Hypothalamic hamartomas (HHs) are a known cause of refractory focal epilepsy. Advancement in microsurgical techniques and introduction of stereotactic ablative methods have led to improved complication rates, but the effect on seizure control is still to be determined. In this systematic review, we present a thorough analysis of published literature on the outcomes of various surgical treatments of HHs for refractory epilepsy.

A literature search using the MedLine, SCOPUS and Cochrane databases was conducted. All English language studies describing surgical treatment of HH with refractory epilepsy, with a minimum of three patients and a follow-up of at least one year, were identified.

An initial selection of 55 studies was reduced to 41 after combining studies from the same groups; 14 open, 4 endoscopic, 8 Gamma Knife radiosurgery (GKRS), 9 laser interstitial thermal therapy (LITT) and 6 radiofrequency thermocoagulation (RF-TC) studies were included. From a total of 832 patients, 209 underwent open (25.1%), 80 endoscopic (9.6%), 124 GKRS (14.9%), 229 LITT (27.5%) and 190 RF-TC (22.8%). Engel I or ILAE 1 or 2 was achieved in: open 115 (55.0%), endoscopic 38 (47.5%), GKRS 49 (39.5%), LITT 176 (76.9%) and RF-TC 128 (67.4%). Invasive surgeries (open and endoscopic) had a higher incidence of neurological complications (27.0%) than ablative surgeries (GKRS, LITT, RF-TC) (7.2%). Reoperation rates were higher for ablative surgeries (23.8%) than invasive surgeries (9.0%).

Surgical treatment of HH causing refractory epilepsy is effective. RF-TC and LITT surgery types have the highest Engel class I outcomes, and ablative surgeries have a lower neurological complication profile compared to open and endoscopic approaches.