Oregon Health & Science University is now the first in Oregon to offer a cutting-edge type of brain surgery that doesn’t involve cutting at all.
The procedure, known as focused ultrasound, directs more than 1,000 sonic beams through the skull to create a small lesion in the focal point of the brain 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 tremor-dominant Parkinson’s disease.
The OHSU neurosurgeon leading the new program expects a surge of interest among patients with tremors across the Pacific Northwest.
“Patients love it, and the results are instantaneous,” said Ahmad M. Raslan, M.D., FAANS, associate professor of neurological surgery in the OHSU School of Medicine.
That’s certainly the case for Raslan’s first focused ultrasound patient, 73-year-old Madras, Oregon, resident Jean Henderson.
For the past three years, the uncontrollable tremor in her hands meant that she couldn’t so much as sign her name or drink a cup of coffee without spilling it.
“I try to eat and I really can’t,” she said. “Sometimes, I have to just use my fingers to put food in my mouth. It’s really hard.”
All that changed in an instant on March 30, when Henderson made history as the first person in Oregon to undergo the procedure.
A bevy of onlookers peered through the window to a magnetic resonance imaging machine as Raslan and health care workers clustered around Henderson after the procedure.
She held up her right hand, rock-steady. A wave of applause and cheers rippled out from the MRI suite in OHSU’s Center for Health & Healing as onlookers realized they were witnessing the dawn of a new era in medicine. Henderson’s steady hand, and the quality of life that it restores, vividly illustrated the true human value of innovation in health care.
No cutting, no radiation
Her husband, Larry Henderson, called the procedure a “medical miracle,” a successful outcome that has been duplicated with several patients who have undergone the outpatient procedure at OHSU since then.
In fact, the technique is as much physics as it is medicine.
The procedure involves the use of high-frequency sound waves directed with pinpoint precision by magnetic resonance imaging to ablate, or burn, the focal point deep within the brain that is causing tremors. Patients are fitted with a stereotactic frame affixed to a specialized helmet that combines the focused energy of more than 1,000 high-frequency sonic beams directed through the skull. The procedure involves no need for direct access to the brain by cutting through the skull. Nor does it involve radiation, such as with previously developed gamma knife technology, which combines beams of radiation to ablate tumors.
Candidates must first undergo a CT scan to ensure a skull density sufficiently thick to accommodate the procedure; an estimated 10% to 15% of people have skulls that aren’t dense enough for the treatment.
In addition, the current procedure allows for the focused ultrasound to be performed only on one side of the body, meaning the patient will still have tremor symptoms on the non-dominant side. Therefore, some patients may be better suited to alternative therapies including deep brain stimulation, a technique pioneered in the United States by OHSU neurosurgeon Kim Burchiel, M.D.
In focused ultrasound, the patient is awake during the procedure and situated within an MRI machine for real-time imaging of the brain.
The surgeon tests the precise location by heating the area, then ensuring the patient is able to control tremors by tracing lines on a spirograph. At that point, the surgeon then permanently ablates the focal point, usually a sphere a few millimeters in length. Aside from treating tremors, the technology has been used for almost 20 years for treatment of uterine fibroids, and also holds promise for various types of tumor ablation and other medical applications.
Henderson’s was the first use of the technology to treat essential tremor in Oregon, but it will be far from the last.
In fact, a large number of people could benefit from the procedure.
An estimated 1.5 million Americans suffer from Parkinson’s, a progressive neurodegenerative disease that affects movement and can also affect speech, balance and cognitive function. Essential tremor is believed to be eight times more widespread in the population than Parkinson’s, according to the International Essential Tremor Foundation — yet many people quietly endure it for years with little relief.
A major improvement
Henderson is one example.
She began noticing tremors in both of her hands about four years ago, with an especially pronounced shaking in her right hand. A local neurologist in central Oregon prescribed medication to dampen the effect, but ultimately found that it failed to adequately control the tremor. With her husband of 46 years, Larry Henderson, she learned about focused ultrasound through their own research.
The couple had begun making arrangements for Jean to undergo the procedure at the Swedish Neuroscience Institute in Seattle when they learned OHSU would soon begin offering it.
“OHSU is a lot closer to home than Seattle,” Larry explained.
On the morning of March 30, they arrived at the OHSU Center for Health & Healing with their adult grandson, who had helped drive them into Portland the day before. As she waited, Jean contemplated the world she hoped would open up to her following the procedure.
“I used to love to cook,” she said.
“And she had beautiful handwriting before,” Larry added.
The procedure took roughly three hours, including the time involved in shaving her head to allow for Raslan to fit the stereotactic frame and device.
Afterward, Larry met her in the recovery room adjoining a corridor filled with OHSU health care workers and staff, along with representatives from InsighTec, the Israel-based company that developed the Exablate Neuro platform. Sparkling cider was poured into a pair of slim flutes, one for her and one for Larry.
Holding the glass in a steady right hand, she didn’t so much as spill a drop.
“Wow,” Larry said. “That’s a major improvement. Thank you to all of you — we never thought we’d get to this point.”
Smiling ear to ear, Jean lifted her flute of sparkling cider high and steady to offer a toast:
“To all of you!”