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This Tremor Treatment Sounds Impossible (But It’s Already Here) · Tremor & Parkinson's Surgery Explained with Dr. Wu

• 0:00
  SPEAKER_00: Just imagine that if a tremor that makes it hard to write, drink from a glass, or use a fork could be reduced in just a matter of hours, all without an incision, without drilling into the skull, and without implanting a device.
• 0:12
  SPEAKER_00: That sounds pretty good, doesn't it?
• 0:14
  SPEAKER_00: And that's what focused ultrasound is designed to do.
• 0:16
  SPEAKER_00: I'm Dr.
• 0:17
  SPEAKER_00: Chin Yan-Wu and I'm a neurosurgeon specializing in the surgical treatments for both essential tremor and Parkinson's disease.
• 0:23
  SPEAKER_00: In this video, I'll explain how focused ultrasound works, who it may help, what patients should expect from the treatment, and what are the major risks and limitations.
• 0:32
  SPEAKER_00: So what exactly is focused ultrasound?
• 0:35
  SPEAKER_00: Well, focused ultrasound is a treatment that uses sound waves, specifically ultrasound, to target a very small part of the brain involved in the tremor.
• 0:43
  SPEAKER_00: And the treatment happens inside an MRI scanner so we can see exactly what we're doing in real time.
• 0:48
  SPEAKER_00: There is no incision in the scalp, no hole drilled into the skull, and no device implanted into the body.
• 0:54
  SPEAKER_00: But the treatment itself is still permanent.
• 0:57
  SPEAKER_00: Here's the dirty little secret that's important for you to understand.
• 1:00
  SPEAKER_00: Focused ultrasound is a new tool that we use to perform a very old type of movement disorder surgery.
• 1:07
  SPEAKER_00: That is ablation or lesioning.
• 1:09
  SPEAKER_00: Those are just fancy ways of saying that we are intentionally but very carefully destroying a very small part of the brain to change an abnormal circuit.
• 1:17
  SPEAKER_00: In fact, surgeons have been doing lesioning procedures long before DBS existed.
• 1:22
  SPEAKER_00: So focused ultrasound is not necessarily a new treatment, but it gives us a new way to perform it without drilling into the skull or opening it at all.
• 1:31
  SPEAKER_00: Instead, focused ultrasound allows us to heat up a very small target in the brain to create a lesion that interrupts part of the abnormal circuit, producing the tremor.
• 1:40
  SPEAKER_00: If you watch my video about the history of movement disorder surgery, this idea fits directly into that story.
• 1:46
  SPEAKER_00: So who should consider focused ultrasound?
• 1:48
  SPEAKER_00: Well, focused ultrasound is usually something that people start thinking about when tremor starts taking things away from you.
• 1:55
  SPEAKER_00: You stop ordering soup at a restaurant because you can't get the spoon up to your mouth.
• 1:59
  SPEAKER_00: You need to use two hands to hold a glass when you drink, or getting buttons done or undone becomes a hassle, or shaving becomes an adventure.
• 2:08
  SPEAKER_00: Or maybe you just stop doing the things that used to feel automatic.
• 2:11
  SPEAKER_00: So this is when we start to ask whether medication is still doing enough.
• 2:16
  SPEAKER_00: Focused ultrasound may be considered when tremors clearly interfering with daily life and medication is either no longer controlling it well enough or causing side effects you just can't tolerate.
• 2:26
  SPEAKER_00: But a severe tremor does not automatically make someone a good candidate for focused ultrasound.
• 2:32
  SPEAKER_00: We also need to know what kind of tremor you have, which symptoms actually are limiting you in your day-to-day life, whether you already have balance or walking problems, whether the anatomy of your skull allows the ultrasound energy to reach the target effectively, and whether you can tolerate laying awake and still inside an MRI scanner for a couple of hours.
• 2:51
  SPEAKER_00: The primary patient population for focused ultrasound are those who are suffering from essential tremor.
• 2:57
  SPEAKER_00: This is where focused ultrasound has the longest track record and where most patients consider this treatment.
• 3:03
  SPEAKER_00: The next group are those with Parkinson's disease, but specifically tremor-predominant Parkinson's disease where tremor is the main problem.
• 3:11
  SPEAKER_00: For those patients, focused ultrasound used the same general tremor target and is really intended to focus on treating the tremor alone.
• 3:18
  SPEAKER_00: More recently, however, focused ultrasound is being used more broadly for other symptoms of Parkinson's disease.
• 3:25
  SPEAKER_00: Specifically, it is now approved for selected patients with Parkinson's disease with some other motor symptoms rather than tremor.
• 3:32
  SPEAKER_00: In this case, the focused ultrasound is used to create a lesion in a different target, a completely different part of the brain.
• 3:38
  SPEAKER_00: Now, this approach can treat symptoms beyond tremor, but remember they treat specific motor symptoms and complications, not the underlying Parkinson's disease.
• 3:46
  SPEAKER_00: And the data are more recent for treating Parkinson's disease.
• 3:49
  SPEAKER_00: So for some of these newer targets, the studies are also smaller or less mature than the essential tremor evidence.
• 3:55
  SPEAKER_00: So I think about the evidence in that order.
• 3:58
  SPEAKER_00: Essential tremor first, then tremor-predominant Parkinson's disease, and then broader Parkinson's symptoms as a more recent application.
• 4:05
  SPEAKER_00: So because of that, the evidence is not equally strong for every focused ultrasound target.
• 4:11
  SPEAKER_00: And the real question is not simply how bad is the shaking or the tremors.
• 4:15
  SPEAKER_00: The real question becomes: is the tremor the main problem we need to solve?
• 4:18
  SPEAKER_00: And can we treat it without creating a new problem?
• 4:21
  SPEAKER_00: That is why the evaluation should involve a movement disorder specialist and a neurosurgical team experienced in treating medically refractory tremor.
• 4:29
  SPEAKER_00: So let's move on to how does focus ultrasound actually work?
• 4:33
  SPEAKER_00: To be honest, the technology behind this is really amazing.
• 4:36
  SPEAKER_00: During the procedure, the patient's head is positioned inside a helmet containing more than a thousand individual ultrasound emitters.
• 4:43
  SPEAKER_00: Each one of those emitters sends a separate beam of ultrasound energy through the skull.
• 4:47
  SPEAKER_00: Now, on its own, each beam carries too little energy to treat the brain tissue it passes through.
• 4:52
  SPEAKER_00: But if all of those beams are focused or aimed at the same tiny target where they meet, the energy becomes concentrated enough to heat that tissue to the point where we are able to create a lesion.
• 5:03
  SPEAKER_00: So this is similar to using a magnifying glass on a sunny day to focus the sunlight onto one single point.
• 5:09
  SPEAKER_00: The energy from the light is not concentrated everywhere it passes, but it becomes powerful when it all comes together and we can use it to burn things.
• 5:16
  SPEAKER_00: For tremor, the target is usually a small area of a structure in the middle of the brain called the thalamus.
• 5:22
  SPEAKER_00: The specific part of the thalam that we are treating is called the ventral intermediate nucleus or Vim.
• 5:28
  SPEAKER_00: And that really represents the motor thalamus.
• 5:31
  SPEAKER_00: That area is part of the circuit of the brain responsible for coordinating movement.
• 5:35
  SPEAKER_00: And in those with tremor, can be responsible for producing the tremor.
• 5:39
  SPEAKER_00: So the MRI allows us to locate that target based off of the patient's individual anatomy and monitor the temperature as the treatment is delivered in real time.
• 5:47
  SPEAKER_00: And that's the real benefit of this technology, being able to see exactly what we're doing in real time as we're doing it.
• 5:55
  SPEAKER_00: So during one treatment session, we deliver a series of carefully controlled ultrasound bursts beginning at a lower energy.
• 6:02
  SPEAKER_00: We don't just go in and create a lesion right away.
• 6:04
  SPEAKER_00: We start with small test doses to make sure we're in the correct location.
• 6:08
  SPEAKER_00: After each step, we check whether tremor is improving or not and ask whether the patient is noticing any other symptoms like numbness, tingling, speech changes, or other effects.
• 6:18
  SPEAKER_00: We can then make very small adjustments to the target or to the amount of energy before delivering the final treatment.
• 6:24
  SPEAKER_00: It's important to know that even if we see a response or a side effect with these tests, the amount of energy that we are initially delivering is too low for these symptoms to be permanent.
• 6:35
  SPEAKER_00: So whatever we see at this point in the treatment, good or bad, is only temporary.
• 6:40
  SPEAKER_00: Only when we are confident that we are in the correct location do we apply the full amount of energy and the final treatment that performs the permanent ablation.
• 6:48
  SPEAKER_00: That combination of MRI guidance and real-time patient feedback is what allows us to treat such a small area with great precision.
• 6:56
  SPEAKER_00: So that's what my experience or the surgeon's experience is like during the focused ultrasound procedure.
• 7:02
  SPEAKER_00: But what does the patient experience?
• 7:03
  SPEAKER_00: Well, before the procedure, your team will give you specific instructions about when to stop eating and when to stop drinking, and whether you need to stop taking any tremor medications or stop taking your blood thinner medications.
• 7:16
  SPEAKER_00: Be sure not to stop any of your own prescription medications on your own.
• 7:19
  SPEAKER_00: Follow the plan provided by your treatment team.
• 7:22
  SPEAKER_00: Now, on the day of the focused ultrasound procedure, when you arrive, we start by getting a baseline exam and measure your tremor.
• 7:28
  SPEAKER_00: So you may be asked to hold your hands out or draw a spiral, hold a cup, or complete another simple movement.
• 7:36
  SPEAKER_00: This is also we have a clear picture of where you are starting in terms of your symptoms and your tremor.
• 7:41
  SPEAKER_00: Next, unfortunately, your entire head will need to be shaved.
• 7:45
  SPEAKER_00: This is done with a razor to make sure there are absolutely no hairs that could interfere with how the ultrasound energy is transmitted into the brain.
• 7:53
  SPEAKER_00: Once we have you bald, no hair, a frame is attached to your head to keep it completely still during the time of the treatment.
• 8:00
  SPEAKER_00: This involves injecting numbing medicine into your scalp at four points.
• 8:04
  SPEAKER_00: Two up in the front and two in the back.
• 8:07
  SPEAKER_00: We then secure the frame to your skull with pins that lock it in place.
• 8:11
  SPEAKER_00: We also need to put what we call a membrane over your head, and it'll feel like a really tight hat, and it needs to be tight to hold the water that is used for the procedure.
• 8:19
  SPEAKER_00: Once you have the frame and the membrane on, we take you to the MRI scanner and get you as comfortable as possible.
• 8:25
  SPEAKER_00: The frame is locked to the MRI table and then connected to the helmet with the ultrasound emitters.
• 8:31
  SPEAKER_00: Cool water then circulates around your scalp to help conduct ultrasound waves and to protect the skin.
• 8:36
  SPEAKER_00: Now, for the duration of the procedure, you'll need to lie awake on your back inside the MRI scanner with your head secured in the frame.
• 8:42
  SPEAKER_00: In general, I tell people to expect approximately two hours in the frame and on the MRI table, although the exact length can vary from procedure to procedure.
• 8:51
  SPEAKER_00: Throughout the procedure, the team can see you, speak with you, and monitor you, and you'll be able to talk to us if needed.
• 8:57
  SPEAKER_00: At different points, we will move the table with you attached to it, partly out of the scanner, and repeat the same tests, holding out your arm, drawing a spiral, maybe holding a cup or another object.
• 9:08
  SPEAKER_00: And we'll also ask you to speak and to let us know if you feel any weakness, numbness, or tingling.
• 9:14
  SPEAKER_00: That allows us to see if the tremor is changing during the treatment while also watching out for possible side effects.
• 9:20
  SPEAKER_00: Now, during the ablations themselves, some patients feel pressure or discomfort on the scalp when the ultrasound is delivered.
• 9:26
  SPEAKER_00: Some describe it as feeling a little bit like a sunburn for a bit on their scalp.
• 9:31
  SPEAKER_00: Others might also feel like they are flipping upside down as if you're on a roller coaster during the ablation itself.
• 9:37
  SPEAKER_00: If you have significant claustrophobia, anxiety about being awake in the MRI, or pain that makes it difficult to lay still for a long period of time, please make sure to tell your team before the procedure because this can really make a difference in terms of how we approach choosing the right treatment for you.
• 9:51
  SPEAKER_00: Now, when we do this procedure, how quickly does a tremor actually improve?
• 9:56
  SPEAKER_00: Well, one of the great and really amazing things about focused ultrasound is the change is immediate and can be visible during the procedure as we're doing it.
• 10:04
  SPEAKER_00: So, like I mentioned before, after a treatment step, we ask the patient to hold the arm out, draw another spiral, or hold an object.
• 10:12
  SPEAKER_00: And after each of these steps, we typically see that the tremor continues to get better and better as we continue the treatment.
• 10:17
  SPEAKER_00: So by the end of the procedure, many patients notice a significant difference in the treated hand or arm.
• 10:23
  SPEAKER_00: And this is effectively the result that we continue to see over time.
• 10:26
  SPEAKER_00: Now, research shows that most patients improve, but durability really depends on which disease we are treating.
• 10:32
  SPEAKER_00: For essential tremor, this is where the evidence is the strongest.
• 10:36
  SPEAKER_00: We have solid five-year data showing that meaningful tremor benefit can persist for years.
• 10:41
  SPEAKER_00: To get a little bit into the details and the specific numbers, in the trials that led to the FDA approval for essential tremor, the shakiness or tremors in the treated hand improved by about 75% on average.
• 10:53
  SPEAKER_00: And long-term follow-up found that benefit was largely maintained five years later.
• 10:58
  SPEAKER_00: When you look at overall hand function, so not just the tremor improvement, but the average improvement in the ability for the hand to function, that is somewhat more modest and closer to 40 to 50% improvement because some tremor can remain and the effect may soften over time.
• 11:13
  SPEAKER_00: But when it comes to what is most important, quality of life, how much does focus ultrasound actually improve your day-to-day quality of life?
• 11:21
  SPEAKER_00: Patients reported that the quality of life improved by roughly 45 to 55%.
• 11:26
  SPEAKER_00: And that really means real gains in the eating, dressing, writing, working, and being comfortable in public.
• 11:32
  SPEAKER_00: So a significant improvement.
• 11:34
  SPEAKER_00: For tremor-predominant Parkinson's disease, the initial response can be very good as well.
• 11:39
  SPEAKER_00: But unfortunately, the long-term durability is a little less reliable.
• 11:43
  SPEAKER_00: Some patients lose benefit over time, and unfortunately, tremor recurrence is more common in those with tremor-predominant Parkinson's disease than it is with essential tremor.
• 11:52
  SPEAKER_00: Now, that difference matters when we are talking about a procedure that is intended to be a permanent treatment.
• 11:57
  SPEAKER_00: Another thing that is important to note, and I want to emphasize, is that when we do research on these outcomes, the numbers on improvement that we get describe groups of patients, very large groups of patients in these studies.
• 12:08
  SPEAKER_00: And that's always something we have to be a little bit careful about when we try to translate that into what it means for an individual person.
• 12:15
  SPEAKER_00: What we know from these studies gives us a likelihood that things will get better and a likelihood of risk, but unfortunately don't guarantee the result for one individual, which is what most patients really care about.
• 12:26
  SPEAKER_00: Ultimately, the degree of improvement varies and some tremor may remain for some people.
• 12:31
  SPEAKER_00: Now, another important detail about focused ultrasound treatment is that it is able to treat one side of the brain.
• 12:37
  SPEAKER_00: And the way that the human body works is that one side of the brain controls the opposite side of the body.
• 12:42
  SPEAKER_00: So if we treat the left side of the brain, we are really treating the tremor on the right side of the body.
• 12:47
  SPEAKER_00: So if you have tremor on both sides, we need to decide which side interferes most with your day-to-day activities, your eating, drinking, writing, working, or other daily activities that are important to you.
• 12:58
  SPEAKER_00: Unfortunately, both sides cannot be treated during the same procedure.
• 13:01
  SPEAKER_00: Focused ultrasound is a one side at a time treatment.
• 13:05
  SPEAKER_00: Now, some patients may be able to have the second side treated, but when we treat the other side, that procedure is staged or delayed by at least nine months after the first treatment.
• 13:15
  SPEAKER_00: This weight is not to torture you, but to make sure that you have had a chance to fully recover and heal from the first procedure, especially if you experience some of the temporary side effects.
• 13:25
  SPEAKER_00: So if you have tremor in both hands, you'll still have tremor on the untreated side after the first procedure.
• 13:31
  SPEAKER_00: And since everything is relative, it's fairly common to feel that the untreated tremor feels quote unquote worse, since the treated side is now so much better.
• 13:39
  SPEAKER_00: Now that we've talked about the procedure itself and what we expect in terms of benefit, what about after the procedure?
• 13:45
  SPEAKER_00: Once the treatment is complete, the frame and the cooling helmet are removed.
• 13:49
  SPEAKER_00: The small pin sights on the scalp are cleaned and covered, and you'll be asked to repeat some of the same movement tests yet again, those that you perform before and during your treatment, such as drawing another spiral, holding the cup, holding out your arms.
• 14:01
  SPEAKER_00: And this is also we can compare the tremor with your initial baseline exam.
• 14:04
  SPEAKER_00: You'll then be monitored for a short period before going home the same day.
• 14:08
  SPEAKER_00: Because there are no surgical incisions, stitches, or implanted hardware.
• 14:12
  SPEAKER_00: In my practice, you can certainly resume eating and get up and around and walking pretty much right away.
• 14:18
  SPEAKER_00: Just to be safe, I recommend having a family member or a friend be around to help you around the house for the first week or so.
• 14:25
  SPEAKER_00: During that first week, I prefer that patients don't drive, but it can be different across practices.
• 14:29
  SPEAKER_00: So make sure to check with your surgeon.
• 14:31
  SPEAKER_00: Again, I want you up and around pretty much right away.
• 14:34
  SPEAKER_00: And after that first week, I'd like you to increase activity as much as you are able to so that you're pretty much back to everything that you're doing after a couple of weeks.
• 14:42
  SPEAKER_00: The team will also provide specific instructions about when to restart tremor medication and any blood thinning medication you may be on already.
• 14:49
  SPEAKER_00: Some patients feel well enough to resume most normal activities as early as within a few days.
• 14:54
  SPEAKER_00: Others might need a little more time because of fatigue, dizziness, issues with balance, or other temporary side effects.
• 15:01
  SPEAKER_00: What it comes down to is make sure to follow the recovery instructions from your own treatment team and from your own surgeon and make sure to report any symptoms that are persistent, worsening, or concerning to you.
• 15:10
  SPEAKER_00: So those are the nuts and bolts of the surgery.
• 15:13
  SPEAKER_00: What about the risks?
• 15:14
  SPEAKER_00: So we've talked about all the good, we got to talk about all the bad that goes with it, unfortunately.
• 15:18
  SPEAKER_00: Now, the real strength of focused ultrasound is that it avoids a scalp incision and implanted hardware, but it is certainly not risk-free.
• 15:24
  SPEAKER_00: The location we are targeting in the brain is part of the same high-value real estate where there are nearby brain pathways involved in sensation, coordination, walking, speech, and swallowing.
• 15:35
  SPEAKER_00: If those pathways are affected, patients may experience numbness or tingling in the face, lips, tongue, or fingers, unsteadiness or difficulty walking because of balance issues, problems with coordination, changes in speech, or difficulty swallowing.
• 15:50
  SPEAKER_00: Most of the time, these side effects, fortunately, are related to temporary swelling around the treated area and will generally improve over days, weeks, sometimes months.
• 16:00
  SPEAKER_00: But unfortunately, some can persist.
• 16:02
  SPEAKER_00: Our current studies show that there can be long-term coordination problems in approximately 15% of patients, gait difficulty, problems with walking in approximately 10% of patients, and persistent sensory symptoms in approximately 13% of patients.
• 16:18
  SPEAKER_00: And again, unfortunately, these are long-term side effects that don't necessarily go away.
• 16:23
  SPEAKER_00: At the same time, most of these permanent side effects reported in the major tremor studies have been mild, but they can still matter.
• 16:29
  SPEAKER_00: And because focused ultrasound creates a permanent lesion, we cannot simply reprogram the lesion.
• 16:34
  SPEAKER_00: If a persistent neurologic effect occurs, it's there for good.
• 16:38
  SPEAKER_00: Now, those focused ultrasound risk numbers deserve to be discussed carefully with your surgeon because the risk and how much the side effects matter depend on your existing balance problems, existing coordination problems, and your specific goals for daily activity, what really matters to you.
• 16:53
  SPEAKER_00: And this is also why we don't judge the procedure only by whether the tremor improves.
• 16:58
  SPEAKER_00: The goal is meaningful tremor reduction without creating a new problem.
• 17:02
  SPEAKER_00: So to wrap things up and go over some of the important points, focused ultrasound uses sound waves and MRI guidance to permanently treat tiny area of the brain.
• 17:11
  SPEAKER_00: For the right patient, the improvement can be visible and it can be remarkable even before the procedure is over.
• 17:18
  SPEAKER_00: But remember the central idea.
• 17:20
  SPEAKER_00: Focused ultrasound is a new tool for an established old surgical technique that we call ablation.
• 17:26
  SPEAKER_00: Today, it is most established in a central tremor, and that is where we have the strongest long-term durability data.
• 17:33
  SPEAKER_00: It has an established role for tremor-predominant Parkinson's as long as we have reasonable expectations of it helping the tremor and not necessarily the other symptoms.
• 17:42
  SPEAKER_00: And in these patients, the early response can be similar, but the long-term benefit is less predictable.
• 17:47
  SPEAKER_00: And it's used for the broader symptoms of Parkinson's disease, things like stiffness, slowness, dyskinesia, dystonia.
• 17:54
  SPEAKER_00: That evolution is important, but also a more recent development.
• 17:58
  SPEAKER_00: And the goal here is simply not to reduce the tremors or other symptoms, but is to reduce those symptoms without creating new ones, new problems like issues with balance or sensation, coordination, speech or swallowing.
• 18:12
  SPEAKER_00: If you want to understand where ablation and DBS fit in the history of movement disorder surgery, watch my history video next.
• 18:18
  SPEAKER_00: And if you're trying to decide between DBS and focused ultrasound, I have a video comparing the two treatments as well.
• 18:23
  SPEAKER_00: If you are wondering whether your symptoms have reached the point whether surgical treatment should even be part of the conversation, watch this video next about whether to consider brain surgery for Parkinson's disease.
• 18:33
  SPEAKER_00: And if tremor is interfering with your daily life and you want to get more information or reach out to someone from my team, feel free to shoot an email in the link below.
• 18:43
  SPEAKER_00: Until next time.
• 18:44
  SPEAKER_00: Bye.