Advanced technology is allowing physicians new ways to treat disease and correct abnormalities. Although the thought of having a wire inserted in the brain, a balloon in the cheek or a defibrillator in the chest can be daunting, technological advances have made implants and surgical devices an everyday reality.
And that reality has produced superior and amazing outcomes.
Trevo and Penumbra
Dr. Mayumi Oka, a neurointerventional radiologist at Methodist Hospital, is using a new device called the Trevo to remove blood clots from the brain of stroke victims. She also uses another mechanism: the Penumbra, which has been in use for several years. Both the Penumbra and the Trevo, which was approved by the FDA in August 2012, must be used within six hours of the time stroke symptoms appear, Oka says.
Which of the two devices Oka chooses “depends on the situation,” and she compares the Penumbra to a vacuum tube that sucks the clot from the vessel it’s occluding. Although the Trevo can only be used on larger vessels, Oka uses that device more often. The Trevo opens the occluded vessel more quickly, which is critical because brain cells die off when their blood supply is interrupted.
“It’s easier to use and opens the vessel quicker,” Oka says. “We’re always fighting for time. The faster, the better.” Unfortunately, not all stroke victims are eligible for the procedure. “If the infarct is complete, there’s no benefit to opening the vessel,” Oka says. “There’s a small window of time for us to do any good. But whenever it opens in a reasonable time, it makes a pretty dramatic outcome.”
Oka was the first physician and Methodist was the first hospital in the Region to use these devices on stroke patients.
Dr. Hytham Rifai, a neurologist and founder of Neurological & Spinal Surgery, is one of the first surgeons in the area to offer minimally-invasive microscopic spinal surgery, vascular neurosurgery and stereotactic radiosurgery using the Gamma Knife modality.
“In every area of medicine, there’s a different device,” Rifai says. “We try to choose the best one. Technology is getting better, surgeons are getting better and patients are benefiting from it.”
Rifai is one of the few neurologists to do a procedure called percutaneous balloon compression of the trigeminal nerve that aids patients with facial pain.
“The pain is like someone sending electric current through the face,” Rifai says. “It’s excruciating pain that keeps people from living a normal life. After the procedure, there’s instant relief. I’ve got more hugs after this procedure than any other.”
During the procedure a balloon is implanted into the cheek and inflated to numb the nerve. Recent improvements in the balloons have improved the outcome of the procedure, says Rifai, who practices Franciscan Alliance, Community Healthcare and Methodist Hospital Healthcare systems, though Methodist is the only hospital that currently uses the Gamma Knife technology.
There also has been improvement in the intra-arterial endovascular treatments for arteriovenous malformations and brain aneurysms using technology and the Gamma Knife, Rifai explains.
“It’s where people are born with a bunch of vessels inside the brain that don’t belong there,” he says. “They can cause a stroke or seizures. Surgery is very risky so now we’re doing it from the outside.”
Seeds made of onyx are inserted into the core of the brain malformation using a small catheter. The onyx seeds destroy or seal the vessels and any troublesome vessels that remain are treated with the Gamma Knife. “There’s no harm to the patient,” Rifai adds.
Subcutaneous Implantable Cardioverter-Defibrillator
Ingalls Memorial Hospital cardiologist Dr. Andy Lin is excited about a new device that removes the need to put wires into the veins leading to the heart to correct arrhythmias.
The Subcutaneous Implantable Cardioverter-Defibrillator helps to restore regular heart rhythms with leads that can be implanted just under the heart muscle, instead of connected directly into the heart. This device is widely available at hospitals across Northwest Indiana as well as south suburban Chicago.
It is a small battery-powered device that constantly monitors a person’s heart rhythm and can deliver a therapeutic dose of electricity to restore the rhythm when it senses the heart is beating dangerously fast or chaotically, causing sudden cardiac arrest.
The new devices are a huge improvement and will prevent many of the problems occurring with the type now commonly used in this area, Lin says.
“In the past we had defibrillators that were implanted under the skin near the clavicle and you have to insert a lead into the vein and down the vein into the upper or lower right chamber of the heart,” Lin says. “Then the lead is connected to the defibrillator.”
Problems can occur when the lead corrodes or become infected, he says.
“Bacteria can be introduced that’s impossible to get rid of,” Lin says. “Once there’s infection, we are forced to extract the leads by surgery—it’s the only way to get rid of infections. Then we wait for the infection to clear and reinsert the leads.”
Many patients have pacemakers prior to having defibrillators, which means that there is another step in the procedure.“The leads are different, and you have to either leave them in or extract them,” Lin explains. “And there are times when they stop working or fracture, which then increases the risk of infection. The subcutaneous implantable cardioverter-defibrillators are a good alternative for people who need defibrillators but are at high risk for blood-borne infections, especially dialysis and immune-repressed patients.”
The new type of cardioverter-defibrillators are also better for pediatric patients because the longer a lead is in place, the more likely that the lead could malfunction or become infected, Lin says. The SICD’s were approved by the U.S. Food and Drug Administration in 2012 and are currently used in only large university hospitals. But Lin says he and others in the area will be trained to use them very soon. “It will be a big step forward,” he says.
Deep Brain Stimulation
Munster’s Community Hospital neurosurgeon, Dr. Wayel Kaakaji, is using a minimally invasive procedure during Deep Brain Stimulation to treat Parkinson’s and Essential Tremor patients. “Deep Brain Stimulation involves placing a wire in the brain that is connected to a pacemaker which delivers electrical treatment to the brain for movement disorders,” Kaakaji says. “I’ve been doing them since 1999. Now they’ve changed dramatically.”
There are three components of the procedure: the implanted pulse generator (IPG), the lead containing four electrodes that are placed in the brain, and the extension, according to medical literature.
The generator sends electrical pulses to the electrodes that eliminate the uncontrolled activity.
The lead is connected to the generator by the extension, which is an insulated wire that runs from the head, down the side of the neck, behind the ear to the implanted pulse generator that is placed under the skin below the clavicle or in some cases, the abdomen.
Deep Brain Stimulation is very labor intensive, complicated and requires a great-deal of coordination, therefore anything that improves the treatment benefits both the medical staff and patient, Kaakaji says.The new method eliminates the use of cumbersome cages put on the patient’s head hours before and during the lengthy surgery, he says. The cages are bolted into a patient’s then screwed into the operating table to keep them immobile while the electrodes and extension are put in position within the brain.
The cage is extremely uncomfortable to the patient, especially one that has Parkinson or tremors that causes uncontrolled movement.
During the surgery, a five-inch wire is directed into an area less than a quarter of an inch wide. “If it’s not right, there are no benefits and may harm the patient,” Kaakaji says. “There needs to be extreme accuracy. Now the treatment’s the same concept, but the frame is a little tiny gizmo that goes on top of the skull and is attached with tiny screws that go into head.”
The screws are the size of pencil lead and the “gizmo” isn’t attached to the operating table.“Patients aren’t pinned down so it’s much easier on them,” Kaakaji explains. The treatment had been used only infrequently in Northwest Indiana until Community invested in the technology. “Hospitals here haven’t historically invested in equipment,” Kaakaji says. Now a program at Community is offering it full service. It’s a full-fledged program. Historically patients were told to go to the city and that’s were the patients went. That was very daunting, especially for the elderly.
Likewise, Neurologist Dr. Arif Dalvi, says that in the future there will be a comprehensive multidisciplinary team approach similar to the program that has been developed at Methodist Hospitals to treat movement disorders. While Deep Brain Stimulation is included in the mix, there are other therapies that improve patient outcomes as well for Parkinson's Disease, spasticity, dystonia and other increasingly common neurological disorders.