For the first time in Israel, and with only a handful of precedents in the
world, doctors at Haifa’s Rambam Medical Center have “ablated” a dysfunctional
part of the brain in a patient with essential tremor (ET) using MRIguided
ultrasound rather than performing surgery.
A 73-year-old man, who was
unable to sign his name clearly or even hold a cup of tea without spilling it,
greatly improved from the painless procedure and was completely awake
throughout, doctor said.
Medical ablation is the removal of tissue by
vaporization or other erosive processes.
The technique of ablation by
heat of deep-seated brain tissue through an intact skull was made possible with
Israeli technology originally developed to remove myomas (benign fibroid growths
in the uterus) but was later applied abroad to ET, which manifests due to a
malfunction in the brain. The therapy was made possible by the integration of
MRI guidance and the heating of the tissue using focused ultrasound.
first Israeli patient, a Jerusalem hardware store owner named Sami Zangi, for
years could not hold a cup of water without spilling it, tie his shoelaces or
use the simplest tools. After the short treatment, he came out of the special
MRI scanner and, as his family watched, he wrote in a steady handwriting Herzl’s
famous quotation: “If you will it, it is no dream.”
reportedly spent three calm, wide-awake hours inside an MRI machine,
communicating with and monitored by Rambam senior neurologist Dr. Ilana
Schlesinger, head of the movement disorders and Parkinson’s center, while
Menashe Zaaroor of the neurosurgery department used a computer
mouse to direct 1,000 ultrasonic beams to the thalamic focal point that had been
targeted for thermal ablation.
The trade name of the noninvasive
treatment that he underwent is ExAblate Neuro.
The technology, a product
of InSightec Ltd., was developed at the Technion-Israel Institute of Technology
and experimented on at Sheba Medical Center at Tel Hashomer.
ultrasound ablation is sometimes still used for uterine surgery along with
conventional surgery. “But using it on myomas was the proof of concept,” said
Rambam director-general Prof. Rafael Beyar, a leading interventional
ET is a slowly progressive movement disorder of rhythmic
shaking whose cause lies deep within the brain.
Although usually not a
dangerous condition, essential tremor worsens over time and can be severe in
Sometimes mistakenly confused with Parkinson’s disease, it
can occur at any age but is most common in people over the age of 40. ET is at
least eight times more common than Parkinson’s, but up to a fifth of ET patients
develop Parkinson’s disease and a tenth have a family history of
Beyar told The Jerusalem Post that his hospital had spent millions of
dollars on the special MRI and InSightec’s ultrasound ablation
Zangi’s treatment was paid for by the patient’s public health
fund, but Beyar would not disclose which insurer it was and could not say
whether the treatment would be included in the basket of health services
available to all Israelis.
“We are a beta site for InSightec’s device,”
Beyar said. “The procedure we did here – this ability to treat problems inside
the brain without making holes – is a breakthrough. Surgeons can actually see
what they are doing from the outside, without going in. We think there is a
potential of also treating Parkinson’s and even [to] perform non-invasive
surgery on the brains of children. As ultrasound gets into children’s soft
skulls more easily than adults’ skulls, it might eventually be used on pediatric
After identifying the diseased part of the brain that
causes the essential tremor, Beyar said, the ultrasound is used to heat it to 40
degrees Celsius. This part of the ablation is reversible. When it is determined
that the warming up is effective, it is heated to 60 degrees to stop the tremor
permanently, and this is irreversible.
Thus one has to work very exactly.
We expect to try it on Parkinson’s symptoms later.”
But Beyar conceded
that Rambam will continue to perform the deep-brain stimulation (DBS) – for
surgically inserting electrodes into the brains of ET and Parkinson’s patients
to relieve their severe tremors. ExAblate Neuro is not suited for everyone, he
Asked to comment during a visit to London, Prof. Shlomo
Constantini, a senior neurosurgeon who heads the pediatric neurosurgery unit at
Dana Hospital of Tel Aviv Sourasky Medical Center, told the Post that his own
hospital was offered the InSightec device free, but that due to lack of
consensus among the staff, it was decided to hold off until treatment results
became more clear.
“The technology has been studied already for 10
It will take a long time, if ever, [before] the US Food and Drug
Administration approves it to ablate tumors or for use on children,” Constantini
said. “[ExAblate Neuro] is a promising technology, but the future will determine
whether conventional surgery or non-invasive ablation will be better. I can’t
predict now, but I am rather skeptical that it will be widely used. Perhaps it
will find a use in treating epilepsy.”
Dr. Zvi Israel, a leading DBS
neurosurgeon at Hadassah University Medical Center in Jerusalem’s Ein Kerem,
told the Post that while theoretically the InSightec technology was a
breakthough, he was not convinced that it would find broad uses.
be used safely only on one side of the brain, and ET usually affects both
sides,” he said. “It has been known for 60 years that making bilateral lesions
on both sides of brains is associated with a high risk of speech and swallowing
difficulties. We at Hadassah will continue to perform DBS implants; we have
performed 350 such implants, and only a small proportion were operated on for
ET. We think the impact of ultrasound ablation therapy will be
Dr. Kobi Vortman, InSightec’s CEO and president, who is an
electro-optics and electrical engineer and not a physician, maintained on his
website that “the way I see the future is the building of the next generation
operating room, replacing traditional surgery by non-invasive outpatient
The company was established in January 1999.
definitely look as the next step at brain tumors, prostate cancer, liver tumors,
breast cancer and so on,” Vortman said. “Eventually, we see it as a next
generation operating room centralized service in the hospital.”