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

Evidence-based recommendations on MRI-guided laser interstitial thermal therapy for drug-resistant epilepsy in adults and children. This involves inserting a laser into the area of the brain causing seizures.

# Recommendations
Evidence on the safety of MRI-guided laser interstitial thermal therapy for drug-resistant epilepsy shows there are serious but well-recognised safety concerns. Evidence on its efficacy is limited in quality. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wishing to do MRI-guided laser interstitial thermal therapy for drug-resistant epilepsy should:
Inform the clinical governance leads in their NHS trusts.
Give patients and their parents or carers clear written information to support shared decision making, including NICE's information for the public.
Ensure that patients and their parents or carers understand the procedure's safety and efficacy, as well as any uncertainties about these.
Audit and review clinical outcomes of all patients having the procedure. NICE has identified relevant audit criteria and developed an audit tool (which is for use at local discretion).
Patient selection should be done by a multidisciplinary team experienced in managing drug-resistant epilepsy. This may include a neurologist, neurosurgeon, neurophysiologist, neuroradiologist and psychiatrist.
The procedure should only be done in specialist centres by clinicians with experience and specific training.
Further research could be in the form of randomised controlled trials, large case series or collaborative registries. It should report details of patient selection, including the size and site of the lesions being created, patient-reported outcomes and long-term follow up, particularly neurodevelopmental outcomes in children.# The condition, current treatments and procedure

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

# Current treatments
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).

# The procedure
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 46C to 60C) 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.