Hooman Azmi, MD, a neurosurgeon at Hackensack University Medical Center, talks about a new non-invasive treatment that has patients tremor-free—immediately.
Dr. Azmi, what causes essential tremor?
AZMI: Essential tremor is a genetic condition. There is circuitry in the brain that control movement, and sometimes there could be some aberrant circuitry that causes the tremors for these patients. It runs in families. Often brothers, sisters, parents of the patient may have had this and their children may have it. It’s not certain that all children will develop it, but it’s possible that it can present itself in some of the progeny.
Does it worsen over time?
AZMI: It can. Not always, but it certainly can worsen over time.
For our viewers who may not be familiar, is it life threatening? Then the second part of that is if it is not life threatening, how does it impact quality of life?
AZMI: It’s not life threatening. It’s not a progressive neurodegenerative disorder. But it can be very, very problematic for one’s quality of life. People’s hands shake, what’s the big deal? Well, things that we take for granted someone with essential tremor has a hard time doing. Simple things as writing checks. Their loved ones must write things for them, fill out forms, write checks for them, brushing their teeth, drinking a cup of coffee, going out to dinner. Cutting their food becomes almost impossible. So, patients suffer quite a bit. They start to withdraw. They’re embarrassed to go out outside of going to dinner. If they’re at work, they give presentations. Their hands are shaking. People think they’re nervous, but it’s really not. It is the tremor condition. So, it could be really difficult for them to get through their daily activities whether it’s at work or at home.
What has been the traditional treatment for the condition?
AZMI: Traditionally, we have two or three line of medications that we use for essential tremor. And often they can be effective, but sometimes they’re not effective. We need higher and higher doses of them. They can cause side effects for patients. So, we try to come up with a concoction of medicine that does help them. A lot of times we’re successful, but sometimes we’re not, and patients do need to stay on the medicine for life long for it to be effective. It’s not that they take it and, you know, the tremor is gone forever. They do need to take it on a daily basiswhen it’s effective to keep the effect going.
Is there a brain surgery? Is there an open, I guess, open skull surgery or invasive brain surgery that can treat this?
AZMI: So, when medicines fail or people are starting to have side effects from the medication, we have a very good surgical option, The surgery involves implanting a pacemaker in the brain called DBS, deep brain stimulation. So, we place the pacemaker in the areas that contribute to the tremor circuitry. The pacemaker emits signals that are not felt by the patient. But it disrupts the abnormal circuitry in the brain and the tremors stop. It’s a very effective operation, but it is surgery. There are always pros and cons to everything that we do.
So, talk to me about the latest option that people with essential tremors may have.
AZMI: Sure. I think the great thing is now we have a midway option in between medicine and surgery, the focused ultrasound option, where we can noninvasively disrupt those tremor circuits. The tremors are permanently taken care of. It is incredible technology that allow us to use sound waves with the help of an MRI. With guidance from an MRI, we’re able to use sound waves and point them to one spot in the brain where the tremor circuits exist. It disrupts them and disrupts them permanently, and the patients leave the hospital without the tremor.
What is it? What’s it called? What’s the system called?
AZMI: It’s called MRI-guided focused ultrasound.
Can you walk me through how patients would go through the surgery and how you perform the surgery? This is awake surgery or you’re awake during it?
AZMI: So, it’s not really surgery. It is a procedure, but you know just like any procedure that there are a lot of aspects that go to it. So, correctly selected patients, that’s very important that we really need to do this on someone that’s a good candidate. There are steps to it that we discuss and tests that we do for determining someone’s candidacy. But once a patient is deemed a good candidate, we proceed with the procedure. On the day of the procedure We use a crown that is placed on the patients head that does two things. One, it holds the head steady and two, it helps us exactly guide the sound waves where we need them to go. So, we put that on the patients, and the patients go in the MRI machine. We begin to obtain imaging to make sure we have the area that we need that, you know, we are very happy with what we’re seeing. Once we’re done with the imaging, we start aiming the sound waves to that area. This process takes a good about five to 10 minutes of utilizing the focused ultrasound, and as we’re doing this, we’re examining the patient, one, to make sure that the tremor is relieved. Also, we look for side effects to make sure that they’re not having any side effects. Once we see the tremors are starting to go away and they’re not having side effects, where know we’re in the exact area we need to be, and we make that process permanent.
So, tell me a little bit about the sound waves that are going in. Again, for our viewers, if you could describe it, is it like shock therapy? Is it like a laser? Could you just describe what it is?
AZMI: Basically, there is a helmet that is on top of the patient’s head. It doesn’t touch the patient, but it has about a thousand small speakers in it. These speakers emit sound that’s ultrasound. It’s above what we can hear, and they have the capability of going through tissues. They go through the skin. They go through the skull, they go through the brain tissue, and with MRI, we focus all of them on one spot. So, these thousand speakers are all converging on that one spot that we want to treat, and that is what does the process. It actually heats that area up and it stops the circuits from working.
How quickly do patients see a difference?
AZMI: Immediately. On the table, their tremor goes away. They basically leave the hospital without the tremor.
We saw a video where you were asking patient Bob to do a couple of things. What were you generally trying to do and what are you trying to gauge from the responses they give you?
AZMI: So, every procedure has pros and cons, and this procedure can have some minimal side effects that there could be some pins and needles in the hand or the face and sometimes clumsiness in the hand. So, we’re asking the patient to speak, to repeat words. We want to hear their speech, make sure they’re OK, make sure they’re not having the pins and needles in their hand and make sure their hand is functioning well, and most importantly, we want to make sure the tremor is gone. So, we ask them to do things that brings out the tremor, for example, hold their arms in a particular way, bring the bottle of water to their mouth. All of these things that they would normally not be able to do because of the tremor we examine during the process of this procedure to make sure that we’re taking care of the tremor properly.
Who is a good candidate for this procedure? On the flip side, who should not, who should look for other methods?
AZMI: It’s very important for the audience to know what this is indicated for. So, it is FDA approved for unilateral meaning one-sided hand tremor. So, if someone has voice tremor or head tremor or leg tremor, this is not a good option for them. It’s really very good for hand tremor, and currently we’re only doing it for one side. So, we ask the patients, which hand do you want to treat, and that’s the hand we treat. They also go through some steps, tests most important of that is a cat scan of the brain, and we calculate the density of the skull to see if the sound waves can penetrate. If they’re in the small minority of people that the sound waves are not able to go through the skull, unfortunately, we can’t offer them this option.
Why only one side?
AZMI: So historically, all of these functional procedures – this is a functional procedure – were approved for unilateral use, and so it’s a matter of safety and that’s how the FDA approaches these.
Can you tell me a little bit about the patient Bob?
AZMI: Sure, he is a very active gentleman and very active with his family, very active in the community. He, even with the tremor, he plays the organ at his community church and he’s very involved with it. It was starting to get to be a problem for him. It was hard for him to keep up, hard for him to control his hand. Actuallythere’s videos of him playing because, you know, some of the events were on YouTube and you really can see he’s struggling with a piano, but he’s doing it. He really was looking for an option that would take care of the tremor for him. He had tried medications. Medications weren’t working. He was on high doses of medications that really weren’t doing much for him. So, he really seeked out the therapy and he didn’t want to have surgery. Even though, you know, I always tell people, surgery is a very reasonable option. If you can avoid surgery, this is a great opportunity and a great option for them.
Is there anything I didn’t ask you, doctor, that you would want people to know about this?
AZMI: No. I think we covered everything. So, if someone is having tremor, essential tremor, it’s very important to see a movement disorder neurologist, someone that can properly diagnose and tease out things that it could be besides essential tremor and properly treat that and properly refer the patient to get the appropriate therapy. There’s a lot of information out for patients if they Google things. They have to be careful. These are unfiltered. I think it’s very important to go to the foundations that support these disorders. For example, the Essential Tremor Foundation has a lot of information about all the things we talked about, the medical side of things, the surgical side of things, the focused ultrasound, how to find a proper neurologist. So, these are very helpful websites that patients can refer to.
How many of these procedures have you done?
AZMI: So, we’ve done about a dozen patients. This is a new program, but it’s essentially a tool that we are using to do a procedure we’ve been doing for many years called a thalamotomy. So, we previously used radiosurgery, or gamma knife radiation to do this, but now we have this non-radiation and non-invasive option to do the exact same procedure. So, it’s a program that started in July. You should know that there’s only 36 or 37 programs in the U.S. that offer this. So, it is a fairly new technology, but we’re very fortunate to be one of those centers to be able to offer this exceptional technology for patients.
Interview conducted by Ivanhoe Broadcast News in December 2018.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Mary McGeever
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
