Laser interstitial thermal therapy for refractory epilepsy in children under 2 years: A single‐center case series and review of the literature

Abstract

Objective

To evaluate the safety, feasibility, and clinical outcomes of magnetic resonance‐guided laser interstitial thermal therapy (LITT) in children under 2 years of age with medically refractory epilepsy.

Methods

We conducted a retrospective case series of five infants who underwent LITT at a tertiary pediatric epilepsy center. Inclusion criteria were age ≤ 24 months, failure of at least two antiseizure medications, and presence of a focal structural lesion on imaging. Clinical data, seizure outcomes (Engel classification), and developmental trajectories were analyzed.

Results

Five patients (mean age at LITT: 9 months) underwent laser ablation for focal cortical dysplasia (FCD; n = 3) or tuberous sclerosis complex (TSC; n = 2). All patients tolerated the procedure without complications. At 12 months post‐LITT, 3/5 patients (60%) achieved Engel Class I outcomes, all of whom had FCD. Both patients with TSC had ongoing seizures, although one showed improvement after subsequent SEEG‐guided open resection. Patients with FCD demonstrated robust developmental progress, whereas those with TSC exhibited only modest gains in attention, engagement, and fine motor skills.

Conclusion

LITT is a safe and feasible option for selected infants with drug‐resistant epilepsy and structural lesions. Favorable seizure and developmental outcomes were more commonly observed in patients with FCD than TSC. These findings support further study of LITT in this age group, with particular attention to early intervention and accurate localization in complex cases.

Key points.

• LITT is a safe and feasible minimally invasive treatment for infants (< 2 years) with drug‐resistant focal epilepsy.

• Seizure outcomes were more favorable in focal cortical dysplasia than in tuberous sclerosis complex.

• Early seizure control after LITT may support improved developmental trajectories in infants.

1. INTRODUCTION

Epilepsy affects approximately one in every 100 pediatric patients. Nearly one‐third of these patients will prove medically refractory to at least two different antiepileptic medications. ¹ , ² Such poorly controlled seizures impose a substantial personal, developmental and psychological burden, as children suffering from this condition are at significantly higher risk of comorbidities such as depression, anxiety, attention deficit hyperactivity disorder (ADHD), conduct problems, developmental delay, autism spectrum disorders, and chronic headaches compared to their peers. Moreover, poorly controlled epilepsy is associated with an increased risk of sudden unexpected death in epilepsy (SUDEP). These serious consequences underscore the need for timely and effective interventions. ¹ , ²

Epileptogenesis in pediatric structural epilepsy is thought to commonly arise from structural abnormalities such as focal cortical dysplasia (FCD), tuberous sclerosis complex (TSC), periventricular heterotopias, and mesial temporal sclerosis. In many cases, patients with structural abnormalities will also prove medically refractory. These patients are often advised to consider surgical options to achieve better seizure control due to the risk of neurodevelopmental regression. Historically, such interventions involved open surgical resection. While effective, such approaches proved more limited in younger patients due to potential complications related to blood loss, wound healing, and prolonged physical and functional recovery.

Laser interstitial thermal therapy (LITT) has recently emerged as a novel alternative to open resection. ¹ , ² In LITT, a laser probe is deployed through a small burr hole craniotomy. Due to its size, the laser probe can be effectively deployed to nearly all areas of the brain. Once deployed, the laser induces tissue destruction through the conversion of light to thermal energy, resulting in protein denaturation, DNA damage, and eventual cell death. LITT has been combined with magnetic resonance thermal imaging (thermography) to detect proton resonance frequency shifts thereby allowing real‐time visualization of developing tissue damage from LITT to ensure precise target engagement while also safeguarding adjacent critical brain regions. Thanks to its small size and ability to target throughout the brain, LITT is proving to be a safe, effective, and less invasive approach to treating pediatric epilepsy, especially in the setting of known structural lesions. In terms of recovery, patients who underwent LITT have been shown to have a faster recovery as well as shorter hospital stays in comparison to those undergoing open craniotomy. ³ , ⁴ , ⁵

To date, most of the work with LITT has focused on its use in adults and older children (ages 12 and above). As such, there is little known about its use in younger kids (those 2 years of age or less). Historically, this was due to technical challenges surrounding LITT use in young kids secondary to the thin calvarium and anatomical limitations. However, recent technological advances and adapted surgical approaches have enabled safe application in this population. In this study, we present a single‐center retrospective case series of patients with medically refractory epilepsy (MRE) 2 years of age and under who underwent LITT, focusing on clinical characteristics, indications, and outcomes.

2. METHODS

We conducted a retrospective case series at Duke University Medical Center, a tertiary academic hospital with a level 4 pediatric epilepsy surgery program. Medical records of all pediatric patients who underwent therapy LITT were reviewed. Inclusion criteria included: age 2 years or younger, medically refractory epilepsy (failure of at least two antiseizure medications), and a structural etiology such as TSC or FCD. All patients underwent multidisciplinary surgical evaluation to localize the epileptogenic zone through noninvasive and/or invasive studies.

All patients underwent a standard Phase I video EEG admission and a refractory epilepsy protocol MRI, with additional studies performed as indicated. Literature was reviewed using PubMed and Google Scholar for English‐language case reports, series, and clinical trials evaluating LITT in infants and children with epilepsy. Key terms included “LITT,” “epilepsy surgery,” “TSC,” “FCD,” and “infant epilepsy.” Papers were selected based on relevance and inclusion of pediatric patients under 2 years of age.

2.1. LITT procedure

The protocol for MRI‐guided LITT has been previously described by Hooten et al., in 2018. ⁶ Briefly, patients are brought to the IMRIS 3T intraoperative MRI suite where general anesthesia is induced. Patients were secured using the Mayfield Infinity Support System. Due to the thin and soft scalp and calvarium, careful attention was given to avoiding any distortion of the skin or skull in these patients. A Brainlab optical reference frame was secured to the headholder and surface mapping was utilized to register patients' intraoperative position to the preoperative MRI. Once registered, a small burr hole was made along the planned trajectory. The Monteris AXiiiS stereotactic miniframe was placed as opposed to the traditional titanium cranial bolt. The miniframe attaches to the skull through three points of fixation thus improving both stability and safety in the infant skull. When feasible, the three fixation points are placed across sutures (namely on different skull bone pieces) for added stability. Additionally, special care was given with the screw depth for these fixation points so as to avoid fully penetrating the skull and damaging the underlying dura. While not perfect, this approach with the miniframe provided sufficient support to safely place the laser along our intended trajectory.

3. RESULTS

This study presents an analysis of the indications, surgical technique, anatomical challenges and postoperative complications of children younger than two years presenting with epilepsy secondary to TSC and FCD and managed with LITT. To the best of our knowledge, this is the first study that implicates LITT in this age range as data regarding laser ablation in children is still limited. ¹

The study included 5 patients (1 male and 4 females). One case included in this cohort (Case 3) has been previously published by K.G. Hooten et al. ⁶ and corresponds to Patient 3 in the present series. The mean age at epilepsy onset in our cohort was ≈ 1.06 months (approximately 4.6 weeks of life). Two patients (40%) were diagnosed with TSC, while the remaining three (60%) were diagnosed with FCD. All patients with TSC exhibited global developmental delay, whereas the patients with FCD demonstrated development appropriate for age. ² The mean age at the time of LITT was 9 months, with a range of 5–22 months. One patient diagnosed with FCD (Patient 5) underwent SEEG prior to the LITT procedure, while another patient diagnosed with TSC (Patient 3) underwent SEEG after LITT, which guided a tailored resection and led to a subsequently improved clinical outcome Table 1.

TABLE 1.

Clinical characteristics, procedural details, and post‐LITT outcomes for the five infants included in our study.

Patient	1	2	3 [11]	4	5
Sex	F	F	F	M	F
Age at first seizure (months)	0.03 (Day 1 of life)	2	2	1	0.25 (1 week)
Age at LITT (months)	5	6	6	6&14	22
Epilepsy etiology	TSC	FCD	TSC	FCD	FCD
Seizure semiology (ILAE 2025) 5	Focal seizure with impaired awareness, tonic posturing, head version, ocular motor involvement, and autonomic features	Focal seizure with impaired awareness, head and eye version	Focal seizure with impaired awareness, tonic posturing, and autonomic/respiratory involvement	Focal seizure with impaired awareness and clonic right upper limb involvement; subclinical left frontal epileptiform activity	Focal seizure with impaired awareness, head and eye version, and clonic right hemibody involvement
MRI findings	Multiple cortical tubers (LITT on right frontal tuber)	FCD at left superior parietal lobule	Multiple cortical tubers (LITT on right posterior frontal tuber)	FCD in left pars opercularis and precentral gyrus	Left temporal FCD
Prior surgeries/Procedures	None	None	None	None	Left temporal lobe open craniotomy followed by SEEG
Post‐LITT surgeries	None	None	SEEG followed by open surgical resection of epileptogenic focus	None	None
Engel classification at last follow‐up	IV C	I A	II B	I A	I A
Seizure course following LITT	No change; daily seizures	Seizure‐free at 22 months	Seizure‐free for 5 months post‐LITT	No clinical seizures; subclinical seizures on follow‐up EEG	Seizure‐free at 3 months
ASM regimen change	Seizure regimen maintained unmodified for 1 year post‐LITT	Seizure regimen maintained unmodified for 1 year post‐LITT, then gradual wean	Seizure regimen maintained unmodified for 1 year post‐LITT, then gradual wean	Seizure regimen maintained unmodified for 1 year post‐LITT	Seizure regimen maintained unmodified for 1 year post‐LITT, then gradual wean
Complications	None	None	None	None	None

At 12 months post‐LITT, two of the three FCD patients (66.7%) achieved an Engel Class I outcome (subclass 1A). Of the patients with TSC, one (50%) had an Engel score of 4C, while the other (50%) had an initial score of 3A. The second endpoint for follow up visits was variable among all five patients and ranged between 14 months and 84 months with a mean follow‐up duration of 31 months. At the last clinic evaluation, all FCD patients (100%) had achieved an Engel score of 1A. One TSC patient initially remained Engel 4C following LITT, while the other improved from 3A to 2B after SEEG‐guided identification of epileptogenic tubers in the right frontal and parietal regions leading to a tailored open resection.

In terms of seizure frequency among patients with TSC, the patient with an Engel 4c score continued to experience daily seizures with no change from baseline. In contrast, the other TSC patient who improved to a 2B score reported 6 months of seizure freedom after LITT, compared to weekly seizures preoperatively. FCD patients who underwent LITT had more favorable seizure outcomes, with seizure freedom achieved from 3 months after the procedure up to 22 months postoperatively.

3.1. Developmental outcomes

Developmental trajectories following LITT varied by etiology but generally reflected stabilization or improvement. Patients with TSC (Patients 1 and 3) continued to demonstrate developmental delays, though seizure reduction allowed mild gains in attention, engagement, and fine motor skills, and helped stabilize regression in the patient with seizure reduction. In contrast, patients with FCD (Patients 2, 4, and 5) showed more robust developmental progress. Patient 2 exhibited notable improvements in speech, language, and motor skills, achieving new milestones such as unsupported sitting, pivoting, pulling to stand, and assisted steps, with fine motor gains evident and a developmental quotient of 75 at follow‐up. Patient 4 achieved age‐appropriate motor and social milestones with emerging expressive language, although persistent subclinical seizures on EEG prompted a second LITT to mitigate any potential developmental delay. Patient 5 remained developmentally appropriate for age, continuing to gain gross and fine motor skills. These findings underscore that timely seizure control, including attention to subclinical epileptiform activity, is critical for supporting developmental outcomes in infants with refractory epilepsy. Summarizes the clinical characteristics, procedural details, and post‐LITT outcomes for the five infants included in our study Table 2.

TABLE 2.

Outcomes following LITT procedures in patients 2 years of age or younger. ² , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹

Study	Patient age	Diagnosis	Procedure	Engel outcome	Follow‐up duration	Seizure outcome	Developmental/behavioral outcome	Complications
Cobourn et al.	2 years	TSC	SEEG‐guided LITT	I	16 months	Seizure‐free	Favorable neurological prognosis; rapid recovery	None
Stellon et al.	2 years	TSC	Craniotomy + LITT (left frontal tubers)	I	1.94 years	Seizure‐free	Favorable neurological prognosis; rapid recovery	None
Tovar‐Spinoza et al.	2 years (2 patients)	TSC	LITT with Visualase (framed) / NeuroBlate (frameless)	I and II (1 each)	Mean 19.3 months	Seizure reduction; Engel I and II achieved	Behavioral improvements in attention, self‐injury, autistic traits	None
Lee et al.	4 months	TSC	LITT with Visualase, frameless using Medtronic Navigus platform	I	4 months	Seizure free	Meeting developmental milestones	None
Chilappa et al.	6 months	FCD	Robot‐assisted MRI‐guided LITT	III	3 months	Ongoing seizure activity leading to second LITT procedure performed at 16 months of age	Improvement in milestone acquisition following seizure reduction.	None
Saenz et al. (2023)	5 months	TSC	Frame‐based MR‐guided laser interstitial thermal therapy (LITT) using paste cast helmet	Not explicitly classified (clinical seizure improvement)	Short‐term (perioperative, follow‐up not clearly specified)	Significant reduction in gelastic seizures	Improvement noted; no adverse developmental impact reported	None

3.2. Review of literature

A focused literature review was conducted to identify published case reports and series describing the use of LITT for MRE in pediatric patients, with particular attention to those under 2 years of age. Our search yielded a total of six relevant publications from 2010 to 2025, encompassing various seizure etiologies such as TSC and mesial temporal lobe epilepsy. Among the reviewed literature, only three articles specifically described the application of LITT in children strictly younger than 2 years of age. Saenz et al. (2023) reported the case of a 5‐month‐old infant with drug‐resistant epilepsy due to a hypothalamic hamartoma who presented with frequent gelastic seizures refractory to antiseizure medications and typical electrophysiological and imaging findings consistent with a seizure focus in the hamartoma. Because conventional frame or pin‐based stereotactic fixation is challenging in infants with immature skulls, the authors used a novel paste cast helmet technique to secure a stereotactic frame, allowing accurate placement of an MR‐guided laser fiber into the hypothalamic lesion. The infant subsequently underwent successful frame‐based MR‐guided LITT with real‐time MRI thermography, achieving effective ablation of the hamartoma and resulting in clinical seizure improvement without perioperative complications. ⁷ Another study by Chilappa et al. (2025) described a full‐term female infant with focal epilepsy secondary to left parietal cortical dysplasia, with seizure onset at 5 weeks of age refractory to multiple antiseizure medications, who underwent robot‐assisted MRI‐guided LITT at 6 months followed by a second ablation at 12 months for residual dysplasia, resulting in significant seizure reduction and developmental improvement. ⁸ Similarly, another case report by Lee et al. (2021) described a 4‐month‐old infant who underwent frameless Visualase LITT with intraoperative MRI guidance, achieving seizure freedom and developmental gains. ⁹

Collectively, these findings underscore the growing feasibility and promise of LITT in very young children with MRE. While seizure freedom is more consistently achieved in non‐syndromic, unifocal pathologies such as FCD, selected TSC patients may also benefit from early intervention with appropriately adapted surgical techniques. Early seizure control not only reduces neurological injury but may also translate into improved developmental trajectories and enhanced quality of life. Summarizes outcomes following LITT procedures in patients 2 years of age or younger. [5–8, 12, 13].

4. DISCUSSION

4.1. Indications

Magnetic resonance–guided LITT has been shown to be a safe and effective alternative to traditional neurosurgery. Due to its less invasive nature compared to open resection, LITT is associated with shorter hospital stays, less pain, faster recovery, improved cosmetic outcomes, and delivery of a surgical cure while minimizing the disruption of family life. ¹⁰

LITT has therefore gained increasing recognition as a promising minimally invasive alternative for treating MRE in the pediatrics population, defined by the International League Against Epilepsy (ILAE) as failure of adequate trials of two tolerated, appropriately chosen, and appropriately dosed antiepileptic drug (AED) schedules (whether monotherapies or in combination) to achieve sustained seizure freedom. ¹² The indications for LITT in the cohort of pediatrics population younger than 2 years of age are anchored in the presence of focal epileptogenic lesions, often in the setting of genetic and structural epilepsies and align with the ILAE‐ established criteria for MRE established by ILAE.

In our series, FCD patients demonstrated more favorable seizure outcomes compared to those with TSC. This aligns with prior reports indicating that multifocality and diffuse epileptogenic networks in TSC are more challenging to treat. ² , ¹³ Although SEEG is valuable for refining surgical targets and optimizing outcomes, particularly in complex cases, this patient was referred directly to LITT due to the severity of seizures, clearly localized focus on EEG, and the patient's young age.

4.2. Outcomes

In our cohort of patients under 2 years of age undergoing LITT, 80% of patients demonstrated a greater than 50% reduction in seizure frequency at 12 months follow up. Notably, 60% achieved Engel Class I status, with all three belonging to the FCD subgroup. These findings are consistent with those reported in the limited literature focused on this age group. In particular, the infant described by Lee et al., a 4‐month‐old with TSC treated using Visualase in a frameless setup with the Medtronic Navigus platform, achieved seizure freedom by 4 months and continued to meet developmental milestones, further supporting the feasibility and early efficacy of LITT in very young patients. Likewise, Chilappa et al. reported an infant with FCD and early‐onset drug‐resistant epilepsy who required two LITT procedures at 9 and 12 months to address residual epileptogenic tissue, ultimately demonstrating meaningful seizure reduction. This case underscores that while single‐session ablation may be sufficient in some patients, others may benefit from staged treatment, particularly when dealing with extensive or deep‐seated dysplastic lesions.

In contrast, a larger pediatric cohort described in Guinle et al.'s study in 2023 reported seizure reduction in 70.6% of cases, with comparable seizure‐freedom rates, but was composed primarily of older children and adolescents, underscoring the limited generalizability of these findings to infants. ⁶

Taken together, within this context and in light of the scarcity of outcome data specific to children under 2 years old;, our findings extend the existing evidence base by providing infant‐focused outcomes and further supporting the feasibility and efficacy of LITT in this vulnerable age group.

An important pattern that emerged in our cohort was the case of the patient who underwent SEEG‐guided open resection after an initial LITT procedure. This patient, who began with an Engel 3A outcome, improved to 2B following tailored resection. The partial seizure reduction observed after LITT appeared to refine the localization of the epileptogenic zones, thereby guiding the subsequent surgical strategy. This aligns with the principle described by Tovar‐Spinoza et al., who reported staged LITT for cortical tubers and emphasized that initial, incomplete ablation can help identify residual epileptogenic tissue and direct more focused intervention. ¹ Together, these observations indicate that partial seizure improvement after LITT may have meaningful localizing value and can support individualized surgical planning in multifocal and complex conditions such as TSC.

With respect to antiepileptic drug (AED) burden, all patients were kept on the same antiseizure regimens for 1 year duration post‐LITT as per our protocol. Concerning the patients who clinically improved post‐intervention, medications have been weaned. Literature search showed more favorable trends in selected infants. For example, Stellon et al. (2019) reported a significant reduction in AED load in one of three infants under 2. ² Similarly Hotten et al. (2019) described decreased reliance on antiseizure medications in both of their sub‐2‐year‐old patients by their final follow up. ¹¹ These trends reflect variations in patient selection, underlying pathology, or preoperative seizure burden. Nonetheless, these findings suggest that in carefully selected cases, LITT has the potential not only to reduce seizure frequency but also to decrease long‐term pharmacologic dependency in infants, which may be particularly advantageous for neurodevelopmental outcomes.

Outcome correlates further highlight the importance of early intervention focus. All three Engel I patients in our cohort had localized seizure onset zones with well‐circumscribed MRI lesions. Conversely, the two patients with suboptimal outcomes had multifocal tubers. These findings mirror those of Hooten et al. (2019) who reported seizure freedom in infants with well‐localized lesional epilepsies and suggest that multifocal discharges and ambiguous seizure onset are strong predictors of poor outcome in this age group. ¹¹

Early seizure control is crucial for optimizing neurodevelopment. In our cohort, developmental outcomes reflected the interplay between underlying etiology and seizure control. Patients with FCD demonstrated steady or accelerated acquisition of motor and language milestones, having achieved Engel I post‐LITT. By contrast, patients with TSC, who often presented with multifocal epileptogenic zones, continued to show developmental delays, though seizure reduction stabilized regression and allowed incremental progress. These findings are consistent with prior literature reporting that early intervention with LITT in infants can not only achieve seizure control but also support developmental recovery. ² , ¹¹ Early stabilization of seizures reduces the cumulative burden of epileptic encephalopathy, allowing therapies such as speech‐language and motor rehabilitation to be more effective. Our case series suggests that even modest improvements in developmental quotient—as seen in Patients 2, 4, and 5—may represent meaningful clinical gains, underscoring the importance of timely intervention in infancy.

In summary, while seizure freedom rates in infants may approach those seen in older pediatric populations, the small but growing body of evidence, including Stellon et al. and Hooten et al. and our present cohort, highlights the unique considerations, risks, and opportunities of intervening in the under‐2 age group. Our findings suggest that with proper selection, LITT can be a safe and effective surgical option even in the first years of life, with implications for developmental trajectory and long‐term seizure control.

5. LIMITATIONS

This study is subject to several limitations. Primarily, the small sample size of five patients limits the generalizability of our findings. Additionally, the follow‐up duration was restricted to a maximum of 84 months, which may be insufficient to capture long‐term outcomes, particularly with respect to seizure frequency, changes in AED, developmental progression, and delayed post‐procedural complications. Longer‐term multicenter studies are warranted to validate our preliminary observations and better delineate the durability of LITT outcomes in this vulnerable age group.

Beyond the limitations inherent to this study, LITT itself presents several technical and clinical limitations, particularly in the pediatric population. Lesion size, shape, and proximity to blood vessels can pose challenges to safe and complete ablation due to the risk of thermal injury to adjacent critical anatomy. ¹¹ Furthermore, the traditional requirement for rigid cranial fixation using stereotactic frames or cranial pins is a relative contraindication in infants and very young children, limiting the applicability of conventional stereotactic approaches. Due to the thin bone, the laser bolts can wobble and lead to decreased accuracy in the very young children <2 years of age. Another consideration is the risk of hypothermia in the MRI scanner, which limits the number of laser trajectories during one anesthetic. In an effort to limit exposure time, we generally do not propose more than 3 trajectories in one sitting for this reason.

Another significant limitation is the paucity of long‐term data and the predominance of case series, which restricts broad generalizability of outcomes. Most published studies have focused on clinical seizure outcomes, with limited exploration of key intraoperative variables such as laser energy distribution, thermodynamics, and ablation volume factors that may directly influence seizure control. ²

Finally, the absence of invasive EEG monitoring, such as SEEG, in certain protocols may limit the precision of seizure onset zone localization. While noninvasive imaging and clinical semiology remain helpful, SEEG could improve the delineation of epileptogenic networks, especially in multifocal pathologies like TSC, and guide more targeted interventions in future applications. ¹⁰

6. CONCLUSION

This study highlights the successful use of LITT in treating refractory epilepsy secondary to TSC and FCD, thus offering a safer and minimally invasive alternative to traditional respective surgery. While promising, further multi‐institutional studies with standardized protocols are needed to assess long‐term outcomes, including seizure control, behavioral and cognitive improvements, and potential complications. Prospective studies should also investigate factors such as ablation volume, epileptogenic zones, and genetic influences on seizure outcomes. Continuous refinement and adaptation of surgical approaches for pediatric patients are essential for optimizing the benefits of LITT in this population.

All authors contributed to the conception and design of the study, collected and analyzed data, and drafted and critically revised the manuscript. All authors have reviewed and approved the final version. The authors thank the multidisciplinary epilepsy surgery team for their contributions to patient care. The authors declare no conflicts of interest relevant to this work. The data supporting the findings of this study are available from the corresponding author upon reasonable request, in accordance with institutional policies and patient confidentiality requirements. This study represents a retrospective review of anonymized clinical data collected during routine clinical care; no identifiable patient information is included. The authors confirm that this manuscript is original, has not been previously published, and is not under consideration elsewhere. This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.

Quiz Questions.

1. Which clinical and radiological factors are most strongly associated with favorable seizure outcomes following LITT in infants with medically refractory epilepsy?

Answer: Favorable outcomes are most strongly associated with well‐localized, unifocal epileptogenic lesions on MRI, concordant electroclinical findings, and absence of multifocal epileptogenic networks.

2. What are the main technical challenges of performing LITT in children under 2 years of age, and how can they be mitigated?

Answer: Key challenges include thin and pliable calvarium limiting secure fixation, risk of inaccurate probe placement, and susceptibility to hypothermia during prolonged MRI‐guided procedures. These can be mitigated by using stereotactic miniframes instead of cranial bolts, distributing fixation points across sutures, carefully controlling screw depth, limiting the number of trajectories per session, and optimizing intraoperative thermal monitoring.

3. How can LITT contribute to subsequent surgical planning in patients with incomplete seizure control, particularly in complex conditions such as tuberous sclerosis complex?

Answer: In cases of partial seizure reduction, LITT may help refine localization of the epileptogenic zone by unmasking residual seizure networks. This can guide further interventions such as stereoelectroencephalography (SEEG) or tailored open resection, ultimately improving seizure outcomes.

Supporting information

Data S1: supporting Information

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.