Duke Health has emerged as a leader in providing Laser Interstitial Thermal Therapy (LITT), or laser ablation, to achieve seizure control in children under two years of age with medically refractory epilepsy. Pediatric neurosurgeon Gerald A. Grant, MD, and team published cases demonstrating Duke’s experience with this minimally invasive procedure, which expands access to the treatment for children under two years of age. 

“Historically, LITT approaches were not routinely used in the youngest patients, but we developed methods demonstrating safe and effective benefits for very young children,” says Grant. He adds that early intervention can have long-term benefits for a child’s growth and development, and spare very young patients from much larger open surgeries later in life. Grant and his team work closely with pediatric epilepsy colleagues, led by Muhammad Zafar, MD, and discuss patient cases weekly with the multidisciplinary team to determine candidacy for a LITT procedure.

Duke's epilepsy surgery volume has continued to grow substantially over the last five years, with additional growth among adult populations performed by Derek Southwell, MD, PhD.

LITT is a minimally invasive surgical technique that uses a focused laser to target the specific brain tissue responsible for seizures. Because it avoids large, open-skull resections, LITT results in a shorter recovery time and a lower risk profile compared to traditional open brain surgery. 

LITT requires only a small incision and minimal bony opening. If laser ablation does not result in seizure freedom, these children can still get open surgery down the road or undergo additional LITT procedures until they are seizure-free. 

Expanding LITT for younger children has additional long-term benefits. Because prolonged seizure activity is a progressive condition, the seizure network grows stronger and becomes harder to treat with each seizure. Grant notes that cognitive development is also at risk, so we try to intervene earlier and earlier to maximize neurodevelopment. 

“Children with epilepsy frequently experience ADHD, anxiety, and learning disabilities. Reducing seizures leads to dramatic improvements in developmental trajectory and school performance, but the window for optimal benefit is limited,” he says.

LITT is considered for medically refractory patients, after medications have failed to control seizures. It is best suited for cases where imaging and EEG reveal a clearly defined seizure focus. Typical candidates include patients with temporal lobe epilepsy originating in the amygdala or hippocampus, as well as children with focal cortical dysplasia or targeting tubers in children with tuberous sclerosis. 

The therapy has limitations with targeting larger areas. “If seizure activity is originating from an entire brain hemisphere, laser ablation is not appropriate,” says Grant. However, if there is more than one hotspot, we might laser up to three areas at the same sitting.

“It is never too early to refer or to start a conversation about the treatment of seizures which are refractory to medication,” says Zafar. Any pediatric epilepsy patient whose seizures are not controlled by medications is an appropriate referral. After a child has failed two anti-seizure medications and is considered medically refractory, the likelihood of achieving seizure freedom with additional drug trials falls below 5%.

Duke's epilepsy surgery team meets weekly in a multidisciplinary conference to review each case in detail. Neurologists confirm medication failure and then present candidates to the team of specialists, which includes neurosurgery, neuroradiology, and neuropsychology. After a thorough case discussion for each child, the team will meet with the patient and family to review treatment options. 

If LITT is not the right fit, the team has a broader toolkit of surgical and neuromodulation options and can personalize recommendations to the child's specific epilepsy type. “Even if LITT is not ultimately the best choice, a comprehensive evaluation will help identify the optimal path to seizure control,” says Grant. 

“Treating children with epilepsy is one of the most gratifying surgeries I do,” says Grant. “Making a child free of seizures is a life-changing event. There is hard work and sacrifice during the several-month journey of the child and family to reach the goal of seizure freedom, but it is well worth the smile on the child’s face to be seizure-free.”