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Stopping The Shakes With Sound

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BALTIMORE, MD (Ivanhoe Newswire) - Millions of Americans suffer from tremors. Patients with constant shaking can have trouble with some of life's everyday activities. Things like eating and drinking or holding a pen to write, are almost impossible. Now, learn about a breakthrough procedure that could help some patients get a steady hand.

"My hand shook constantly, it would never stop," Billy Williams, a tremor patient, told Ivanhoe.

For the past 10 years, Billy Williams suffered from a tremor in his hand.

"Constantly, it never, never quit," Williams said.

No one knows why he shakes, but the tremor was so bad, Billy stopped eating out in public and his writing became illegible.

"I had trouble writing my name, I couldn't sign anything," Williams explained.

Now, neurosurgeons are using a new procedure called MRI guided focused ultrasound that stops some types of tremors.

"It involves high resolution MRI scanning as well as ultrasound technology," Jeff Elias, M.D., neurosurgeon at the University of Virginia Medical Center told Ivanhoe.

Other procedures involve invasive brain surgery, but the new scalpel-free surgery is the first to use ultrasound in the brain to treat tremors.

"We really have to be precise to within a millimeter to stop the tremor," Dr. Elias said.

The procedure is done in an MRI scanner that allows doctors to aim pulses of harmless ultrasound waves through a patient's skull to a targeted region within the brain known to be effective for treating some types of tremors. Thousands of ultrasound waves converge, heating up the area being treated, so that tremor-causing cells die.

"One of the real advantages of this technology is that it allows us the opportunity to test the patient during the treatment," Dr. Elias explained.

Billy and his doctors watched his tremor get better, and better during treatment. The end result?

"Almost immediately after the procedure my hand was as it is right now," Williams said.

The world's first clinical trials using MRI guided focused ultrasound to treat essential tremors recently wrapped up at the University of Virginia Health System. Officials say patients are experiencing immediate improvement that's been sustained through the study's three month follow-up period. Future trials are planned to investigate the technology in treating functional brain disorders like Parkinson's disease, epilepsy and stroke.

RESEARCH SUMMARY

BACKGROUND: A tremor is the most common of all involuntary movements that affect that hands, arm, head, face, vocal cords, and legs. A tremor consists of a somewhat rhythmic muscle movement of one or more parts of the body; most often occurring in the hands. Tremors most frequently affect middle-aged and older men and women. A tremor may indicate other neurological disorders in some people but can occur in otherwise healthy individuals. A tremor is not life-threatening but can make performing daily tasks difficult. (Source: www.medicinenet.com)

ABOUT THE NERVOUS SYSTEM: The brain is "hardwired" with connections, which are made by billions of neurons that make electricity whenever they are stimulated. The electrical patterns are called brain waves. Neurons act like the wires and gates in a computer, gathering and transmitting electrochemical signals over distances as far as several feet. The brain encodes information not by relying on single neurons, but by spreading the information across large populations of neurons, and by rapidly adapting to new circumstances. Motor neurons carry signals from the central nervous system to the muscles, skin, and glands of the body, while sensory neurons carry signals from those outer parts of the body to the central nervous system. Receptors sense things like chemicals, light, and sound and encode this information into electrochemical signals transmitted by the sensory neurons. And interneurons tie everything together by connecting the various neurons within the brain and spinal cord. The part of the brain that controls motor skills is located at the rear of the frontal lobe.

CAUSES: Tremors can be caused by; genetics, drug use, injuries, and others by unknown reasons. Commonly tremors are caused by neurological disorders, or other conditions that can produce tremors such as multiple sclerosis, stroke, traumatic brain injury, and neurodegenerative diseases that damage or destroy parts of the brainstem or the cerebellum. Tremors may be triggered by or become exaggerated when the individual is physically exhausted, during times of stress or strong emotion, or during certain postures or movements.
(Source: www.medicinenet.com)

NEW TREATMENT: Traditional therapies for tremor treatment involve invasive brain surgery, but with the use of MRI's and ultrasounds neurosurgeons are using a new, non-invasive procedure on patients to help stop certain types of tremors that interfere with their everyday lives. The technique uses a combination of an ultrasound to heat up and kill the problem cells, and an MRI to allow surgeons to visualize and precisely target the affected regions of the brain. Patients most prefer this new treatment over traditional therapies for tremor treatment because the new procedure provides a scalpel-free approach to reduce and eliminate tremors. (Source: www.aip.org)

HOW ULTRASOUND WORKS: Ultrasound is a medical imaging technique that uses high-frequency sound waves and their echoes.  It is similar to the echolocation that bats use to navigate in the dark and the SONAR that submarines use to navigate underwater.. An ultrasound machine transmits high-frequency sound pulses into the body through a probe. The sound waves travel until they hit a boundary between two kinds of tissue—for example, the boundary between soft tissue and bone. When this happens, some of the sound waves are reflected back to the probe, while others travel further through the body until they hit another boundary. All the reflected waves or "echoes" are recorded by the machine, which then calculates the distance each sound wave traveled based on how long it took the sound wave's echo to return. This data is used to form a two-dimensional image based on the distances and intensities of the echoes.

INTERVIEW

Dr. Jeff Elias, Neurosurgeon, Associate Professor of Neurosurgery at the University of Virginia, discusses a new procedure in clinical trials that allows deep brain procedures for tremors without invasive surgery.

Tell me about the MR Guided focus ultrasound, what is the purpose of it?

Dr. Elias: MR guided focus ultrasound surgery is a new technology that really combines two technologies into one. It involves high resolution MRI scanning as well as ultrasound technology. And the combination of these two technologies provides a very precise noninvasive treatment for patients with many different problems.

Can you give me an idea of some of those problems?

Dr. Elias: For instance to date most of the applications of MR guided focus ultrasound surgery have been for body applications like for uterine fibroids, prostate problems and breast problems. More recently some of the technological hurdles of sending ultrasound waves to the skull have been solved so that treatments for the brain are now possible.

What is new or unique about this particular system?

Dr. Elias: The real unique feature of this system is the way the two technologies have been combined they're both very compatible and complimentary for each other. MRI provides the real precise visualization of the body structures whereas ultrasound can provide very safe non invasive therapeutic treatments. So we can combine close precise visualization and accurate noninvasive nonpainful treatments or therapies.

How does it work exactly?

Dr. Elias: Well the patient came to our unit on the morning of the procedure, we did have to shave his hair to optimize the transmission of ultrasound through the scalp. And then he was placed in a stereotactic frame which really is a frame to stabilize his head and allows us to really precisely with three dimensional coordinates target areas deep in the brain. We placed him in to the ultrasound MRI device and then began a series of localizing MRI images so we could plan our treatment from those MRI images. And then we were able to deliver the ultrasound treatment though the scalp and the skull and focus on precisely in the deep structure of the brain which is called the thalamus.

What were you targeting exactly, was it a tumor?

Dr. Elias: For Mr. Williams he suffers from essential tremor it's the most common movement disorder that affects people around the world. It involves tremor which can be very disabling and disruptive to a person's lifestyle. We've known for many years that there's a very small area in the thalamus of the brain which is deeply centered within the brain. It's a very accurate target to treat tremors and we target that region of the brain for his tremors.

Give me more details about how the ultrasound works.

Dr. Elias: This particular ultrasound devise has over a thousand ultrasound transducer elements and so each one basically creates an ultrasound wave or acoustic wave just like if a submarine was sending sonar through the water we do the same with these ultrasound elements. So we create a thousand ultrasound waves and they are sent through the skull and they deflect through the skull and all converge on a single point. The area where they converge on the single point absorbs a lot of energy so there's heat that forms at that one precise spot and that's where the treatment occurs.

How is it working exactly?

Dr. Elias: All the ultrasound waves that travel through the brain are safe but the area, the single point where they converge, absorbs a lot of heat. A lot of energy which heats the tissue and actually cauterizes a very small hole or spot right in the abnormal area of the brain that we're seeking to treat.

How precise is this, is that pretty important?

Dr. Elias: It's extremely precise. We know from contemporary surgery we really have to be within a millimeter to have a very successful accurate surgery and that's the same with this type of surgery this noninvasive procedure. We really have to be precise to within a millimeter to stop the tremor.

What have your results been, in general what type of results have you seen from this technology?

Dr. Elias: Mr. Williams was the first patient that we have treated, this is an experimental clinical trial that's approved by the FDA for us to treat fifteen patients. So it's still investigational but so far early results have been very successful in our first group of patients we've been able to stop all the tremors so far.

Is there a perfect patient for this type of technology?

Dr. Elias: The ideal patient currently we studying is essential tremor but it's typically a patient that has had tremor all of their life, Its gotten to the point that it's disabling and disruptive to their work or home lifestyle. They've failed medical treatments and really don't have any other options for controlling their tremor.

What is the best benefit to patients with this?

Dr. Elias: Essential tremor is very common out in the public. It's the most common movement disorder. It's considered kind of a benign problem in that people don't die from it but it can be very disabling to home lifestyle and work. So there are a lot of people living with disabilities and they really don't seek medical attention because they don't feel that they want to pursue and open surgical treatment. So this is really a great opportunity for a new treatment that could be noninvasive and potentially very safe to provide them some functional improvements in their life.

Would it be safe to say it could change a person's life?

Dr. Elias: It could. It could really change a person's life.

What are the benefits of the technology as a doctor, what do you see as a benefit to this technology?

Dr. Elias: As a researcher and doctor I think there's a lot of potential benefits to this new technology. Some are research oriented such as we may have the ability to map different areas of the brain in a safe noninvasive way. Therapeutically we may be able to treat many diseases that require open surgical procedures. Diseases like Parkinson 's disease or Epilepsy or pain problems are all being investigated or considered as a potential treatment option for focused ultrasound.

Is it because this is so new that you only use it for tremors, why not other types of diseases?

Dr. Elias: That's right. Here at the University of Virginia we've started the first human clinical trial for essential tremor. We plan to investigate other disorders.

Can you give me an example of those disorders?

Dr. Elias: We plan to investigate other disorders like Parkinson 's disease and Epilepsy, pain problems as well as brain tumors and stoke.

What about the testing?

Dr. Elias: One of the real advantages of this technology is that it allows us the opportunity to test the patient during the treatment. Which not only can increase the safety but it can also increase the precision or accuracy of the treatment. So for Mr. Williams while we were delivering the treatment we were able to test him in between each ultrasound sonication. And we were really able to steer and hone in on the ideal tremor spot to ablate with the treatment.

When you say test the patient what did you do?

Dr. Elias: We were able to test his tremor while he was in the MRI scanner. We were able to monitor his tremor as well as have him do some drawings and that really allowed us to very objectively monitor what kind of treatment we were delivering to him and we could hone that until he had complete tremor control.

Can you compare it to the other alternatives?

Dr. Elias: Currently the contemporary state of the art treatment for tremor and Parkinson 's disease and other movement disorders involves deep brain stimulation. And that basically involves placing a pacemaker system in to the brain. So it's an invasive procedure we have to make a small hole in the skull to insert the electrode. Patients are awake so that we can test them during the procedure and it's often a very difficult procedure for patients to get through. Awake surgery always causes a lot of anxiety for patients. So the potential to offer a noninvasive treatment where the patients are awake, there's no pain and there's the same type of high precision and efficacy would be really welcomed by patients and their referring doctors.

Do you think this would ever replace deep brain stimulation?

Dr. Elias: There's certainly a lot of merits to deep brain stimulation there's a lot of benefits. It's a treatment that we can do bilaterally or on both sides of the brain whereas lesioning whether it's with ultrasound or any other type of open surgical lesioning is typically a unilateral one-sided procedure. But they certainly each have their place in the treatment of algorithms for doctors and patients.

FOR MORE INFORMATION, PLEASE CONTACT:
 
Meghan Bradley
UVA Health System
Marketing Communications
mbradley@virginia.edu

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