Magnetic resonance imaging–guided stereotactic laser ablation therapy for the treatment of pediatric epilepsy: a retrospective multiinstitutional study
Authors: Arocho-Quinones Elsa V. , Lew Sean M. , Handler Michael H. , Tovar-Spinoza Zulma , Smyth Matthew D. , Bollo Robert J. , Donahue David , Perry M. Scott , Levy Michael , Gonda David , Mangano Francesco T. , Kennedy Benjamin C. , Storm Phillip B. , Price Angela V. , Couture Daniel E. , Oluigbo Chima , Duhaime Ann-Christine , Barnett Gene H. , Muh Carrie R. , Sather Michael D. , Fallah Aria , Wang Anthony C. , Bhatia Sanjiv , Eastwood Daniel , Tarima Sergey , Graber Sarah , Huckins Sean , Hafez Daniel , Rumalla Kavelin , Bailey Laurie , Shandley Sabrina , Roach Ashton , Alexander Erin , Jenkins Wendy , Tsering Deki , Price George , Meola Antonio , Evanoff Wendi , Thompson Eric M. , Brandmeir Nicholas , _ _ 
Published: March 2023

OBJECTIVE
The authors of this study evaluated the safety and efficacy of stereotactic laser ablation (SLA) for the treatment of drug-resistant epilepsy (DRE) in children.

METHODS
Seventeen North American centers were enrolled in the study. Data for pediatric patients with DRE who had been treated with SLA between 2008 and 2018 were retrospectively reviewed.

RESULTS
A total of 225 patients, mean age 12.8 ± 5.8 years, were identified. Target-of-interest (TOI) locations included extratemporal (44.4%), temporal neocortical (8.4%), mesiotemporal (23.1%), hypothalamic (14.2%), and callosal (9.8%). Visualase and NeuroBlate SLA systems were used in 199 and 26 cases, respectively. Procedure goals included ablation (149 cases), disconnection (63), or both (13). The mean follow-up was 27 ± 20.4 months. Improvement in targeted seizure type (TST) was seen in 179 (84.0%) patients. Engel classification was reported for 167 (74.2%) patients; excluding the palliative cases, 74 (49.7%), 35 (23.5%), 10 (6.7%), and 30 (20.1%) patients had Engel class I, II, III, and IV outcomes, respectively. For patients with a follow-up ≥ 12 months, 25 (51.0%), 18 (36.7%), 3 (6.1%), and 3 (6.1%) had Engel class I, II, III, and IV outcomes, respectively. Patients with a history of pre-SLA surgery related to the TOI, a pathology of malformation of cortical development, and 2+ trajectories per TOI were more likely to experience no improvement in seizure frequency and/or to have an unfavorable outcome. A greater number of smaller thermal lesions was associated with greater improvement in TST.
Thirty (13.3%) patients experienced 51 short-term complications including malpositioned catheter (3 cases), intracranial hemorrhage (2), transient neurological deficit (19), permanent neurological deficit (3), symptomatic perilesional edema (6), hydrocephalus (1), CSF leakage (1), wound infection (2), unplanned ICU stay (5), and unplanned 30-day readmission (9). The relative incidence of complications was higher in the hypothalamic target location. Target volume, number of laser trajectories, number or size of thermal lesions, or use of perioperative steroids did not have a significant effect on short-term complications.

CONCLUSIONS
SLA appears to be an effective and well-tolerated treatment option for children with DRE. Large-volume prospective studies are needed to better understand the indications for treatment and demonstrate the long-term efficacy of SLA in this population.