LITT vs Surgery mTLE Meta-Analysis
Neuropsychological outcomes comparing traditional surgical approaches and laser interstitial thermal therapy for refractory mesial temporal lobe epilepsy: A systematic review and meta-analysis
Clinical Question
Does MRgLITT preserve cognitive function—especially naming and verbal memory—better than traditional open resection in patients with drug-resistant mesial temporal lobe epilepsy?
Study Overview
Objective
To compare neuropsychological outcomes—verbal memory, visual memory, and naming—following traditional open surgical approaches (ATL/SAHE) versus MRgLITT in adults with drug-resistant mesial temporal lobe epilepsy, stratified by surgical laterality.
Study Summary
- Left-sided naming decline was significantly lower with MRgLITT (9%, 95% CI 3%–22%) than open resection (43%, 95% CI 27%–61%; p < .0001), with MRgLITT retaining a protective effect after adjusting for seizure outcomes (β = −1.36, 95% CI −2.20 to −0.51; p = .0016)
- Left-sided verbal memory decline showed a nonsignificant trend favoring MRgLITT (29%, 95% CI 9%–62%) over open resection (36%, 95% CI 28%–45%; p = .5967)
- Right-sided visual memory decline was comparable between MRgLITT (19%, 95% CI 3%–61%) and open resection (16%, 95% CI 8%–29%; p = .8027)
- Naming improvement occurred in 27% of patients in each group after right-sided surgery; higher seizure freedom rates showed a borderline association with greater naming decline (p = .0508)
Intervention
Systematic review and meta-analysis comparing open resection (anterior temporal lobectomy [ATL] or selective amygdalohippocampectomy [SAHE]) versus MR-guided laser interstitial thermal therapy (MRgLITT) for drug-resistant mesial temporal lobe epilepsy; 34 studies included, searched through June 15, 2025
Patients per Arm
Not reported in available source text
Bottom Line
MRgLITT offers a significant and clinically meaningful advantage over open resection for preserving naming after left-sided mTLE surgery, independent of seizure outcomes; verbal and visual memory outcomes are comparable across approaches, and clinicians should weigh the naming benefit against MRgLITT's modestly lower seizure freedom rates when counseling patients.
Major Points
- MRgLITT significantly preserved naming after left-sided surgery compared to open resection (9% vs 43% decline; p < .0001), with the advantage persisting after meta-regression adjustment for seizure freedom rates (β = −1.36, 95% CI −2.20 to −0.51; p = .0016)
- Left-sided verbal memory decline showed a nonsignificant trend favoring MRgLITT (29% vs 36%; p = .5967), consistent with better but not statistically superior preservation
- Right-sided visual memory decline was statistically equivalent between MRgLITT (19%) and open resection (16%; p = .8027)
- Naming improvement after right-sided surgery occurred in 27% of patients in both groups, reflecting substantial cognitive recovery when the dominant hemisphere is preserved regardless of approach
- An exploratory meta-regression identified a borderline association between higher seizure freedom and greater naming decline (p = .0508), suggesting a potential efficacy–language trade-off that warrants individualized counseling
- MRgLITT's naming benefit is independent of seizure outcomes, supporting its use as the preferred approach when language preservation is a priority in left-sided mTLE
Design
Study Type: Systematic Review and Meta-Analysis
Randomization:
Enrollment Period: Studies published up to June 15, 2025; databases searched: MEDLINE/PubMed, Embase, Scopus
Follow-up Duration: Minimum 6 months postoperatively; 12-month data prioritized where available
Centers: 0
Countries:
Sample Size: 34
Analyzed: 34
Analysis: Random-effects model with logit transformation (metaprop, R meta package); meta-analyses of proportions stratified by intervention and laterality; subgroup comparisons with χ² test for interaction; mixed-effects meta-regressions (metafor package, rma); Hartung-Knapp adjustment for 95% CIs; heterogeneity quantified with τ² and I²; PRISMA 2020 guidelines
Registration: PROSPERO CRD420251114728
Inclusion Criteria
- Original, peer-reviewed publications in English
- Adults ≥16 years with drug-resistant mesial temporal lobe epilepsy
- Underwent open resection (ATL or SAHE) or MRgLITT
- Reported proportion of patients with decline or improvement in ≥1 cognitive domain (verbal memory, visual memory, or naming)
- Outcomes stratified by surgical laterality
- Used validated methods for cognitive change: Reliable Change Index, standardized regression-based approaches, or study-defined thresholds (e.g., ≥1 SD change)
- Minimum postoperative follow-up of 6 months
- For overlapping cohorts from the same institution, only the most comprehensive report included
Exclusion Criteria
- Non-original or non-peer reviewed studies (case reports, reviews, editorials, conference abstracts)
- Sample size <5
- Pediatric-only populations (<16 years) without separately reported adult data
- Overlapping cohorts without distinguishable data based on institutional affiliation and recruitment periods
- Lacking laterality-specific neuropsychological outcomes
- Studies limited to non-resective or palliative procedures (vagus nerve stimulation, corpus callosotomy, responsive neurostimulation)
- Studies in which patients were treated with radiofrequency thermocoagulation
Arms
| Field | Control | MRgLITT |
|---|---|---|
| N | 0 | 0 |
| Intervention | Anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SAHE); 24 studies reported outcomes for open resection only and 3 studies reported outcomes for both procedures (27 total study contributions) | MR-guided laser interstitial thermal therapy (MRgLITT); 7 studies reported outcomes for MRgLITT only and 3 studies reported outcomes for both procedures (10 total study contributions) |
| Duration |
Outcomes
| Outcome | Type | Control | Intervention | HR / OR / RR | P-value |
|---|---|---|---|---|---|
| Proportion of patients with cognitive decline or improvement in verbal memory (left-sided surgery), visual memory (right-sided surgery), and naming (left-sided surgery), compared between open resection and MRgLITT | Primary | Open resection — naming decline (left): 43% (95% CI 27%–61%); verbal memory decline (left): 36% (95% CI 28%–45%); visual memory decline (right): 16% (95% CI 8%–29%) | MRgLITT — naming decline (left): 9% (95% CI 3%–22%); verbal memory decline (left): 29% (95% CI 9%–62%); visual memory decline (right): 19% (95% CI 3%–61%) | Naming (left), meta-regression: MRgLITT β = −1.36 (protective effect vs open resection, adjusted for seizure freedom) | Naming (left): p < .0001; verbal memory (left): p = .5967; visual memory (right): p = .8027; meta-regression (naming, adjusted): p = .0016 |
| Naming improvement after right-sided surgery: 27% in both MRgLITT and open resection groups | Secondary | ||||
| Exploratory meta-regression: borderline association between higher seizure freedom rates and greater naming decline (p = .0508) | Secondary | ||||
| MRgLITT retained independent protective effect on naming after adjusting for seizure freedom (β = −1.36, 95% CI −2.20 to −0.51; p = .0016) | Secondary | ||||
| Subgroup analysis of ATL vs MRgLITT for verbal memory, visual memory, and naming | Secondary | ||||
| Subgroup analysis of SAHE vs MRgLITT for verbal memory (insufficient data for other domains) | Secondary | ||||
| Subgroup analysis in studies reporting outcomes by language dominance rather than laterality | Secondary | ||||
Subgroup Analysis
Subgroup meta-analyses compared open resection vs MRgLITT for three domain–laterality pairings: verbal memory decline (left), visual memory decline (right), and naming decline (left). ATL vs MRgLITT subgroups conducted for all three domains; SAHE vs MRgLITT feasible for verbal memory only. Language dominance-based subgroup conducted separately. Subgroup differences tested with χ² test for interaction.
Criticisms
- Wide confidence intervals for MRgLITT outcomes (visual memory 3%–61%; verbal memory 9%–62%) reflect the small number of MRgLITT studies (n=10) and limited sample sizes, limiting precision
- High between-study heterogeneity likely present given variability in surgical extent, cognitive test batteries, and definitions of 'decline' across included studies
- Retrospective, observational design of all included studies precludes causal inference and introduces potential selection bias
- Patients selected for MRgLITT may systematically differ from open resection candidates in unmeasured ways (e.g., lesion volume, comorbidities), confounding comparative estimates
- Seizure freedom data were not uniformly available across studies, limiting the power of the seizure–cognition meta-regression
- Stereoelectroencephalographic confirmation data were rarely reported, precluding planned subgroup analyses on this variable
- Cognitive assessment instruments varied across studies; pooling proportions across heterogeneous tools may obscure domain-specific differences
Based on: LITT vs Surgery mTLE Meta-Analysis (Epilepsia, 2026)
Authors: Stavrogianni K, Poprelka K, Fasilis T, ..., Tsalouchidou PE
Citation: Stavrogianni K, et al. Neuropsychological outcomes comparing traditional surgical approaches and laser interstitial thermal therapy for refractory mesial temporal lobe epilepsy: A systematic review and meta-analysis. Epilepsia. 2026;67(2):588-605. doi:10.1111/epi.18687
Content summarized and formatted by NeuroTrials.ai.