Neurosurgical strategies in mTORopathies: from resection to disconnection and laser ablation

Abstract The mammalian target of rapamycin (mTOR) pathway orchestrates neuronal proliferation, migration, and synaptic regulation. Dysregulation of this pathway through germline or somatic mutations underlies a spectrum of cortical malformations collectively termed “mTORopathies,” including tuberous sclerosis complex (TSC), focal cortical dysplasia (FCD) type II, and hemimegalencephaly (HME). These conditions are major causes of drug-resistant epilepsy (DRE) in childhood. Since the early 1990s, neurosurgical approaches have evolved from open lesionectomies toward network-based resections, functional disconnections, and minimally invasive laser interstitial thermal therapy (LITT). This narrative review synthesizes evidence on presurgical evaluation, operative strategies, outcomes, and molecular integration in the modern era of precision neurosurgery.