Long-term Outcomes of Laser Ablation Therapy for Drug-Resistant Epilepsy
NYP features Dr. Brett Youngerman's Innovative Alternative to Open Surgery
NewYork-Presbyterian has long been a leader in the development of laser ablation techniques to eliminate dysfunctional or diseased brain tissue. Building on that history, Brett Youngerman, MD, a neurosurgeon at NewYork-Presbyterian/Columbia, is actively exploring the efficacy of laser ablation in treating drug-resistant epilepsy.
“At NewYork-Presbyterian, we’re at the forefront of developing laser ablation techniques and technology, and we are one of the most experienced centers with laser ablation,” says Dr. Youngerman. “We're using that experience to constantly improve the technique, both by learning who are the best candidates for the procedure and how to best carry out the procedure technically.”
Patients with drug-resistant epilepsy have less than a three percent chance of seizure freedom with medications alone. This puts them at risk of significant morbidity and mortality that includes injuries and direct consequences of seizures, and long-term adverse effects on their mood, cognition, and psychological status. They are also at risk of Sudden Unexpected Death in Epilepsy (SUDEP).
All patients with drug-resistant epilepsy should be evaluated for surgery. The specific surgical intervention required depends on the location in the brain where the seizures originate. The most common location is the temporal lobe, where the gold standard treatment is anterior temporal lobectomy. Surgery offers a better chance of seizure freedom than medications alone and is generally well tolerated. Despite this, epilepsy surgery is underused.
“Surgical removal of the area of the brain that’s causing the seizures is actually very well tolerated, and it has a much better chance of seizure freedom,” says Dr. Youngerman. “Patients have improved cognitive function and quality of life after successful surgery. But for many patients, the idea of undergoing an open brain surgery and removal of part of the brain with surgery is still very unappealing and is a barrier to many patients considering a surgical procedure.”
Pursuing Alternatives to Open Surgery
Magnetic resonance image-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive alternative to open surgery. Unlike open surgery, this technique enables clinicians to access deep structures of the brain with minimal disruption to the overlying cortex and white matter. “We are actually able to ablate that area while the temperature is monitored in real time with the MRI,” says Dr. Youngerman. “We’re able to prevent overheating and minimize risk of injury to the surrounding structures while focusing on removing the area that we believe the seizures are originating from.”
This approach may appeal to patients as it is performed through a less than one-centimeter incision, is associated with minimal pain, and enables most patients to return home the next day. However, only small single-center studies had analyzed the seizure freedom rate with MRgLITT, reporting variable results, and long-term durability remained largely unknown.
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(L) MR thermography allows for monitoring of the ablation temperature to protect the surrounding critical structures from injury. Multiple ablations along the laser fiber trajectory allow for removal of the target areas. (R) A post-procedure MRI demonstrates the completed desired ablation of the epileptogenic focus.
