Inova Begins Era of MRI-guided Neurosurgery with Implantation of Deep Brain Stimulator

Mahesh Shenai, MD, MBA, is a specialty care physician at the Inova Movement Disorders Program at the Inova Neuroscience & Spine Institute. He has a special interest in functional and restorative neurosurgery. Read Dr. Shenai’s profile.

Last week, for the first time at the Inova Health System, we performed brain surgery inside the MRI scanner to treat a patient with Parkinson’s Disease. It’s an exciting new approach that has the potential to help many more patients going forward.

The patient was a 62-year-old man with Parkinson’s Disease, a degenerative brain disorder that causes symptoms such as tremor (involuntary shaking), stiffness and slowed movement. Although standard medications initially worked to treat his symptoms, the progression of the disease began to overpower his medications. His neurologist (and my colleague), Sean Rogers, MD, suggested Deep Brain Stimulation (DBS), an FDA-approved surgical procedure to implant a brain “pacemaker” that counteracts the symptoms of Parkinson’s Disease.

The patient was enthusiastic about receiving DBS – but there was a catch. Normally, the procedure is done while a patient is awake, allowing our surgical team to test the patient for its good and bad effects and make adjustments as necessary. However, this patient experiences anxiety and panic attacks, and he just was not comfortable being awake during surgery. So, in a process that took several months to put into place, we adopted a cutting-edge process to implant DBS while he was “asleep,” or under general anesthesia.

Deep Brain Stimulation: Real-Time Feedback

DBS involves surgically implanting an electrode into a specific target structure, located deep within the brain. This electrode is later connected to a battery-operated device that sends electrical stimulation to the deep brain target, blocking the abnormal signals that cause tremors and other movement problems.

Typically, we take MRI scans of the patient’s brain, before the procedure, so we can identify the target to place the device. However, our methods of placing the electrode to this target are relatively imperfect, as we need to be precise by less than a single millimeter. Without advanced imaging available in the OR (operating room), we are instead forced to keep the patient awake, continuously testing the effects of stimulation and deciding to make adjustments in its placement. While still rewarding in the long term, this process can be uncomfortable to patients – and many avoid the procedure altogether because of the fear of staying awake.

But, in the past few years, the neurosurgical and radiology team at the University of California, San Francisco, has developed a new approach, allowing surgeons to implant the device while the patient is inside the MRI scanner. Rather than relying on the patient’s feedback to find the right targets in the brain, we can use real-time images from the MRI to guide us to the perfect location.

A New Surgery Model

I knew this new technique could be a great choice for this patient and others for whom awake surgery is not an option. But merging the MRI room with the operating room was easier said than done.

To make this surgery a reality at Inova, we had to install special equipment in our MRI scanner and furnish it with new MRI-compatible tools (such as scalpels and drills) that allowed us to perform surgery. Until now, we’d never made an incision inside the MRI scanner, so we had a series of technical and administrative steps to go through to make it happen.

Most importantly, we brought together a team of nearly two dozen people, including surgeons, neurologists, radiologists, anesthesiologists and imaging experts, to make sure the surgery would go smoothly and safely. We even tested the procedure on a cadaver to ensure every detail was accounted for.

A Promising New Option For Patients with Parkinson’s Disease, Essential Tremor and Dystonia

While this new MRI-guided procedure has its benefits, the traditional “awake” DBS surgery will still be the procedure of choice for many patients – as awake feedback is irreplaceable. Nevertheless, for a large group of patients who fear this concept, we can now offer an alternative.

Inova is the first hospital system in the DC-Maryland-Virginia area that can routinely offer this type of procedure. Inova’s excellence in multiple fields – including neurosurgery, neurology, radiology and anesthesia – allows for the seamless multidisciplinary coordination required for this type of surgery.

Learn more about the Inova Movement Disorders Program.