF 18.4 (7.9-28.6) GS: 12/15 (80) GS: 9/12 (75) 7 (39%) transient neurological
NGS: 5/9 (56) NGS: 5/9 (56) deficits (hemiparesis, facial
droop); 4 (22%) persistent
(3 leg/foot weakness, 1 Horner’s
syndrome) 2 (11%)
hypothyroidism 4 (22%)
short-term memory deficit
4 (22%) weight gain
Curry 201859 (incl. 71 GS ± NGS V/NB + CRW/ 12 (12) a GS: 66/71 (93) GS: 66/71 (93) 1 (1%) worsened DI; 1 (1%) severe
Curry 2012,26 ROSA/ClearPoint NGS: NR NG: NR short-term memory loss (in
Boerwinkle patient with previous right ATL);
201860 ) 3 (4.2%) transient hyponatremia;
4 (5.6%) delayed wound healing;
9 (12.7%) temporary increase in
gelastic seizures
Arocho-Quinones 1 GS/NS NR + Leksell 36 GS: 1/1 (100) GS: 1/1 (100) None
201961 NGS: 1/1 (100) NGS: 1/1 (100)

AS – absence seizures; ATL – anterior temporal lobectomy; AXiiiS – Monteris AXiiiS skull-mounted mini-frame; ClearPoint – ClearPoint skull-mounted stereotactic system; CPS –
complex partial seizure; CRW – Cosman-Robert-Wells stereotactic head frame; DI – diabetes insipidus; EDH – epidural hematoma; FCD – focal cortical dysplasia; f/u – follow-up; GS
– gelastic seizures; HF – head frame, unspecified; Leksell – Leksell stereotactic head frame; LITT – laser interstitial thermal therapy; NB – NeuroBlate laser ablation system; NGS –
nongelastic seizures; NR – not reported; NS – nocturnal seizures; RA – rage attacks; ROSA – ROSA robotic surgical assistant; SGS – secondary generalized seizures; SPS – simple partial
seizures; TCS – tonic-clonic seizures; V – Visualase laser ablation system.
a
A total of 23% of patients required more than 1 ablation; 25% had failed other surgical or radiosurgical interventions; 12% were seizure free off medication. A total of 21 patients “had
secondary seizures that were lessened by ablation and controlled with medicines.”

Immediate postablation diffusion-weighted (DWI), fluid-
attenuated inversion recovery (FLAIR), and/or contrast-enhanced
MR images confirm the maximal ablation distribution and
volume, which then decreases and stabilizes after 24 h.98 The laser
assembly and anchor bolt can be removed in the MRI holding
area, and the incision can be closed with a single suture or staple.
MESIAL TEMPORAL LOBE EPILEPSY (MTLE)
MTLE, in which seizures arise from the amygdalohip-
pocampus and adjacent structures, is the most common cause of
DRE,32 and selective laser amygdalohippocampotomy (SLAH)
is the most widely reported application of MRgLITT for

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 MRI-GUIDED LASER ABLATION FOR EPILEPSY

TABLE 3. Neocortical Epilepsy

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F/u, months, Engel I outcome, n (%)
iEEG LITT median
Study N (n) technique (range) Last F/u ≥1-Yr F/u Adverse events

Curry 201226 1 FCD 0/1 V + CRW 3 (3) 1/1 (100) - None

Lewis 201549 16 peds: 11 NR V + Leksell 15.8 (4-36) 7/16 (44) 4/11 (36) 1 inaccurate fiber placement
FCD, 4 TS, leading to IVH, aseptic meningitis,
1 RE and ventriculostomy; required
reoperation to complete ablation;
1 mechanical cooling malfunction
with broken and retained fiber; 1
post-ablation edema with steroid
induced gastritis
Devine 201662 1 FCD 1/1 NR 12 (12) 1/1 (100) 1/1 (100) None
Ellis 201663 1 FCDa 1/1 V + CRW 12 (12) 1/1 (100) 1/1 (100) None
Perry 201764 20 peds 14/20 V + Leksell/R 18.5 (7-39) 10/20 (50) 6/13 (46) 6 (30%) mild/transient
insulab : 3 OSA hemiparesis; 1 (5%) transient
FCD, 14 NL, expressive aphasiac
2 TS, 1 BFIP
Brown 201836 4 FCD; NR NR NR (NR); 2/4 (50); NR - NR
2 NL 3 (3) 1/2 (50)
Ross 201865 3 NL 3 V + ROSA 26 (20-44) 3/3 (100) 3/3 None
Marashly 201866 1 NL 1/1 V + Leksell 17 1/1 (100) 1/1 (100) None
Tovar-Spinoza 7 TS 0/7 V/NB + Leksell Mean 19.3 d 3/7 (43) NR None
201867 (4-49)
Hooten 201868 1 TS 0 NB + AXiiiS 6 0/1 (0) - None
(without head
fixation or
anchor bolt)
Kuo 201969 5 peds: 2 1/5 V + CRW NR (0-20) NR 1/1 (100) 1 (20%) EDH requiring evacuation
GG, 1 FCD,
1 gliosis,
1 RN
Cobourn 201970 4 peds: 2 4/4 V + Clear- 8 (5-16) 3/4 (75) 1/1 (100) None
FCD, 2 TS Point/ROSA
Alexander 201971 4 NL insula 4/4 V + ROSA Mean 3.4 (NR) 3/4 (75) - None
Hale 201972 14 total 14/14 NR 19 (12-38) 6/14 (43) 6/14 (43) 5 (36%) unilateral weakness;
insulab : 1 (7%) dysphagia; 1 (7%) facial
7 FCD 6 NL droop (all resolved within 3
1 TS months)c
Upadhyayula 1 NL 1/1 V + ROSA 23 0/1 0/1 None
201973
BFID – bilateral frontal insular polymicrogyria; CRW – Cosman-Robert-Wells head frame; EDH - epidural hematoma; FCD – focal cortical dysplasia; f/u – Follow-up; GG – ganglioglioma;
iEEG – intracranial EEG; IVH – intraventricular hemorrhage; Leksell – Leksell headframe; Monteris AXiiiS Stereotactic Miniframe (skull-mounted); NB – NeuroBlate (Monteris); NL –
nonlesional (normal MRI); NR – not reported; peds – pediatric; RE – Rasmussen’s encephalitis; RN – radiation necrosis; ROSA – ROSA Robotic Surgical Assistant; TS – tuberous sclerosis;
V – Visualase (Medtronic).
a
Patient underwent staged MRgLITT followed by resection for large frontal FCD.
b
All ablations involved in the insula cortex.
c
Formal language or neuropsychological testing not performed.
d
Results include final outcomes after 5 of 7 patients had repeat or staged ablations following persistent or recurrent seizures after a first ablation.

epilepsy. Most series report rates of seizure freedom below that
in the far more robust literature on open resection. Among
series with at least 1-yr follow-up in 10 or more patients,
rates of seizure freedom range from 36% to 62% (Table 1).
The largest series, including 234 patients from 11 centers,
reported 58% 1-yr Engel I outcome.48 By comparison, anterior
temporal lobectomy (ATL) reliably yields 60% to 80% seizure
freedom,99-102 including results from 2 class I trials.99,102
Two meta-analyses100,101 found that ATL and open selective
amygdalohippocampectomy (SAH), with relative sparing of the
lateral temporal neocortex, had pooled seizure freedom rates of
73% and 67%, respectively (follow-up at ≥1 yr). However, it

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YOUNGERMAN ET AL

TABLE 4. Other Epileptogenic Pathologies Treated With LITT

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Pathology/ LITT F/u, months, Engel I outcome, Adverse
Study N target iEEG (n) technique median (range) n (%) events

Esquenazi 2 PVNH 2/2 V + Leksell 10.5 (9-12) 0/2 (0) 0/1 (0) 1 VFD (HH)
201474
Clarke 201475 1 PVNH 1/1 V + Leksell 8 1/1 (100) - None
(bilateral)
Thompson 2 PVNH 2/2 NR 9 (6-12) a 2/2 (100) a 1/1 (100) None
201676
Cvetkovska 1 PVNH 1/1 NR 16 1/1 (100) 1/1 (100) None
201877
Brown 201836 3 PVNH NR NR NR 2/3 (67) - NR
Willie 201978 19 CM 1/19 V + CRW/ 32 (2-49) NR 14/17 (82) 1 VFD (SQ),
(incl. ClearPoint 1 transient
McCracken hand
201679 ) weakness,
1 perioral
sensory
disturbance
Hawasli 1 Post- 1/1 NB + AXiiiS 23 1/1 (100) 1/1 (100) Post-op
201480 (incl. stroke speech,
Hawasli (Insular) memory,
201381 ) emotional
difficulties
Bandt 201682 1 TE 0/1 NR 24 1/1 (100) 1/1 (100) None
and Kamath
201783
Ranjan 201984 2 TE 0/2 V + Stealth 12 (6-18) 2/2 (100) 1/1 (100) None
Ho 201685 1 CC 0/1 V + Stealth 4 DA: 1/1 (100) - None
Palma 201886 3 CC 0/3 V + CRW/ 39 (33-48) DA: 3/3 (100) DA: 3/3 (100) None
VarioGuide
Tao 201887 2 CC 0/2 V + CRW 12.5 (7-18) DA: 1/2 (50) DA: 1/2 (50) 1 transient
hypersomnia
Lehner 201888 5 CC 3/5 V + CRW 24 (1-24) DA: 4/5 (80) DA: 4/5 (80) 1 inaccurate
fibers
requiring
reoperation,
1 mild SMA
syndrome,
1 small ICH
Karsy 201989 1 CC NR NR 9 DA: 0/1 (0) DA: 0/1 (0) None
Ball 201990 1 CC NR NB + NR 5 DA: 1/1 (100) - None

AXiiiS – Monteris AXiiiS MiniFrame; CC – corpus callosotomy; CM – cavernous malformation; CRW – Cosman-Robert-Wells Headframe; DA – freedom from drop attacks (or atonic
seizures); f/u – follow-up; HH – homonymous hemianopsia; ICH – intracerebral hemorrhage; iEEG – intracranial EEG; Leksell – Leksell head frame; LITT – laser interstitial thermal
therapy; NB – NeuroBlate laser ablation system; NR – not reported; PVNH – periventricular nodular heterotopia; SMA – supplementary motor area; SQ – superior quadrantanopsia;
Stealth – Medtronic Stealth frameless navigation system; TE – temporal encephalocele; V – Visualase laser ablation system; VFD – visual field deficit.
a
One patient received combined temporal lobectomy and laser ablation of ipsilateral PVNH.

should be kept in mind that patients unwilling to consider open
surgery may be more amenable to a minimally invasive SLAH
approach and outcomes appear superior to continued medical
management.28,103
Compared with open resection, SLAH may better
preserve neurocognitive functions supported by the lateral
temporal neocortex and white matter, though there have
been no direct comparisons and many series do not report
formal testing. In several reports, SLAH largely preserved
naming and object recognition following language dominant
ablations,34,37-40,45,104,105 functions that commonly decline
following ATL or SAH.43,106-108 Verbal memory may decline
following dominant SLAH38-40 ; however, the risk appears to be
lower than with open surgery.16,30,31,43,104 Kang30 parsed out

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 MRI-GUIDED LASER ABLATION FOR EPILEPSY

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FIGURE 1. MRgLITT technique and mesial temporal laser ablation. A, Trajectory planning along the long axis of the amygdalohippocampal
complex for SLAH. B, Stereotactic placement of laser fiber assembly in the operating room. C, Intersecting orthogonal MRI slices are obtained
to allow the ablation to be monitored in 2 to 3 planes. D, Real-time MR thermometry. Low safety points (numbered) protect adjacent structures
and high safety points prevent excess heat at the catheter tip. The “irreversible damage zone” is calculated based on the cumulative effects of the
time-temperature history of each voxel and depicted as an overlay on anatomic images. After the desired ablation with the laser in its initial
position, the inner fiber is withdrawn from the outer catheter in 5 to 10 mm increments to complete 3 to 5 serial ablations along the trajectory. E,
Postoperative diffusion-weighted and contrast-enhanced T1 images confirm the anticipated ablations. Reprinted from Epilepsia, Youngerman
BE et al, Staged laser interstitial thermal therapy and topectomy for complete obliteration of complex focal cortical dysplasias, 59(3), 595-606,
Copyright 2018,35 with permission from Wiley Periodicals, Inc.  C 2018 International League Against Epilepsy.

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YOUNGERMAN ET AL
verbal memory changes and found a decline in noncontextual
(word list) verbal memory, which is localized to the mesial struc-
tures, but preservation of contextual (narrative) verbal memory,
which is supported by the temporal neocortex.
SLAH is also less invasive than open surgery, with patients
routinely discharged on the first postoperative day in many
reports. Serious neurological complications, such as hemiparesis,
and wound infections have not been reported and clinically signif-
icant hemorrhage is rare (Table 1). These complications occur
in 1% to 5% of open surgeries.109 The most common compli-
cation with SLAH is a visual field deficit (3%-9% in larger
series), typically a contralateral superior quadrantanopsia due to
posterolateral extension of the ablation into the optic radiations.
Most were transient or nondisabling, and rates appear compa-
rable to those following SAH (1.8%-10.3%), and lower than with
ATL (as high as 70% when specifically tested).109 Many centers
report using the superior and medial turn of the hippocampus
at the level of the quadrigeminal plate as a posterior limit to
avoid the optic radiations on the lateral aspect of the ventricle,
even if it means sparing the tail of the hippocampus.35,38,46
A more severe homonymous hemianopsia can result from superior
ablation spread into the lateral geniculate nucleus or optic tract
and has been reported in at least 5 cases. A handful of transient
third and fourth cranial nerve palsies have been reported following
SLAH30,35,43 and may result from a more medial anterior
trajectory, though these also occur with open surgery (∼5%109 ).
A transient increase in seizures during the first 2 wk following
SLAH has been reported.30,35,46
Several studies have attempted to define the ideal ablation and
trajectory for both seizure control and safety. Most centers use
a trajectory along the long axis of the amygdalohippocampus
from an occipital entry point (Figure 1).91,110 The laser fiber
can be incrementally pulled back to complete an ellipsoid
shape ablation along the length of the hippocampus. Retro-
spective imaging analysis suggests that ablations that prioritize the
amygdala and include the hippocampal head, parahippocampal
gryus, and rhinal cortex maximize the chances of seizures freedom,
whereas extending the ablation more posteriorly has diminishing
returns.48 Growing experience and computer-assisted planning
have the potential to optimize ablation volume and trajectories
for efficacy and safety.93
Ideal candidates for SLAH remain to be defined. As with
surgical resection,111-114 rates of seizure freedom have been
higher in those with imaging evidence of mesial temporal
sclerosis (MTS) in several series.33,37,43 However, MTS was not
a predictor of seizure freedom in the large multicenter series,
and similar outcomes have been achieved in carefully selected
patients with MRI negative MTLE,35,38 particularly when onsets
are localized to the amygdalohippocampus with stereoelectroen-
cephalography (SEEG).35 A prospective industry-sponsored
trial for FDA labeling in patients with radiographic MTS is
underway.115 However, in practice, many centers are already
offering SLAH as a first-line surgical option for MTLE. In
this treatment algorithm, open surgery is reserved for patients
with persistent seizures after one or more failed ablations,
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those who desire the highest chance of seizure freedom with
a single procedure, or those with more lateral involvement in
the EZ.28,30,103
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There are several alternative stereotactic approaches. RF-TC
produces smaller ablations with less-discrete heat drop-offs and
no ability to monitor temperature beyond the probe tip. A few
experienced centers10-12 have reported promising outcomes, but
seizure freedom appears lower and it has not been as readily
adopted as MRgLITT. Stereotactic radiosurgery (SRS) may
have a role for patients who cannot tolerate surgery, but rates of
seizure freedom have been similar, or below those with SLAH,
there is a latent period and possible temporary increase in seizure
frequency, and lesions appear less well demarcated (ie, radiation
does not contour to fluid in the ventricles and cisterns).116,117
Neuromodulation, such as Responsive Neurostimulation ((RNS)
NeuroPace, Inc., Mountain View, CA, USA), offers a nonde-
structive option when the risk of deficit is intolerable (ie,
bilateral or dominant MTLE with preserved function) but yields
primarily reductions in seizure frequency, with low rates of seizure
freedom.118
HYPOTHALAMIC HAMARTOMA (HH)
HHs are rare,119,120 non-neoplastic developmental malforma-
tions in the ventral hypothalamus that most commonly present
with medication-resistant gelastic seizures.59 HHs are deep-seated
lesions with numerous surrounding critical structures, making
them ideal targets for MRgLITT (Figure 2). Curry59 reported
93% 1-yr gelastic seizure freedom, with minimal side effects,
in a large series of 71 patients. Of note, 25% of these patients
had failed other surgical or radiosurgical intervention. Based
primarily on this single-center experience, MRgLITT potentially
offers improved safety and efficacy. Open or endoscopic resection
using transcallosal and skull-base approaches only achieves 20%
to 54% seizure freedom55,121-123 and has relatively high rates of
serious complications including transient hemiparesis (2%-30%),
hormonal disturbances (8%-57%), weight gain (11%-59%),
long-term memory impairment (8%-43%), optic tract injury
(3%-10%), stroke (15%-31%), and death (0%-20%).122-124
MRgLITT for HH is not without risks, and it is not clear
if the results from Curry59 are generalizable to less-experienced
centers for this rare indication. Most other reports include only a
handful of patients with 1-yr follow-up and have less-favorable
seizure freedom and safety outcomes (Table 2). Some smaller
series have reported rates of transient neurologic deficits as high
as 39% to 50%.54,58 There have been 2 reports of disabling
amnestic syndromes due to bilateral mammillary body damage in
patients with likely prior unilateral injury from ATL.50,59 Setting
low thermal limits on critical surrounding structures such as the
mamillothalamic tract, cerebral peduncles, and fornix may help
avoid unintended damage. Most centers used the smaller diameter
Visualase system, but there is at least one report in which the
NeuroBlate side-fire probe was particularly helpful to disconnect
a primarily intraventricular HH.56
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FIGURE 2. HH. A, Preoperative T1 MRI demonstrating left HH. B, T2 orthogonal MRI demonstrating laser fiber trajectory. C, Postoperative T2 MRI demonstrating
completed ablation.
Few side effects have been reported with SRS, but seizure
freedom ranges from 37% to 60%, and treatment effect is delayed
by several months.55,125,126 RF-TC shares some of the benefits
of MRgLITT in terms of accessing HH, but it is not possible to
accurately monitor the extent of ablation or off-target effects. One
large series reported slightly lower rates of freedom from gelastic
and all seizures (86% and 71%, respectively), with more of the
complications seen with open surgery.13
FOCAL CORTICAL DYSPLASIA (FCD) AND
NONLESIONAL EXTRATEMPORAL EPILEPSY
FCD is a common source of refractory, focal, neocortical
epilepsy that begins in childhood. Surgical resection achieves 50%
to 70% seizure freedom.127-129 However, resectability and adverse
outcomes vary with the architecture of the dysplastic tissue,
eloquence of surrounding brain, and surgical accessibility.130
Early series of MRgLITT report approximately 50% seizure
freedom, though rates are slightly lower in the few reports with
at least 1-yr follow-up (Table 3). Notably, these series treated
FCD in locations that can be difficult to access safely with open
surgery, such as the insula and depth of sulcus, with infrequent
or transient complications, though formal neurocognitive testing
was rarely reported. The series by Perry64 and Hale72 included all
pediatric patients with insular involvement and many who had
failed prior resections, reporting promising safety and efficacy.
Kuo69 reported 5 ablations near eloquent cortex without deficits,
and Devine62 targeted FCD at the sulcal depth anterior to the
precentral gyrus without motor deficit. MRgLITT may also have
a role in the treatment of large, complex FCD. Ellis63 reported
MRgLITT to approach the posterior medial basal component of
a large frontal FCD (Figure 3). After staged resection of the more
superficial portion, the patient achieved seizure freedom.
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Intracranial monitoring was frequently used to define the EZ,
especially with normal appearing MRIs, as occurs in approxi-
mately a third of patients with FCD.131 SEEG, in particular,
is useful for sampling from the difficult to access areas ideally
suited for MRgLITT. Both Perry64 and Hale72 reported similar
rates of seizure freedom, approximately 50%, for nonlesional
(NL) and lesional epilepsy. Ross65 described 3 patients with NL
extratemporal epilepsy whose seizures were localized with SEEG
to small (<2 cm3 ) and difficult to access areas (mesial frontal,
orbitofrontal/anterior insula, and posterior insula). Electrical
stimulation elicited the patients’ habitual seizures. After removal
of the electrodes, the patients underwent MRgLITT using the
previous robot-assisted trajectories to the stereotactic location of
epileptogenic contacts. All patients were seizure free between 20
and 44 mo follow-up. Marathly66 and Upadhyayula73 reported
similar SEEG-guided ablation in the cingulate gyrus, including a
multifiber complex ablation in the latter case.
The treatment of FCD is an evolving field with growing use of
high-field, high-resolution MRI to identify previously not visible
dysplasia. RF-TC has been reported in limited series for primarily
small lesions and can be performed via existing SEEG electrodes,
but rates of seizure freedom are low (approximately 18%),12 and it
is not possible to contour ablations to larger, more complex lesions
or monitor temperature in nearby eloquent cortex. SRS has been
used for lesions in eloquent or difficult to access cortex with a
favorable adverse event profile but relatively low rates of seizure
freedom (33% in one series132 ). RNS is also employed primarily
for seizure reduction in insula133 and eloquent cortex onsets.134
TUBEROUS SCLEROSIS (TS)
TS is an inherited disease causing abnormal noncancerous
growths throughout the brain and body. Seizures affect almost
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YOUNGERMAN ET AL
FIGURE 3. FCD. Preoperative axial T1 A and coronal T2 B MRI demonstrating a posterior basal frontal FCD (arrows) as later confirmed by pathology from a staged
surgical resection. C, Postoperative T1 gadolinium enhanced MRI demonstrating the completed ablation. Panel C reprinted from Journal of Clinical Neuroscience,
31, Ellis JA et al, Staged laser interstitial thermal therapy and topectomy for complete obliteration of complex focal cortical dysplasias, 224-228, Copyright 2016,63
with permission from Elsevier.
90% of children with TS,135 and only a third achieve control with
medication.136 Epileptogenic tubers are often multifocal and can
be in deep locations, making open surgery challenging. In a large
multicenter series, rates of seizure freedom following resection
were 65% at 1 yr and 50% at 2 yr, though this does not reflect
the many patients who are not surgical candidates.137
MRgLITT may have a role for deep or difficult to access tubers,
but experience is limited (Table 3). Tovar-Spinoza67 and Lewis49
reported preliminary seizure freedom in 3 of 7 and 2 of 5 patients
with TSC, respectively, but 1-yr outcomes were not available. One
patient developed postablation edema. The pediatric insular series
by Perry64 and Hale72 reported seizure freedom past 1-yr in 2 of
3 patients with TS. It should be noted that the EZ often includes
the perituberal surrounding area,137 and successful ablations may
need to include this area.
PERIVENTRICULAR NODULAR HETEROTOPIA
(PVNH)
PVNH is caused by abnormal migration of neurons during
development leading to clusters of ectopic gray matter along
ventricle walls associated with DRE.138 Nodules are deep to
frequently uninvolved white matter and cortex, making it
challenging to treat surgically, particularly in cases of bilateral or
multifocal disease.
MRgLITT has shown promising early results for PVNH in
the first few cases reported (Table 4), though defining the extent
of the EZ with SEEG appears critical, and more extensive
ablations or resections may be needed. In 1 case, ablation
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of a small SEEG-confirmed heterotopia near the head of the
caudate led to seizure freedom after medication changes,74 and
in another, bilateral SEEG-guided ablations achieved prelim-
inary (8-mo) seizure freedom.75 However, PVNH is frequently
part of a larger epileptogenic network.139 Seizure freedom has
been achieved when the ablation included overlying polymi-
crogyria (n = 1)76 , white matter micronodules,77 or adjacent
MTLE (n = 2)35 (Figure 4). Two patients who underwent PVNH
ablations ultimately achieved seizure freedom after subsequent
ATL,74,76 and 2 patients with multifocal epilepsy who underwent
palliative MRgLITT of PVNH and RNS at separate sites had
significant reductions in seizure frequency.36
MRgLITT requires significantly less disruption of overlying
white matter and cortex than open surgery, but there has
been at least one report of transient homonymous hemianopsia
following a complex, multifiber PVNH ablation near geniculo-
calcarine fibers.74 Other small case series describe SRS and RF-
TC targeting PVNH.12,139,140 Though numbers are too small
for meaningful comparison, MRgLITT maintains theoretical
advantages of immediate treatment effect and monitored ablation
volume.
CEREBRAL CAVERNOUS MALFORMATIONS
(CCM)
CCMs are vascular lesions characterized by abnormal, disor-
ganized capillaries that present most commonly with seizures.
Surgical resection is associated with high rates of seizure
freedom (75%-80%).141,142 MRgLITT may offer a less invasive
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FIGURE 4. PVNH. A, Preoperative T1 MRI demonstrating bilateral temporo-occipital PVNH. B, Postoperative T1 gadolinium
enhanced MRI demonstrating laser ablation of mesial temporal lobe and adjacent PVNH with 2 fiber trajectories. C, Ablation of PVNH.
D, Ablation of mesial temporal lobe.

option, particularly for CCMs that are deep to eloquent cortex
(Figure 5). Willie78 reported MRgLITT in 19 patients with
CCMs, including deep medial and basal temporal lesions. 14
of 17 patients (82.4%) with over 1-yr follow-up had Engel I
outcomes. Two patients achieved seizure freedom after subse-
quent open resection. There were no hemorrhagic complications.
Two patients developed neurologic deficits (1 nondebilitating
superior quadrantanopia and 1 transient intrinsic hand motor
weakness), both of which were predictable based on the location
of the lesions.
POSTSTROKE EPILEPSY
MRgLITT may play a role in poststroke epilepsy, a leading
cause of seizures in older patients. Hawasli80 reported a patient
with gliosis in the frontal-insular region confirmed to be the

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YOUNGERMAN ET AL
FIGURE 5. Cavernous malformation. A, Preoperative T1 MRI demonstrating left parahippocampal gryus cavernous malformation. B, MR thermometry. C,
Cumulative damage estimate.
seizure focus with invasive monitoring. He underwent MRgLITT
with 2 lesions in the anterior and posterior insular cortex. Postop-
eratively, he remained seizure free at 23 mo, though he did
experience mild worsening of baseline impairments in speech and
memory.
TEMPORAL ENCEPHALOCELE
A temporal encephalocele is a herniation of temporal lobe
parenchyma through the skull base and is a rare, but under-
recognized, cause of surgically treatable temporal lobe epilepsy.143
Treatment varies from focal resection or disconnection to ATL,
all of which yield high rates of seizure freedom.143,144 MRgLITT
for local disconnection and tailored cortical ablation has been
reported in at least 3 cases with seizure freedom (Table 4).82-84
LASER CORPUS CALLOSOTOMY
Corpus callosotomy (CC) is an effective palliative procedure
that aims to prevent seizure spread between the 2 hemispheres
rather than remove the EZ.86,145 It is most often used to treat
atonic seizures, or drop attacks, which are highly refractory,
but is also used to prevent generalization of other seizure
types.146 In a recent meta-analysis, 58% of patients achieved
freedom from atonic seizures following CC.147 Anterior two-
thirds callosotomy is often effective while minimizing neuro-
logical deficits. Complete callosotomy, including the splenium,
confers an estimated 10% additional improvement in seizure
control; however, morbidity, especially disconnection syndrome,
is significantly more likely and many reserve it for recurrence.146
Several reports86,88-90,87 (Table 4) describe patients who
underwent primary anterior callosotomy using 1 to 3 fiber
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trajectories, with most experiencing resolution of drop attacks
and many having significant reductions in disabling seizures
(Figure 6). One patient with partial agenesis of the corpus
callosum underwent complete callosotomy with resolution of
drop attacks.88 Larger series are needed to determine if there
is benefit over open or endoscopic anterior callosotomy, which
requires an interhemispheric approach and has reported compli-
cation rates between 12% and 21%.148-150
MRgLITT may also be used to complete the callosotomy
in patients who have persistent seizures after prior surgery. Ho
described laser ablation of the splenium as a salvage procedure
for a patient who failed previous open anterior CC.85 Similarly,
2 of the patients in Palma underwent ablation of residual intact
splenium after prior hemispherectomy.86 Given that reoperation
and dissection of a scarred interhemispheric fissure is technically
challenging and associated with a higher risk of surgical compli-
cations, MRgLITT may be especially useful in these scenarios.
CONCLUSION
MRgLITT is an increasingly popular surgical option for DRE.
It provides minimally invasive access to make immediate, well-
demarcated lesions of the EZ virtually anywhere in the brain
with minimal disruption to overlying white matter and cortex
and real-time thermal monitoring. Compared to open surgery,
most reports note significantly less pain and shorter length of
stay. Although more evidence of safety and longer-term efficacy
is needed, many surgeons are offering MRgLITT as a first-line
surgical option for a variety of indications, particularly when
targets are in deep or difficult to access locations. Rates of
seizure freedom are likely lower than with surgical resection for
some indications, such as MTLE and extensive FCD, but this
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FIGURE 6. Laser callosotomy. Postoperative MRI demonstrating the 2 laser fiber trajectory technique to an anterior laser corpus callosotomy. A, Frontal entry
targeting the rostrum and genu. B, Parietal entry targeting the body and remaining genu. Reproduced from Journal of Neurology, Neurosurgery and Psychiatry,
Tao JX et al, 89, 542-548, Copyright 2018,37 with permission from BMJ Publishing Group Ltd.
must be weighed against potential neurocognitive side effects and
morbidity with open surgery. MRgLITT does not preclude the
option of subsequent more extensive ablations or open surgery.
The combination of SEEG and MRgLITT is also offering a
surgical option to patients who are unwilling to consider a
more invasive approach and would otherwise be unlikely to
achieve seizure freedom with medical management. Safety and
efficacy may improve as ideal trajectories and ablation volumes are
defined, but the long-term outcomes must be compared against
proven surgical resection techniques, as well as other rapidly
advancing stereotactic and neuromodulation options.
Disclosures
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
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Supplemental digital content is available for this article at www.neurosurgery-
online.com.
Supplemental Digital Content. Methods. Systematic review methodology
and PRISMA flow diagram. The supplemental digital content expands on the
systematic review methods. Figure, PRISMA flow diagram.
COMMENT
R eal-time MRI guided laser ablation is being increasingly utilized for
the treatment of multiple intracranial pathologies such as metastatic
or recurrent primary lesions, cavernous malformations, radiation necrosis
and lesional epileptic foci. Initially utilized in France in 2006 for the
treatment of metastatic tumors, it has subsequently had broadened
utility and global presence. Epileptogenic areas, including tubers
(in tuberous sclerosis), mesial temporal sclerosis (via selective laser
amygdalohippocampotomy), cavernous malformations, as well as focal
cortical dysplasias and hamartoma, have been successfully treated. There
www.neurosurgery-online.com
 MRI-GUIDED LASER ABLATION FOR EPILEPSY

are many characteristics associated with this approach including the the safety profile, the precise role of this therapeutic modality is still under
small cranial access to accommodate the narrow ablation catheter, short investigation. I congratulate the authors for this important contribution,
operative time and short post-operative recovery that have all been touted hoping that further studies will continue to clarify the indications of laser

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as contributing the minimal invasive nature of this approach when therapy in patients with medially refractory epilepsy.
compared against open surgery. In this literature review, the authors
provided a broad perspective related to historical development, surgical
technique for real-time MRI guided ablations for epilepsy. Although Jorge Gonzalez-Martinez
results are promising and clearly expressing some advantages related to Pittsburgh, Pennsylvania

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