Doctor's specialty is re-wiring brain
Deep brain stimulation treats symptoms, improves quality of life
By Peggy Peck
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Dr. Ali Rezai performs deep brain stimulation surgery.
CLEVELAND, Ohio (MedPage Today) -- Dr. Ali Rezai is a doctor of last resort.
Patients who come to him at the Cleveland Clinic's Center for Neurological Restoration have already spent years trying anything from traditional treatments such as Levodopa for Parkinson's disease to acupuncture for migraine headaches.
But all these patients have reached the end of the treatment road -- no treatment, conventional or unconventional, has worked.
That's when they come to Rezai. Here, some of these patients will finally find relief through a brain surgery technique called deep brain stimulation.
"This is functional neurology," Rezai said. "This is a rapidly growing field that uses implantable devices similar to the pacemakers used to regulate heartbeats in patients with conditions that disrupt the normal functioning of the heart."
Rezai, 40, a pioneer in a growing field, has performed more than 900 procedures to implant the neurostimulator devices to treat tremors in people with Parkinson's disease and pain in people with migraine headaches or other chronic pain syndromes.
He has also implanted devices as treatment for depression and obsessive-compulsive disorder. And recently, he has implanted devices in stroke survivors as a way to improve movement problems, and in drug addicts as a way to turn off the craving.
The devices, he said, have transformed the world of brain surgery from crude techniques of "cutting, burning or freezing brain tissue to affect function to a more elegant approach in which we are actually able to re-wire the brain."
The final frontier
The brain, or more specifically the way the brain controls the body, from the simplest flick of a finger to the most complex of emotions, is "the last frontier of medicine," Rezai said. It was this unknown frontier that captured his imagination from his days in medical school at the University of Southern California.
Rezai was born in Iran and came to the United States when he was 10. He grew up in Los Angeles and went to college at UCLA. But even when he was in high school he knew he wanted to be a doctor.
He said he was, like many future doctors, fascinated by science -- "really fascinated by all science. But in my second year of medical school, I became really interested in neurology and the complex nature of the brain."
As he delved into brain research, he realized that little was known about how the brain controls function. This became his quest, leading him to training at New York University, the University of Toronto, and the Karolinska Institute in Stockholm. Finally, he returned to New York to practice what he had learned.
After a few years there, he accepted an offer from the Cleveland Clinic to join a growing staff of neurosurgery clinicians and researchers at the Center for Neurological Restoration.
That was more than six years ago. Since then Rezai has spearheaded research efforts so that he and his colleagues are now conducting more than a dozen clinical trials using the neurostimulators.
Pacemaker for the brain
The stimulator consists of two parts: a unit that is implanted under the skin high on the chest, similar to a pacemaker. This device is attached to tiny flexible wires called leads implanted in the brain. The device sends tiny electrical pulses to the leads. Those pulses stimulate the brain to control the targeted function, be it physical or emotional.
The first step involves an imaging process called functional MRI that allows Rezai and his colleagues to map the areas of the brain that control different functions.
"We know that different brain areas control different functions, but in each patient there are slight variations in function, and it is important for us to pinpoint exact regions," he said.
Functional MRI allows neurosurgeons to do this by injecting a dye that allows them to trace brain cells as they "light up" when responding to different commands.
But pre-surgical mapping is only part of the process. During surgery, the patient is awake, so Rezai can see the exact effect of the stimulator. This is important, he said, because "if we are off by even one millimeter in the placement of the lead, we will not improve function. This requires extreme precision. It [is] probably the most precise surgery performed."
"Every day we are operating on patients who, for example, have had tremor for decades," he said. "Suddenly, when we have the right placement, the tremor stops or the stiffness disappears. Right there on the table we see the benefits because they are very visible."
That moment validates Rezai's efforts.
The neurostimulator is not, however, a cure for Parkinson's disease.
"It is a treatment for symptoms, not a cure," he said. "The disease will still progress, but this device can greatly improve function and quality of life in ways that medications often cannot do."
Once the leads are implanted, the device can be fine-tuned by changing the electrical parameters, again similar to how pacemakers keep the heart beating rhythmically.
When Rezai started using the neurostimulators, only a handful of centers in the United States were doing these procedures. Now there are about 250, and about 500 in the world.
"And we are training more people all the time," he said. "So far we have trained 16 neurosurgeons here at the clinic."
Rezai said the surgery usually takes a few hours, and patients often are discharged in three or four days.
When Rezai is not in surgery, or in the neurosurgery laboratory where he and others are developing new and better neurostimulators, he spends his time studying history and enjoying music.
But his greatest joy, he said, comes from the "miracles" he witnesses in his patients.
"Every day I am reaffirmed in my belief that neurostimulators are transforming the world of neurosurgery," he said.
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