The Neuravive Procedure

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How it Works

The Neuruavive procedure uses MR guided focussed ultrasound to perform a “non-invasive” thalamotomy to relieve medication refractory tremor. The procedure involves no incisions and the patient is fully conscious throughout. A stereotactic head frame is placed on the patient’s head with local anaesthetic and the patient lies in the MR scanner. If required some sedation can be given to help maximise comfort and relaxation during the procedure.

The focussed ultrasound sends 1024 individual ultrasound beams through the brain that intersect at a single point in the thalamus and can destroy the tremor-causing cells. This is all monitored in real time on the MRI and by repeatedly checking the patient and their tremor until the tremor has been adequately treated.

When the treatment is over there is an immediate and significant reduction in tremor.

This chart shows the immediate effect that Neuravive can have on tremor.
This chart shows the immediate effect that Neuravive can have on tremor.
  

Key Publications

MRgFUS for essential tremor has been the subject of intense global research and clinical trials culminating in landmark publications in journals such as “The New England Journal of Medicine”, “The Lancet” and “Neurology”.

Krishna V, Sammartino F, Agrawal P, Changizi BK, Bourekas E, Knopp MV, Rezai A. Prospective Tractography-Based Targeting for Improved Safety of Focused Ultrasound Thalamotomy. Neurosurgery. 2018 Mar 21. doi: 10.1093/neuros/nyy020.

Jung NY, Park CK, Chang WS, Jung HH, Chang JW. Effects on cognition and quality of life with unilateral magnetic resonance-guided focused ultrasound thalamotomy for essential tremor. Neurosurg Focus. 2018 Feb;44(2):E8. doi: 10.3171/2017.11.FOCUS17625.

Chazen JL, Sarva H, Stieg PE, et al. Clinical improvement associated with targeted interruption of the cerebellothalamic tract following MR-guided focused ultrasound for essential tremor. J Neurosurg. October 2017:1-9. doi:10.3171/2017.4.JNS162803.

Kim M, Jung NY, Park CK, Chang WS, Jung HH, Chang JW. Comparative Evaluation of Magnetic Resonance-Guided Focused Ultrasound Surgery for Essential Tremor. Stereotact Funct Neurosurg. 2017 Aug 16;95(4):279-286. doi: 10.1159/000478866.

Niranjan A, Raju SS, Monaco EA 3rd, Flickinger JC, Lunsford LD. Is staged bilateral thalamic radiosurgery an option for otherwise surgically ineligible patients with medically refractory bilateral tremor? J Neurosurg. 2017 Apr 7:1-10. doi: 10.3171/2016.11.JNS162044.

Ravikumar VK, Parker JJ, Hornbeck TS, Santini VE, Pauly KB, Wintermark M, Ghanouni P, Stein SC, Halpern CH. Cost-effectiveness of focused ultrasound, radiosurgery, and DBS for essential tremor. Mov Disord. 2017 Apr 3. doi: 10.1002/mds.26997.

Schlesinger D, Lee M, Ter Haar G, Sela B, Eames M, Snell J, Kassell N, Sheehan J, Larner J, Aubry JF. Equivalence of cell survival data for radiation dose and thermal dose in ablative treatments: analysis applied to essential tremor thalamotomy by focused ultrasound and gamma knife. Int J Hyperthermia. 2017 Jan 3:1-27. doi: 10.1080/02656736.2016.1278281.

Hughes A, Huang Y, Pulkkinen A, Schwartz ML, Lozano AM, Hynynen K. A numerical study on the oblique focus in MR-guided transcranial focused ultrasound. Phys Med Biol. 2016 Nov 21;61(22):8025-8043.

Jang C, Park HJ, Chang WS, Pae C, Chang JW. Immediate and Longitudinal Alterations of Functional Networks after Thalamotomy in Essential Tremor. Front Neurol. 2016 Oct 24;7:184.

Elias WJ, Lipsman N, Ondo WG, Ghanouni P, Kim YG, Lee W, Schwartz M, Hynynen K, Lozano AM, Shah BB, Huss D, Dallapiazza RF, Gwinn R, Witt J, Ro S, Eisenberg HM, Fishman PS, Gandhi D, Halpern CH, Chuang R, Butts Pauly K, Tierney TS, Hayes MT, Cosgrove GR, Yamaguchi T, Abe K, Taira T, Chang JW. A Randomized Trial of Focused Ultrasound Thalamotomy for Essential Tremor. N Engl J Med. 2016 Aug 25;375(8):730-9. doi: 10.1056/NEJMoa1600159.

Bond AE, Dallapiazza R, Huss D, Warren AL, Sperling S, Gwinn R, Shah BB, Elias WJ. A Randomized, Sham-Controlled Trial of Transcranial Magnetic Resonance-GuidedFocused Ultrasound Thalamotomy Trial for the Treatment of Tremor-Dominant, Idiopathic Parkinson Disease. Neurosurgery. 2016 Aug;63 Suppl 1:154. doi: 10.1227/01.neu.0000489702.18785.5f.

Gallay MN, Moser D, Rossi F, Pourtehrani P, Magara AE, Kowalski M, Arnold A, Jeanmonod D. Incisionless transcranial MR-guided focused ultrasound in essential tremor: cerebellothalamic tractotomy. J Ther Ultrasound. 2016 Feb 13;4:5. doi: 10.1186/s40349-016-0049-8. eCollection 2016.

Research

In addition to the treatment of movement disorders such as Essential Tremor and Parkinson’s disease, MRgFUS has enormous research potential in neuroscience. For example, it is currently being exploited to cause reversible manipulation of the blood brain barrier, one of Medicine’s biggest hurdles, in order to facilitate entry of medications to treat various brain diseases including devastating brain tumours and dementia.

Currently there is no cure for Alzheimer’s disease and potentially promising drug and antibody therapies are often limited by their inability to efficiently cross the blood brain barrier. Promising preclinical studies have demonstrated that focussed ultrasound together with microbubbles can safely temporarily open the blood brain barrier and enable enhanced delivery of anti-amyloid antibodies to the brain. Studies suggest that this method can lead to reduction in the number of amyloid plaques and improved cognition in Alzheimer’s disease models. Based on this, a human trial was recently completed. Read the article here:

https://www.nature.com/articles/s41467-018-04529-6

There are also multiple active global research projects investigating the use of MRgFUS for Parkinson’s disease, Dystonia, Epilepsy and brain tumours. More information regarding these trials can be accessed at:

https://www.fusfoundation.org/

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