September 6, 2023 • 19 mins
Murray Bocian, 76, was prone to spilling things: His hands were so shaky that he had to begin using a child's sippy cup. Murray was battling a condition called essential tremor, and it was impacting many aspects of his daily life. A nervous system disorder, essential tremor starts in the brain and triggers shakiness in the extremities, most often the hands. For most of the 10 million Americans living with essential tremor, lifestyle changes and medications can help manage symptoms. But when the condition interferes with daily activities as it was Murray, more targeted therapies are needed. For decades, the solution has been to open the skull and operate on the brain. Now there's a new incision-less procedure called high-intensity focused ultrasound — HIFU — which can be done with an MRI scanner in a single two-hour outpatient session. And the effects are immediate. On this episode, we hear from Murray and speak with his surgeon, Albert Fenoy, MD, who explains how this new procedure works, who is a candidate, and how HIFU is improving the quality of life for patients living with essential tremor.
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Episode Transcript
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(00:00):
if this is as good as it gets. Did a great job. this is 300% improvement.
Oh. That's great to hear. Yeah. There you go.
That was Murray Bocian talking to his doctor minutes after a procedurethat eased the uncontrollable shaking in his hands that had plagued him for 30 years To our
(00:27):
My daily living was really bad. I mean, I shook, I dropped things. I couldn't do things myself. My wife had to help.
Murray has essential tremor, a nervous system disorder that causes shaky extremities, most often in the hands. And as Mary pointed out,it makes everyday tasks like tying shoes or holding a glass very difficult. Some even have to stop working
(01:00):
From the kitchen to the family room, it was how much I could spell by way of I.
Otherwise, I really Mary, peopleliving with this type of tremor
have done so for years, if not decades.
Most patients don't require treatment
or can manage the conditionwith lifestyle changes and medication.
(01:22):
But when those don't help,there are few other options,
including the one that has Mary feelinglike his old self again.
Hello and welcome to 20 Minutes.
How talk. I'm sandra Lindsay.
(01:43):
today on the showwe explore what everyone needs to know
about essential tremorand the latest treatments.
While surgery has been available
since the 1950s, a new incision.
This procedure called high intensity
focused ultrasound or high fu,
(02:04):
is improving quality of lifefor people like Mary.
Without the need for surgery.
and the effects are immediate.
Recently my colleague
Rob Hoyle sat down with Murray'ssurgeon, Dr.
Albert Finney,director of functional neurosurgery
(02:28):
and the deep brain stimulation and Programat Northshore University Hospital.
To learn more.
Thanks, Sandra.
In the United States,there are approximately
10 million Americansliving with essential tremor, which Dr.
Noy said makes it the most common movementdisorder.
it's a degenerative disease,It's progressive.
(02:49):
We usually call itbenign essential tremor,
because it's not a realitythat will lead to your death.
It's something that just happened onceyou have it, it's progressive over time.
And because it's progressive,it's really about quality of life.
the biggest factor for patientswith a sense
tremor is their progressiveloss of their quality of life.
So, yeah, simple facts of eating,drinking, cutting their meat,
putting on makeup, very big topic,you know, drinking
(03:12):
water, coffee and peoplewho are a handyman and a craftsman
and they want to use a hand tools. Sure.
That's a
you know, it
gets it interferes with their abilityjust to do fine things with their hands.
So there's no other symptomthat's really debilitating them.
And you know, it comes to an issueabout how long can a patient handle
having their tremor interferewith their life. Right.
Because you said it's progressive,
which means it's going to get worse overtime.
(03:34):
It's not going to get better.That's for stay the same.
That's why we call it essential.
Because we don't know exactly.
There's nothing that we use in medicine.
We call things essential because there'sno cause, there's no tumor, there's no
abnormality structurally in the brainthat is causing the tremor.
While the cause is unknown, Dr.
Finau says the biggest risk factoris genetics.
(03:56):
But 80% of essential tremor is familial,meaning that there's a large hereditary
component of itas opposed to being sporadic,
whereas that's the kind of the oppositefor Parkinson's disease.
This is a common point of confusion.
Many people think of essential tremoras being related to Parkinson's,
but there is an easy wayto tell the difference.
essential tremor is really a tremorthat at intention, not at rest.
(04:18):
So they may noticeas they're trying to use their hands
to do some type of manipulation, say,holding a cup or trying to eat
or write with a pen or using a utensil,that's when it becomes manifest.
Unlike Parkinson's disease,where tremor is simply at rest.
that really classifiesthe type of disease.
There's also a testfor Parkinson's disease that can help.
(04:40):
one of the things that provider could dois automate that scan.
That's a dopamine transporter, PETscan, positron emission tomography scan.
Basically it's radio nucleotide.
Looking at the mean dopamine transporter.
Dopamine is important in Parkinson'sdisease, but not in essential tremor.
So if there's an abnormal levelof that transporter in
the scan, then that would signify moreParkinson's disease than essential tremor.
(05:03):
But it's not 100% either.
Typically, patients with
essential tremor have turn, it gets worsewhen they're stressed or anxious.
Typically when theyif you ask them do you drink alcohol
and make patients who drink alcoholsocially may notice that okay,
after a glass of wine or beer at night,their tremor actually gets better.
(05:26):
And that's because there's just respondto a depressing nervous system. do.
We would obviously want to getan imaging of the brain at this
the first time we're seeing thisto make sure
there is no structural abnormalitythat's there.
if a patient has a stroke or aso you had some type of hemorrhage
that could cause a different typeof trauma that would be related to that.
And if it's there isn't, as we wouldexpect, then we would make that diagnosis.
(05:49):
Unfortunately, many people don't seekmedical care for a central tremor
due to a lack of awareness, embarrassmentor stigma.
Essential tremor is one of those reallyundiagnosed situations, because it usually
afflicts patients when they're olderSo a patient may develop a tremor
very subtly over time, and that becomesmore manifest as they age,
(06:10):
but they may think nothing of it.
So it's, hey, it's this is old age,or maybe it's due to nerves or anxiety.
And so they're not going to seekmedical attention.
They're not going to have a properdiagnosis.
Unfortunately, patients with tremorthat is progressive,
they seek less of social situationsand try to be more reclusive
so that they can not be seenwith their tremor.
That's a source of an embarrassment.
(06:30):
That's one type of lifestyle change.
Another one which is a little bit moreprogressive, would be weighted objects.
So say if they're using a fork, a weightedfork or spoon, or specifically patients
complain of, you know, having a spoonwith cereal or a spoon with their peas.
Uh, very difficult to control.
But the weight, it obvious that patientshave a little bit better use of.
There are alsosome bracelets that are actually supplied
(06:51):
by a prescribed by a neurologistthat have ability to dampen that tremor
pretty decently in the initial stages.
Dr. Van Noy says it's importantto see a doctor because, as he mentioned
before, the condition worsens over timeand can cause severe problems for some.
And for patientswho aren't sure where to start.
who your family practitioner
(07:12):
should be able to diagnose youwith this, your general practitioner,
but a neurologistobviously be better equipped to do so.
Go see in or out.
Just now, once you get see a neurologist,
they would differentiate in tensiontremor versus a resting tremor.
They would probably start youon some medication.
Typical medications would be Hannelore,which is a beta blocker.
It's actually a heart rate
reducing medicationused for people who have blood pressure.
(07:33):
That's a typical onethat's been very common to use.
Another one is called Printed down.
It's an anti-seizure medicine.
One or both of thosewould be used initially.
They have a tendency
they're not directly targetedat essential tremor, but
because of the way they suppress activityin your nervous system,
they have the ability
to attenuate the amplitude, which meansthe degree of movement of your tremor
(07:55):
you can suppress.
It can be highly effective in a patientwith a very small tremor.
That is typically an initial thingthat patients can get by for years.
But he points outthat medication is not for everybody.
these medications are they suppressactivity, but they can make you drowsy.
They can make you nauseous.
Patients don't like itor it's not working.
So once that occurs,we look for treatments that are targeted
(08:16):
actually at the problemthat we have already identifying,
which is this pathwaythat's apparently working.
Surgery offers that more targeted approachthat Dr.
Finley just mentioned.
While the medications used to treatessential tremor were initially designed
for other conditions, procedures like deepbrain stimulation and lesion therapy
have been around for decadesand are designed to stop or control
(08:36):
the area of the brain,causing the tremors.
deep brain stimulation,
a very common procedurethat's FDA approved in the last 30 years,
where we put an electrodeinto this location,
and through high frequency
stimulation, we can then train the cellsto fire at a normalized firing pattern.
This can immediately take away the tremorAs your measure of disease
progresses, you have the abilityto continue to control your tremor.
(08:59):
like deep brain
stimulation, lesion therapy targetsbrain tissue that is causing tremors
while lesion on the brainis typically caused by injury or disease.
Surgeons have been able
to turn it into a treatment for conditionslike essential tremor.
In this approach, they create a lesionin the affected area of the brain
to disrupt the electrical signals
between the brainand the body that caused the tremors.
(09:20):
This previously had beena surgical situation where we make
an incision, cut a hole and put a probeinto this target and cause a lesion
And the node that is is involved in thispathway is in the thalamus,
The thalamus, locatedin the middle of the brain,
relays nerve singlesbetween the body and the brain.
So to intercept that information flow,we will create a lesion
(09:42):
or create stimulation to stop that,and that automatically changes the tremor.
It causes tremor improvement.
the approach to lesiontherapy has evolved.
And the same effect can be achievedwithout surgery.
There are two approaches.
One uses radiation to slowlycreate the same lesion in the same spot
of the brain, and the benefitsdevelop over several months.
(10:03):
This is called gamma knife therapy.
Then there's high fu.
I intensely focused ultrasound or highfood has been FDA approved since 2016.
this is a new way of creating a reasonthat making that
roadblock of information transferthat improves tremor.
What's interesting about thisis that a patient can be outpatient
and on one day can have an hour and a halfprocedure and go home without tremor.
(10:27):
High fu occurs completely in an MRIscanner and uses sound waves to target
the tremor causing tissue in the brainwithout harming the surrounding tissue.
No anesthesia necessary.
The process starts with a quick headCT to determine
if a patient is a good candidatefor the innovative procedure.
essentially,we want to focus ultrasound beams
through your skullwithout creating an incision.
(10:48):
But we need to look at theactually the skull density ratio, the
the difference between the innerand outer tables of your skull
so that we can focus those ultrasoundbeams well enough to create that lesion.
If that skull density is too low,
then actually we can't focusthose ultrasound beams well enough
and we are not going to be ableto create that lesion,
which is kind of a disappointing.
But we need to know that ahead of time.Right?
(11:09):
So morethan 95% of patients are candidates.
But this is one of our this is the onlyscreening test that we have.
Our team followed Murrayon the day of his high fu procedure,
the second modestly, many years ago,I would have a seat in our lovely little
chair here. The chair Right
Put your hands up for me.
It's a little bit worse on the rightand put your hands up like this.
(11:30):
All right.
We just want to make sure obviouslywe're Peterson,
So we're going to be treating the oppositeside of your brain for the right side.
So that's what we need to do, that you'regoing to sign this and then I'll sign it.
And we should have a haveto shave their head.
While not an issue for Murray.
It can be a barrier for some.
As you might expect, this has been verymuch more common in females than males.
And so, yes, so males have no problemwith shaving their head.
(11:54):
Women, we have this is our this is aconstant struggle that we do see.
But some women are getting around it.
And the immediate benefit of high fu iswhat's helping women get around it.
Those who get the procedure saythe process is a minor inconvenience
on their way to feeling freedom
finally from the uncontrollableshaking in their hands.
So why is shaving your head necessaryfor this procedure?
(12:15):
that's going to affect how we canfocus as well for something.
So we want to make it very uniform.
Once we see the patient's headright down to using a razor,
we then put a stereotacticframe on a patient.
And this is so that we can visualizeyour brain in three dimensional space
with the MRI and pick a coordinate outto place that target.
That frame is only on for the procedure.
This frame looks like a vise and acts
as a foundation for a visorlike head covering.
(12:38):
and brain area, pulling it down as lowas it goes, Right over.
So on top of top of the frame.
So like a Once that frame is on,
you know,
we then put a membrane over the scalpwhich we will circulate water around
to cool the scalp.
As we're performing this procedure,we will then walk you over to the patient,
over to the MRI scanner, which will thenlay them down, connect the frame,
(13:02):
and they will get some short sequencesto visualize the chart,
which we kind of need to dojust at that moment.
that process involves multiple testsduring the actual procedure, which Dr.
for Noy explained midwaywe want to play this lesion.
We want to make sure that we're actuallycreating focusing those ultrasound
beamsdirectly into the area that we target.
So we check it
(13:23):
three differentways at least make sure of the three
different orientations that we're actuallygetting it into this area correctly.
If we have to make changes in how we'reactually function, those beams we do.
And then once we have that,then we can actually perform
a test sonicationSo we can kind of kind of treat the area
but not create a permanent lesionjust to treat, to see if we're actually
(13:45):
providing efficacy without a side effect.
And so we do that, we're going to test it,we can test it multiple times.
And what if that's all good set?
We don't have to make any furtheradjustments.
Then we'll create the actual permanentfeature you.
risks involved in complex brain surgery
as well as radiation from the gamma knifeapproach mentioned earlier.
(14:06):
This is FDA approved for only unilateraltreatment, meaning that we can only create
a an effect on one side of the brainto affect one side, one arm.
Only nine months after the first side,we can do the second side.
so we can see that we're trying.
We are increase in temperaturewithin the brain?
this is going toif we get this temperature
(14:26):
to rise above 50 or so,that we will start seeing an improvement.
And he says he has an improvement already,but we're not quite
where we want it to go.
So we need to get there
the reasonwhy we're doing this in the MRI scanner
so we can see real time
that we're actually affecting the areathat we want to target.
In 2023, Dr.
Van Noy and Team beganusing Hai Fu the first and only to do so
on Long Island, and Murraywas their second patient Murray is a great
(14:50):
guy, had really bad essential tremorsuffering for years
both handsconstant very difficult to eat drink right
spilling on himselfall the time wonderful support family
so he had to with this back inmaybe early May
and you know, had a great outcome.
and that family support includes his wife,Beth, who first learned about Hai Fu
(15:13):
and encouraged her husbandto seek treatment prior to Hai Fu,
Murray was unable to complete
a simple test that required himto draw a spiral and a straight line.
Following the high fu session,he was able to easily draw both.
right, all right.
Both between the lines stuff.
One 200% success.
(15:35):
Better than I did it before.
Close look.
More smooth, that's for sure.
nine months to obtain the same benefiton his left side.
The difference on his right.
He said, is night and day.
he can, you know, hold hands with hiswife, can eat without spilling on himself.
And he says that his laundry billshave gone down.
It's just like really, reallya huge improvement in quality of life.
(15:57):
I got it. And I already got it.
Very well.
It's good. It's pretty good. Nice.
All right.
Your head is not spinning. this year.
Murray and his wife are looking forwardto a lot more hand-holding
and both consider Hai Fu a miracle.
I would say in terms of efficacy,
I would say greater than 90%improvement of his tremor on one side.
(16:18):
And that's typical for most patients.
We would have an initial improvementof over 90%
improvement of their tremor,and that is sustained for a years now.
Um, there has not beenan amazing amount of studies,
but we do know that the efficacyis sustained over time.
the amount of tremor improvement will gowell, we're reduced over time.
That's a function of many things.
(16:40):
Function of, you how great of a lesionthe patient had
and how that the progressionof their disease.
at three years post lesion in post
treatment there is about at leasta 75% efficacy efficacy rate.
So still 75% betterthan as they were started,
not as great as 90% still perfect.
So after three years you could go backand get another procedure.
(17:00):
Definitely could go backand get another procedure.
Patients undergoing Hai Fu may experiencesome balance issues, but Dr.
Finau says it's only temporary.
we're creating a lesion.
There's some swelling
that occurs around this lesionfor a couple of days, two weeks,
and that can affecta little bit of an imbalance.
So actually we
provide patients with a walk or actuallyTypically it's gone in the next few weeks.
in addition to his role at NorthshoreUniversity Hospital, Dr.
(17:22):
for Noy also conducts researchin Essential Tremor through North Wales.
Feinstein Institutes for Medical Research.
And so actually I have an NIH grantsand a principal investigator on a
an R one,which is a special type of grants from the
NIH investigating tremor and how different
areas in the brain communicatewith each other post-treatment.
So when we do these procedureson these types of patients,
(17:45):
we want to seewhat is actually happening in the brain
because maybe we can make these treatmentsbetter.
do you think you're gonna get to a point
where it's going to open up doorwaysfor treating other abnormalities?
Absolutely.
So the only way we're going to progress inscience is to in medicine is to buy,
is to investigate what we have
and see how we can use the samewe're using here for other diseases.
(18:06):
So say, for example,deep brain stimulation,
which has been around much longerthan focus ultrasound,
where we are interveningjust like leaves or lesion sales,
either one surgery, we're creating lesionsin different pathways.
These white matter tracts are abnormal.
Well, initially they were used
just for essential tremor or Parkinson's,these very common disorders.
But we have branched out and nowwe're tackling psychiatric disorders
(18:29):
such as treatment resistant depressionor obsessive compulsive disorder.
We're looking at Alzheimer's disease.
And these are we are treating thesethrough surgery, not in a down the road.
We possibly can be helping these patientsthrough focused
ultrasound,creating a lesion without doing surgery.
But it's only through really studying
these patients and the pathwaysand how things are changing.
(18:51):
Will we ever really get to know. Wow,
on behalf of Rob, I want to thank Dr.
Albert for for joining us on this episodeall about essential tremor
and this new innovative procedure that ischanging lives for patients like Murray.
(19:13):
Until next time. I'm Sandra Lindsay.
And this has beenanother episode of 20 minute
how talk.
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insight from some of the leading voicesin health care today.
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if this is as good as it gets. Did a great job. this is 300% improvement.
Oh. That's great to hear. Yeah. There you go.
That was Murray Bocian talking to his doctor minutes after a procedurethat eased the uncontrollable shaking in his hands that had plagued him for 30 years To our
(00:27):
My daily living was really bad. I mean, I shook, I dropped things. I couldn't do things myself. My wife had to help.
Murray has essential tremor, a nervous system disorder that causes shaky extremities, most often in the hands. And as Mary pointed out,it makes everyday tasks like tying shoes or holding a glass very difficult. Some even have to stop working
(01:00):
From the kitchen to the family room, it was how much I could spell by way of I.
Otherwise, I really Mary, peopleliving with this type of tremor
have done so for years, if not decades.
Most patients don't require treatment
or can manage the conditionwith lifestyle changes and medication.
(01:22):
But when those don't help,there are few other options,
including the one that has Mary feelinglike his old self again.
Hello and welcome to 20 Minutes.
How talk. I'm sandra Lindsay.
(01:43):
today on the showwe explore what everyone needs to know
about essential tremorand the latest treatments.
While surgery has been available
since the 1950s, a new incision.
This procedure called high intensity
focused ultrasound or high fu,
(02:04):
is improving quality of lifefor people like Mary.
Without the need for surgery.
and the effects are immediate.
Recently my colleague
Rob Hoyle sat down with Murray'ssurgeon, Dr.
Albert Finney,director of functional neurosurgery
(02:28):
and the deep brain stimulation and Programat Northshore University Hospital.
To learn more.
Thanks, Sandra.
In the United States,there are approximately
10 million Americansliving with essential tremor, which Dr.
Noy said makes it the most common movementdisorder.
it's a degenerative disease,It's progressive.
(02:49):
We usually call itbenign essential tremor,
because it's not a realitythat will lead to your death.
It's something that just happened onceyou have it, it's progressive over time.
And because it's progressive,it's really about quality of life.
the biggest factor for patientswith a sense
tremor is their progressiveloss of their quality of life.
So, yeah, simple facts of eating,drinking, cutting their meat,
putting on makeup, very big topic,you know, drinking
(03:12):
water, coffee and peoplewho are a handyman and a craftsman
and they want to use a hand tools. Sure.
That's a
you know, it
gets it interferes with their abilityjust to do fine things with their hands.
So there's no other symptomthat's really debilitating them.
And you know, it comes to an issueabout how long can a patient handle
having their tremor interferewith their life. Right.
Because you said it's progressive,
which means it's going to get worse overtime.
(03:34):
It's not going to get better.That's for stay the same.
That's why we call it essential.
Because we don't know exactly.
There's nothing that we use in medicine.
We call things essential because there'sno cause, there's no tumor, there's no
abnormality structurally in the brainthat is causing the tremor.
While the cause is unknown, Dr.
Finau says the biggest risk factoris genetics.
(03:56):
But 80% of essential tremor is familial,meaning that there's a large hereditary
component of itas opposed to being sporadic,
whereas that's the kind of the oppositefor Parkinson's disease.
This is a common point of confusion.
Many people think of essential tremoras being related to Parkinson's,
but there is an easy wayto tell the difference.
essential tremor is really a tremorthat at intention, not at rest.
(04:18):
So they may noticeas they're trying to use their hands
to do some type of manipulation, say,holding a cup or trying to eat
or write with a pen or using a utensil,that's when it becomes manifest.
Unlike Parkinson's disease,where tremor is simply at rest.
that really classifiesthe type of disease.
There's also a testfor Parkinson's disease that can help.
(04:40):
one of the things that provider could dois automate that scan.
That's a dopamine transporter, PETscan, positron emission tomography scan.
Basically it's radio nucleotide.
Looking at the mean dopamine transporter.
Dopamine is important in Parkinson'sdisease, but not in essential tremor.
So if there's an abnormal levelof that transporter in
the scan, then that would signify moreParkinson's disease than essential tremor.
(05:03):
But it's not 100% either.
Typically, patients with
essential tremor have turn, it gets worsewhen they're stressed or anxious.
Typically when theyif you ask them do you drink alcohol
and make patients who drink alcoholsocially may notice that okay,
after a glass of wine or beer at night,their tremor actually gets better.
(05:26):
And that's because there's just respondto a depressing nervous system. do.
We would obviously want to getan imaging of the brain at this
the first time we're seeing thisto make sure
there is no structural abnormalitythat's there.
if a patient has a stroke or aso you had some type of hemorrhage
that could cause a different typeof trauma that would be related to that.
And if it's there isn't, as we wouldexpect, then we would make that diagnosis.
(05:49):
Unfortunately, many people don't seekmedical care for a central tremor
due to a lack of awareness, embarrassmentor stigma.
Essential tremor is one of those reallyundiagnosed situations, because it usually
afflicts patients when they're olderSo a patient may develop a tremor
very subtly over time, and that becomesmore manifest as they age,
(06:10):
but they may think nothing of it.
So it's, hey, it's this is old age,or maybe it's due to nerves or anxiety.
And so they're not going to seekmedical attention.
They're not going to have a properdiagnosis.
Unfortunately, patients with tremorthat is progressive,
they seek less of social situationsand try to be more reclusive
so that they can not be seenwith their tremor.
That's a source of an embarrassment.
(06:30):
That's one type of lifestyle change.
Another one which is a little bit moreprogressive, would be weighted objects.
So say if they're using a fork, a weightedfork or spoon, or specifically patients
complain of, you know, having a spoonwith cereal or a spoon with their peas.
Uh, very difficult to control.
But the weight, it obvious that patientshave a little bit better use of.
There are alsosome bracelets that are actually supplied
(06:51):
by a prescribed by a neurologistthat have ability to dampen that tremor
pretty decently in the initial stages.
Dr. Van Noy says it's importantto see a doctor because, as he mentioned
before, the condition worsens over timeand can cause severe problems for some.
And for patientswho aren't sure where to start.
who your family practitioner
(07:12):
should be able to diagnose youwith this, your general practitioner,
but a neurologistobviously be better equipped to do so.
Go see in or out.
Just now, once you get see a neurologist,
they would differentiate in tensiontremor versus a resting tremor.
They would probably start youon some medication.
Typical medications would be Hannelore,which is a beta blocker.
It's actually a heart rate
reducing medicationused for people who have blood pressure.
(07:33):
That's a typical onethat's been very common to use.
Another one is called Printed down.
It's an anti-seizure medicine.
One or both of thosewould be used initially.
They have a tendency
they're not directly targetedat essential tremor, but
because of the way they suppress activityin your nervous system,
they have the ability
to attenuate the amplitude, which meansthe degree of movement of your tremor
(07:55):
you can suppress.
It can be highly effective in a patientwith a very small tremor.
That is typically an initial thingthat patients can get by for years.
But he points outthat medication is not for everybody.
these medications are they suppressactivity, but they can make you drowsy.
They can make you nauseous.
Patients don't like itor it's not working.
So once that occurs,we look for treatments that are targeted
(08:16):
actually at the problemthat we have already identifying,
which is this pathwaythat's apparently working.
Surgery offers that more targeted approachthat Dr.
Finley just mentioned.
While the medications used to treatessential tremor were initially designed
for other conditions, procedures like deepbrain stimulation and lesion therapy
have been around for decadesand are designed to stop or control
(08:36):
the area of the brain,causing the tremors.
deep brain stimulation,
a very common procedurethat's FDA approved in the last 30 years,
where we put an electrodeinto this location,
and through high frequency
stimulation, we can then train the cellsto fire at a normalized firing pattern.
This can immediately take away the tremorAs your measure of disease
progresses, you have the abilityto continue to control your tremor.
(08:59):
like deep brain
stimulation, lesion therapy targetsbrain tissue that is causing tremors
while lesion on the brainis typically caused by injury or disease.
Surgeons have been able
to turn it into a treatment for conditionslike essential tremor.
In this approach, they create a lesionin the affected area of the brain
to disrupt the electrical signals
between the brainand the body that caused the tremors.
(09:20):
This previously had beena surgical situation where we make
an incision, cut a hole and put a probeinto this target and cause a lesion
And the node that is is involved in thispathway is in the thalamus,
The thalamus, locatedin the middle of the brain,
relays nerve singlesbetween the body and the brain.
So to intercept that information flow,we will create a lesion
(09:42):
or create stimulation to stop that,and that automatically changes the tremor.
It causes tremor improvement.
the approach to lesiontherapy has evolved.
And the same effect can be achievedwithout surgery.
There are two approaches.
One uses radiation to slowlycreate the same lesion in the same spot
of the brain, and the benefitsdevelop over several months.
(10:03):
This is called gamma knife therapy.
Then there's high fu.
I intensely focused ultrasound or highfood has been FDA approved since 2016.
this is a new way of creating a reasonthat making that
roadblock of information transferthat improves tremor.
What's interesting about thisis that a patient can be outpatient
and on one day can have an hour and a halfprocedure and go home without tremor.
(10:27):
High fu occurs completely in an MRIscanner and uses sound waves to target
the tremor causing tissue in the brainwithout harming the surrounding tissue.
No anesthesia necessary.
The process starts with a quick headCT to determine
if a patient is a good candidatefor the innovative procedure.
essentially,we want to focus ultrasound beams
through your skullwithout creating an incision.
(10:48):
But we need to look at theactually the skull density ratio, the
the difference between the innerand outer tables of your skull
so that we can focus those ultrasoundbeams well enough to create that lesion.
If that skull density is too low,
then actually we can't focusthose ultrasound beams well enough
and we are not going to be ableto create that lesion,
which is kind of a disappointing.
But we need to know that ahead of time.Right?
(11:09):
So morethan 95% of patients are candidates.
But this is one of our this is the onlyscreening test that we have.
Our team followed Murrayon the day of his high fu procedure,
the second modestly, many years ago,I would have a seat in our lovely little
chair here. The chair Right
Put your hands up for me.
It's a little bit worse on the rightand put your hands up like this.
(11:30):
All right.
We just want to make sure obviouslywe're Peterson,
So we're going to be treating the oppositeside of your brain for the right side.
So that's what we need to do, that you'regoing to sign this and then I'll sign it.
And we should have a haveto shave their head.
While not an issue for Murray.
It can be a barrier for some.
As you might expect, this has been verymuch more common in females than males.
And so, yes, so males have no problemwith shaving their head.
(11:54):
Women, we have this is our this is aconstant struggle that we do see.
But some women are getting around it.
And the immediate benefit of high fu iswhat's helping women get around it.
Those who get the procedure saythe process is a minor inconvenience
on their way to feeling freedom
finally from the uncontrollableshaking in their hands.
So why is shaving your head necessaryfor this procedure?
(12:15):
that's going to affect how we canfocus as well for something.
So we want to make it very uniform.
Once we see the patient's headright down to using a razor,
we then put a stereotacticframe on a patient.
And this is so that we can visualizeyour brain in three dimensional space
with the MRI and pick a coordinate outto place that target.
That frame is only on for the procedure.
This frame looks like a vise and acts
as a foundation for a visorlike head covering.
(12:38):
and brain area, pulling it down as lowas it goes, Right over.
So on top of top of the frame.
So like a Once that frame is on,
you know,
we then put a membrane over the scalpwhich we will circulate water around
to cool the scalp.
As we're performing this procedure,we will then walk you over to the patient,
over to the MRI scanner, which will thenlay them down, connect the frame,
(13:02):
and they will get some short sequencesto visualize the chart,
which we kind of need to dojust at that moment.
that process involves multiple testsduring the actual procedure, which Dr.
for Noy explained midwaywe want to play this lesion.
We want to make sure that we're actuallycreating focusing those ultrasound
beamsdirectly into the area that we target.
So we check it
(13:23):
three differentways at least make sure of the three
different orientations that we're actuallygetting it into this area correctly.
If we have to make changes in how we'reactually function, those beams we do.
And then once we have that,then we can actually perform
a test sonicationSo we can kind of kind of treat the area
but not create a permanent lesionjust to treat, to see if we're actually
(13:45):
providing efficacy without a side effect.
And so we do that, we're going to test it,we can test it multiple times.
And what if that's all good set?
We don't have to make any furtheradjustments.
Then we'll create the actual permanentfeature you.
risks involved in complex brain surgery
as well as radiation from the gamma knifeapproach mentioned earlier.
(14:06):
This is FDA approved for only unilateraltreatment, meaning that we can only create
a an effect on one side of the brainto affect one side, one arm.
Only nine months after the first side,we can do the second side.
so we can see that we're trying.
We are increase in temperaturewithin the brain?
this is going toif we get this temperature
(14:26):
to rise above 50 or so,that we will start seeing an improvement.
And he says he has an improvement already,but we're not quite
where we want it to go.
So we need to get there
the reasonwhy we're doing this in the MRI scanner
so we can see real time
that we're actually affecting the areathat we want to target.
In 2023, Dr.
Van Noy and Team beganusing Hai Fu the first and only to do so
on Long Island, and Murraywas their second patient Murray is a great
(14:50):
guy, had really bad essential tremorsuffering for years
both handsconstant very difficult to eat drink right
spilling on himselfall the time wonderful support family
so he had to with this back inmaybe early May
and you know, had a great outcome.
and that family support includes his wife,Beth, who first learned about Hai Fu
(15:13):
and encouraged her husbandto seek treatment prior to Hai Fu,
Murray was unable to complete
a simple test that required himto draw a spiral and a straight line.
Following the high fu session,he was able to easily draw both.
right, all right.
Both between the lines stuff.
One 200% success.
(15:35):
Better than I did it before.
Close look.
More smooth, that's for sure.
nine months to obtain the same benefiton his left side.
The difference on his right.
He said, is night and day.
he can, you know, hold hands with hiswife, can eat without spilling on himself.
And he says that his laundry billshave gone down.
It's just like really, reallya huge improvement in quality of life.
(15:57):
I got it. And I already got it.
Very well.
It's good. It's pretty good. Nice.
All right.
Your head is not spinning. this year.
Murray and his wife are looking forwardto a lot more hand-holding
and both consider Hai Fu a miracle.
I would say in terms of efficacy,
I would say greater than 90%improvement of his tremor on one side.
(16:18):
And that's typical for most patients.
We would have an initial improvementof over 90%
improvement of their tremor,and that is sustained for a years now.
Um, there has not beenan amazing amount of studies,
but we do know that the efficacyis sustained over time.
the amount of tremor improvement will gowell, we're reduced over time.
That's a function of many things.
(16:40):
Function of, you how great of a lesionthe patient had
and how that the progressionof their disease.
at three years post lesion in post
treatment there is about at leasta 75% efficacy efficacy rate.
So still 75% betterthan as they were started,
not as great as 90% still perfect.
So after three years you could go backand get another procedure.
(17:00):
Definitely could go backand get another procedure.
Patients undergoing Hai Fu may experiencesome balance issues, but Dr.
Finau says it's only temporary.
we're creating a lesion.
There's some swelling
that occurs around this lesionfor a couple of days, two weeks,
and that can affecta little bit of an imbalance.
So actually we
provide patients with a walk or actuallyTypically it's gone in the next few weeks.
in addition to his role at NorthshoreUniversity Hospital, Dr.
(17:22):
for Noy also conducts researchin Essential Tremor through North Wales.
Feinstein Institutes for Medical Research.
And so actually I have an NIH grantsand a principal investigator on a
an R one,which is a special type of grants from the
NIH investigating tremor and how different
areas in the brain communicatewith each other post-treatment.
So when we do these procedureson these types of patients,
(17:45):
we want to seewhat is actually happening in the brain
because maybe we can make these treatmentsbetter.
do you think you're gonna get to a point
where it's going to open up doorwaysfor treating other abnormalities?
Absolutely.
So the only way we're going to progress inscience is to in medicine is to buy,
is to investigate what we have
and see how we can use the samewe're using here for other diseases.
(18:06):
So say, for example,deep brain stimulation,
which has been around much longerthan focus ultrasound,
where we are interveningjust like leaves or lesion sales,
either one surgery, we're creating lesionsin different pathways.
These white matter tracts are abnormal.
Well, initially they were used
just for essential tremor or Parkinson's,these very common disorders.
But we have branched out and nowwe're tackling psychiatric disorders
(18:29):
such as treatment resistant depressionor obsessive compulsive disorder.
We're looking at Alzheimer's disease.
And these are we are treating thesethrough surgery, not in a down the road.
We possibly can be helping these patientsthrough focused
ultrasound,creating a lesion without doing surgery.
But it's only through really studying
these patients and the pathwaysand how things are changing.
(18:51):
Will we ever really get to know. Wow,
on behalf of Rob, I want to thank Dr.
Albert for for joining us on this episodeall about essential tremor
and this new innovative procedure that ischanging lives for patients like Murray.
(19:13):
Until next time. I'm Sandra Lindsay.
And this has beenanother episode of 20 minute
how talk.
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