Sunnybrook neurosurgeons Dr. Nir Lipsman (left) and Dr. Michael Schwartz (right) prepare tremor patient Noreen Smith for focused ultrasound treatment.
Just moments after brain surgery, 76-year-old Noreen Smith stood up and did a pirouette.
She was feeling fine, and pleased to be rid of the dramatic tremors in her dominant right hand that, for decades, had hampered her ability to write, paint or even raise a glass of water to her mouth.
The scalpel-less procedure and its results, she says, were "miraculous."
Noreen's therapy, conducted using revolutionary focused ultrasound technology, is indeed a modern marvel. It signifies the dawn of a new era, a time when beams of sound are used to alter the brain's function and make it more accessible to treatment.
Focused ultrasound is so promising, it is poised to take its place among humanity's most important medical advances — right alongside insulin, penicillin and the X-ray. Its potential to save lives and eliminate suffering is inestimable.
Sunnybrook is leading the way into this future.
The hospital has the most comprehensive and successful brain-based focused ultrasound program in the world. This distinction was recently recognized by the Focused Ultrasound Foundation in the U.S., which designated Sunnybrook as the first Focused Ultrasound Centre of Excellence in Canada – and one of only six globally.
While Sunnybrook's focused ultrasound program spans many applications, including cancer, cardiology, orthopedics, urology and gynecology, a major focus is on brain diseases.
Focused ultrasound is a method of focusing ultrasonic waves, guided by state-of-the-art MR imaging, through skin, bone or skull to destroy or modify tissue.
'Sunnybrook is at the intersection of technology, neuroscience and medicine'
Dr. Nir Lipsman,
Scientist
Hurvitz Brain Sciences Program,
Sunnybrook Research Institute
In Noreen's case, focused ultrasound energy was directed from a specially designed helmet to burn away a tiny area deep in her brain that is known to cause essential tremor.
Her neurosurgeon Dr. Michael Schwartz carefully explained what Noreen should expect, and then carried out the procedure with her awake so that she could participate and be examined.
Inside the MRI machine, she was able to experience a real-time reduction of her tremors. "It all seemed quite futuristic. I am grateful to Sunnybrook and thrilled with the result," she says.
This revolutionary technology is developing at a furious pace, thanks in large part to Dr. Kullervo Hynynen, a brilliant medical biophysicist at Sunnybrook Research Institute. He pioneered the technology more than two decades ago and continues to refine it, including building the helmet used in Noreen's procedure.
Dr. Hynynen came to Sunnybrook from Harvard in 2006, attracted by its imaging expertise and the opportunity for clinical collaboration.
A quiet and understated visionary, Dr. Hynynen sees a day coming when focused ultrasound devices are portable, economical, and routinely used to treat brain disorders. Transforming Alzheimer's disease is one example.
"Twenty-five years from now, Alzheimer's disease won't be hopeless like it is now. It will be treatable, and focused ultrasound will have a role," he says.
Focused ultrasound can be used at either high or low intensities, with distinct effects. High-intensity focused ultrasound (HIFU), the type Noreen received, works by heating up and destroying diseased cells.
Low-intensity focused ultrasound (LIFU) stimulates cells, causing them to move or change their physical aspects.
LIFU can be used in one of two ways. It can open the blood-brain barrier to allow researchers to deliver stem cells, gene therapy, immunotherapy, growth factors or medications directly into the brain. The blood-brain barrier prevents materials, including 97 per cent of all drugs, from entering the brain.
In 2015, Sunnybrook was the first hospital in the world to demonstrate that focused ultrasound can be used to temporarily and non-invasively open the blood-brain barrier to allow medication into the brain. Dr. Hynynen and neurosurgeon Dr. Todd Mainprize achieved this in a brain cancer patient.
The other way that LIFU can change lives is by using it on its own, with no therapy. Dr. Hynynen and Sunnybrook brain repair scientist Dr. Isabelle Aubert were the first in the world to show, in pre-clinical models, that LIFU alone can stimulate the growth of new neurons.
This process, called neurogenesis, is the Holy Grail of dementia treatment, for the hope it offers in restoring lost brain function.
The scientists also showed that LIFU alone improves memory. Repeating this in humans would be a game-changer for those with neurodegenerative diseases.
Sunnybrook will be the first to explore this frontier. The hospital has received regulatory approval to begin the first-ever clinical trial of focused ultrasound in patients with Alzheimer's disease.
Dr. Nir Lipsman, a specialist in functional neurosurgery, will be leading the Alzheimer's blood-brain barrier trial and has other focused ultrasound studies either underway or planned, to investigate its merit in treating obsessive-compulsive disorder, major depression, Parkinson's and stroke.
Dr. Lipsman helped lead the essential tremor trial that Noreen was involved in, successfully steering the procedure through safety protocols and the other complexities of moving a discovery from the lab to the clinic.
"Sunnybrook is the epicentre of focused ultrasound brain research," says Dr. Lipsman. "We are positioned at the intersection of technology, neuroscience and medicine, ready to change the future for people with intractable brain disorders."
For Noreen, this technology made a world of difference.
No longer haunted by a tremor in her right hand, she is holding firm to life's pleasures: writing, completing crossword puzzles and even playing a game of basketball with her family.
FUS milestones at a glance
1992:
Dr. Hynynen first to combine FUS with MRI to guide and monitor treatment.
1995:
Dr. Hynynen and team first to show that FUS can be used for controlled opening of the blood-brain barrier.
1997:
Dr. Hynynen and colleague use FUS for through-skull focusing and ablation.
2001:
Dr. Hynynen and team first to show that low-intensity FUS can disrupt the blood-brain barrier under MRI guidance.
2010:
Drs. Hynynen and Isabelle Aubert first to show that antibodies delivered with MRI-guided FUS can reduce amyloid in mice with Alzheimer's disease.
2012:
Dr. Michael Schwartz and Dr. Nir Lipsman lead first trial in Canada using high-intensity FUS to treat essential tremor.
2014:
Drs. Hynynen and Aubert first to show MRI-guided FUS alone increases neurogenesis and improves cognitive function in a mouse model of Alzheimer's disease.
2015:
Sunnybrook team first to use FUS to open the blood-brain barrier successfully to deliver chemotherapy into the brain of a patient with brain cancer.
2016:
Sunnybrook is designated a FUS Centre of Excellence.
Brain surgery without a scalpel
Focused ultrasound uses beams of sound, guided by state-of-the-art MR imaging, to reach deep into the brain and destroy disease or disrupt malfunctioning brain circuitry. Focused ultrasound can be used to open the blood-brain barrier, a protective barrier that prevents toxins, including drugs, from reaching the brain.
Download the Spring Sunnybrook Magazine
This content was produced by The Globe and Mail's advertising department. The Globe's editorial department was not involved in its creation.