A new treatment for tremors: an advanced brain

Oregon Health and Science University is now the first university in Oregon to offer an advanced type of brain surgery that does not involve cutting at all.

The procedure, known as focused ultrasound, directs more than 1,000 sound beams through the skull to create a small lesion in the brain’s focal point that causes a condition known as essential tremor. Approved by the Food and Drug Administration for clinical use in 2016, the procedure also treats a related condition known as Parkinson’s disease-dominant disease.

The OHSU neurosurgeon who is leading the new program anticipates increased interest among patients with tremors across the Pacific Northwest.

“Patients love it, and the results are immediate,” he said. Ahmad M. Raslan, MD, FAANSassociate professor of neurosurgery at the OHSU School of Medicine.

That’s certainly the case for Ruslan’s first focused ultrasound patient, 73-year-old Madras, Oregon, and resident Jan Henderson.

For the past three years, the uncontrollable tremor in her hands meant she couldn’t sign her name or drink a cup of coffee without spilling it.

“I’m trying to eat and I really can’t,” she said. “Sometimes I just have to use my fingers to put food in my mouth. It’s really hard.”

That all changed in an instant on March 30, when Henderson made history as the first person in Oregon to undergo the procedure.

A flock of onlookers peered through the window into the MRI machine as Ruslan and health care workers gathered around Henderson after the procedure.

She raised her right hand steadily. A wave of applause and cheers erupted from the MRI ward at OHSU’s Center for Health and Healing as onlookers realized they were witnessing the dawn of a new era in medicine. Henderson’s steadfast hand, and the quality of life it brings back, clearly demonstrates the true human value of healthcare innovation.

No cutting, no radiation

Her husband, Larry Henderson, called the procedure a “medical miracle,” a successful finding that has been repeated with many patients who have had the OHSU outpatient procedure since.

In fact, this technique is as much physical as it is medicine.

The procedure involves using high-frequency sound waves precisely guided by an MRI to ablate or burn the focal point deep within the brain that causes the tremors. Patients are provided with a specialized helmet-mounted stereotaxic frame that combines the focused energy of more than 1,000 high-frequency sound beams directed across the skull. The procedure does not involve any need for direct access to the brain by cutting the skull. It also does not involve radiation, as is the case with the previously developed Gamma Knife technology, which combines radiation beams to excise tumours.

Candidates should first undergo a CT scan to ensure a skull density thick enough to accommodate the procedure; It is estimated that 10% to 15% of people have skulls that are not dense enough for treatment.

In addition, the current procedure allows focused ultrasound to be performed on only one side of the body, which means that the patient will still have symptoms of tremor on the non-dominant side. Therefore, some patients may be more suitable for alternative therapies including deep brain stimulation, a technique pioneered by an OHSU neurosurgeon in the United States. Kim Burchill, MD

promising technology

In focused ultrasound, the patient is awake during the procedure and located inside an MRI machine to image the brain in real time.

The surgeon tests the exact location by heating the area, then making sure the patient is able to control the tremors by tracing the lines on the breathing machine. At this point, the surgeon then permanently removes the focal point, usually a ball a few millimeters long. Aside from treating Parkinson’s, this technique has been used for nearly 20 years to treat uterine fibroids, and it also shows promise for various types of lumpectomy and other medical applications.

Henderson’s was the first use of the technology to treat idiopathic tremor in Oregon, but it won’t be the last.

In fact, a large number of people can benefit from this procedure.

An estimated 1.5 million Americans have Parkinson’s disease, a progressive neurodegenerative disease that affects movement and can also affect speech, balance, and cognitive function. Essential tremor is thought to be eight times more common in the population than Parkinson’s disease, according to the International Essential Tremor Foundation—and yet many people endure it quietly for years with little relief.

big improvement

Henderson is one example.

She started noticing tremors in both her hands about four years ago, with a visible tremor in her right hand. A local neurologist in central Oregon prescribed medication to lessen the effect, but eventually found that it failed to adequately control the tremor. With her husband of 46 years, Larry Henderson, she was introduced to focused ultrasound through their own research.

The couple began arranging for Jane to undergo the procedure at the Swedish Neuroscience Institute in Seattle when they learned OHSU would soon begin offering her.

“OHSU is a lot closer to home than Seattle,” Larry explained.

On the morning of March 30, they arrived at OHSU’s Health and Recovery Center with their adult grandson, who had helped bring them to Portland the day before. As she waited, Jane thought of the world she hoped would open up to her after the procedure.

“I loved cooking,” she said.

“She had a beautiful handwriting before,” Larry added.

The process took approximately three hours, including the time it takes to shave her head to allow Ruslan to fit the stereotaxic frame and device.

Larry then meets her in the recovery room next to a hallway filled with OHSU health care workers and staff, along with representatives from InsighTec, the Israel-based company that developed the Exablate Neuro platform. Sparkling apple juice was poured into a pair of thin flutes, one for her and the other for Larry.

Holding the glass in her steady right hand, she wasn’t pouring a drop.

“Wow,” Larry said. “This is a huge improvement. Thank you all – we never thought we would get to this point.”

Smiling from ear to ear, Jane raised her sparkling apple juice flute high and steady to make a toast:

“To all of you!”

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