Shabbar Danish, M.D., the chairman of neurosurgery at Jersey Shore University Medical Center, talks about how lasers interact with the cells and organs in our bodies, and how long it will take to cause damage to abnormal cellular tissue while protecting normal tissue.
Interview conducted by Ivanhoe Broadcast News in January 2022.
Do you have a specific area of expertise within neurosurgery?
DR DANISH: My specific area of expertise is in neurooncology and functional disorders, which includes movement disorders, such as Parkinson’s disease and epilepsy.
Could you talk to me a little bit about laser ablation? Some of our viewers may have heard the term but may not really know what it’s being used for. Could you describe it?
DR DANISH: Lasers are a common tool in medicine. And there are a lot of different kinds of lasers that are used in all sorts of applications, right? The most common being a laser pointer. Different kinds of lasers are good for different applications. There are types of lasers and wavelengths along the spectrum that are applicable to treatments in the human body. There are specific lasers and wavelengths that are applicable to treatments in the brain and the nervous system. Laser ablation is the use of lasers to create cell death, and that’s where the term ablation comes from. The laser is light, and that light invokes heat, that heat invokes cell death. And one of the challenges over the last 30, 40, 50 years is the ability to understand how the body and the organs, and the targets interact with the exposure of heat and the exposure of that heat with respect to a certain amount of time to create damage of abnormal cellular tissue while protecting normal tissue.
Is this a minimally invasive procedure?
DR DANISH: I’m going to refer to it as MR-guided laser interstitial thermal therapy. The acronym is MRLITT. That term has become accepted in its use in the field for its application in the brain. The laser itself is a very small fiber. probably thinner than the end of a ballpoint pen, but it does require insertion. it’s minimally invasive, but it still requires patients to be under general anesthesia for the most part. You have to drill a small three-millimeter hole in order to create access through the skull to get into targets in the brain.
Could you walk our viewers through the procedures?
DR DANISH: Patients will come into a hospital, and they will get planning images done by MRI. Those are images done ahead of time to make sure you understand the target, where the target is, how you’re going to enter the target with the laser. All of this planning is done on a workstation, and there are one of several workstations that exist in the scientific community that allow surgeons and teams to do this. Once this happens, patients get placed under general anesthesia for the most part. And in that operating room setting, once the targeting is done and the trajectory is optimized, the lasers are placed in the operating room. You have to use a drill to drill this small three-millimeter hole, and then you have to implant the laser and fix it. That laser gets secured as it goes into the target and then comes out through the scalp. Once that laser is secured, the patient is moved to an MRI. Now, depending on the facility, the patient is physically moved to a diagnostic scanner that is outside the operating room or an MRI is moved into the operating room, or the procedure is done in an operating room that has an MRI. All of these are options nowadays. Regardless, the patient was dealing with a cavernous malformation that was enlarging, had bled, and was causing her seizures. We offered laser therapy as an alternative and, again, it avoided open incision and a standard craniotomy. She went through the procedure beautifully. The technical aspects were straightforward. She stayed one night overnight and has not had a seizure since.
How many people are treated, roughly, in the United States with the laser?
DR DANISH: I have to admit that I don’t know that I can give you an exact answer, but I’d say that the total number of patients treated to date probably exceeds 10,000.
Is there anything I didn’t ask you, doctor, about the procedure that you would want to make sure that people know?
DR DANISH: What people need to understand is that procedures, whether they’re noninvasive, minimally invasive, or what you would consider maximally invasive, all have pros and cons. There’s no such thing as something being perfect for everybody. One of the challenges is that patients need to have a discussion with teams and physicians who are knowledgeable with all the possible options that exist for their particular disease process. If they have a brain tumor and they’re being counseled at a facility or by a team that doesn’t have access to a competent or busy laser program, they’re doing themselves a disservice because they’re not getting the benefit of that education and that counseling.
I had one question about Sky’s – the tangle. Is that a life-threatening condition or was that something that could be managed?
DR DANISH: I don’t want to say that it’s life-threatening because I don’t think it was going to be fatal for her. But it certainly was taking – you know, any time you take anybody at any age and they have uncontrollable seizures, it is a detriment on your life that is extremely impactful. Simply not being able to drive is a life altering event.
What temperature does the laser need to be heated to achieve that cell death?
DR DANISH: Sixty degrees Celsius and above, instantaneous cell death. But where these devices take advantage of what’s called time-dependent cell death is in this range between 45 and 60 degrees Celsius. In that range, you create cell death based on time exposure, and you can watch it happen. As the software calculates irreversible cell death, you can actually map it to the target. And sometimes it’s much more accurate than doing open surgery with the naked eye or a microscope because you can see these targets on MR imaging clearer than you would with the naked eye. Once we determine that the target has been ablated or procedure is finished, this small probe comes out right in the MRI. It’s a small two – you know, three-millimeter hole. It’s closed with a single stitch. Patients usually stay overnight and are discharged the next day.
What’s the benefit to be able to do this with ablation?
DR DANISH: There are two major benefits. One is you avoid a major opening. You don’t have to do a large incision or a large opening in the brain. Most surgeons or most people don’t realize that, even if you go through a completely uncomplicated, open operation, that 1/3 of people will have lifelong headaches just by virtue of having a craniotomy. This avoids that completely. The other is that there are locations in the brain that just cannot be accessed safely through traditional open techniques. This technology allows you to access those deep parts of the brain where, 10 years ago, these were considered inoperable or inaccessible.
Which conditions is this used for?
DR DANISH: Laser therapy in the brain is broadly divided into applicable for two disease categories. One is neurooncology, the world of primary and secondary brain tumors, and the other is epilepsy. And this is true for both adults and children
Prior to this technology, if someone had epilepsy, what are they looking at in terms of treatment?
DR DANISH: Depending on the type of epilepsy and what’s causing it – if it was surgical epilepsy, you’re looking at open surgery.
Are you able to speak to the patient, Skye, at all on her case?
DR DANISH: Skye is a young patient who, many years ago, developed an epilepsy syndrome secondary to what’s called a cavernous malformation. Cavernous malformations are benign formations of blood vessels. It’s a benign tangle of blood vessels that can leak a little bit of blood over time. That’s their natural history. That blood then can cause irritation in the brain and then patients can develop epilepsy from it. There are, over the years, been many procedures that have been developed to treat these things from medicines to open surgery. When open surgery becomes an option, patients over the last decade have looked to laser therapy as an alternative.
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.
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