ObjectiveTo evaluate the clinical efficacy and safety of magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) for mesial temporal lobe epilepsy (MTLE), and to compare its outcomes with anterior temporal lobectomy (ATL). MethodsA retrospective cohort of 120 MTLE patients treated at Beijing Tiantan Hospital between August 2022 and August 2024 was analyzed, including 31 patients who underwent MRgLITT and 89 patients who underwent ATL. All patients received comprehensive presurgical evaluations, and stereoelectroencephalography (SEEG) was performed in selected cases. Clinical outcomes at 1 year were compared between the two groups, including seizure control (Engel classification, seizure reduction rate), cognitive and memory changes, quality of life, and postoperative complications. ResultsBaseline characteristics were comparable between groups. At 1-year follow-up, Engel class I outcomes were achieved in 71.0% of patients in the MRgLITT group and 67.4% in the ATL group. Seizure reduction rates were (89.6 ± 26.2)% for MRgLITT and (87.0 ± 28.7)% for ATL, with no significant difference (P=0.92). Postoperative changes in memory, cognition, and quality of life were not significantly different between groups (all P>0.05). The incidence of complications was low and similar between MRgLITT and ATL, including hemorrhage (3.2% vs. 2.2%), infection (16.1% vs. 19.1%), and neurological deficits (3.2% vs. 2.2%). ConclusionMRgLITT provides seizure control and safety outcomes comparable to ATL when applied to carefully selected MTLE patients, with the added advantages of minimal invasiveness and faster recovery. For patients with well-localized epileptogenic foci and hippocampal sclerosis, MRgLITT represents an important alternative to open resection.