Tremors caused by Parkinson’s disease and essential tremor are not life-threatening, but they can become disabling for many patients, according to Dr. Umber Akbar, a neurologist and co-director of the Movement Disorders and Deep Brain Stimulation programs at Rhode Island Hospital. The shaking from these tremors can make daily tasks such as holding drinking glasses, eating, buttoning a shirt, and writing difficult.
While a treatment plan for these tremors typically starts with medication, tremors can become worse over time and the medication can become ineffective in treating them.
“Having treated hundreds of people with tremors and other movement disorders, I can attest to the devastating effects these disorders can have on the lives of patients and their families,” Akbar said.
But a new incisionless procedure is now available in Rhode Island.
Dr. Wael Asaad, who received his PhD in systems neuroscience from Massachusetts Institute of Technology and his medical degree from Yale University, is the director of the Functional Neurosurgery and Epilepsy division at the Norman Prince Neurosciences Institute, which is headquartered at Rhode Island Hospital. He performed the first incisionless thalamotomy procedure this summer, making the hospital the second provider in New England to offer the treatment. (The first was Brigham and Women’s Hospital in Boston.)
Q. What happens during this procedure, an incisionless outpatient thalamotomy?
Asaad: The procedure uses focused ultrasound energy, guided by magnetic resonance imaging, or MRI. The MRI is used to target the location in the brain that’s responsible for the tremor and then an ultrasound helmet sends more than a thousand beams of energy through the patient’s skull [to thermally ablate the area] without damaging any nearby brain tissue.
The patient is awake throughout the procedure, and we evaluate (by having the patient draw or write something, for example) the tremor’s improvement throughout. The procedure takes about two to three hours. An MRI scan is done afterwards to assess the treatment.
Q. What is recovery like for patients?
Asaad: In most cases, patients leave the hospital that same day. But because you’re disconnecting the circuit from the cerebellum to the motor cortex, there could be some swelling that day. And it can affect more of the circuits in the area, so it can [temporarily] cause people to have a little bit of trouble speaking and can impact their balance — almost like having a cerebellar injury (which is an area of the brain that controls the body’s balance and coordination). Within the next few days or a couple of weeks, the patient will see improvements.
Q. The patient is awake throughout the procedure. Is there any pain?
Asaad: There will be some discomfort. Two things can cause this: We put a stereotactic frame on their head to keep their head still. And when we deliver the energy, it can be more difficult for some compared to others. If you have a thicker skull, it means there’s more air in the skull and it’s hard for the ultrasound to pass through. So to get the energy hitting precisely, we have to crank it up a little. There is a sense of pressure that can be uncomfortable, but it only lasts a few seconds at a time, and really only a couple of minutes overall in that two- to three-hour procedure.
And prior to the procedure, we have to put patients through a special CT scan before they get the procedure so we can measure their skull.
Q. How many patients have you conducted this procedure on so far?
Asaad: We received the technology this summer and conducted one procedure so far last month. But we have several more being seen next week that are interested, so we are starting to build a group of patients that are ready, and qualified to have this done. Before COVID-19, we were doing 40 to 50 deep-brain stimulation cases per year. I think this is going to be more popular than that. I won’t be surprised if we see 50 to 100, or more, a year. It’s definitely going to be a routine procedure.
Q. Who is the right candidate for this type of procedure?
Asaad: This procedure is approved by the FDA to help with essential tremor and tremor-dominant Parkinson’s disease. But if patients are developing other motor symptoms in Parkinson’s, then it’s not really the best therapy since it won’t treat their other issues.
Q. Is the procedure covered by most insurance?
Asaad: Insurance companies still have a long way to go in keeping up-to-date on technology. They’re just catching up. I saw that another insurance company just approved this procedure last week. (In Rhode Island, Blue Cross Blue Shield, the largest health insurer in the state, now covers this procedure.)
Q. Could MRI-guided ultrasound technology be used to treat other issues besides tremors?
Asaad: We just got the machine, but we’re hoping to start applying it for other things as well. With slight modifications to the hardware, you can open up the blood-brain barrier, which could allow chemotherapy to get in more easily to treat tumors.
Studies are also showing that in animals, you can deliver focused ultrasound to rodents that have Alzheimer’s. You can open up the blood-brain barrier around their memory structures and it can help wash accumulated plaque out of the brain. And it’s showing that their memory is getting better. There’s a study being done (outside of Rhode Island) to see if this could be safe in humans.