Functional Neurosurgeons Innovate New Methods for Improved Patient Care

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Intractable brain disorders often reduce the quality of life for patients. Surgery can be beneficial, but it may take years before it is considered a viable option. However, the field of functional neurosurgery, which focuses on the use of advanced imaging technologies and focal neural stimulation, may fundamentally change how physicians incorporate these practices into their treatment plans.

Mark Richardson, MD, PhD, the director of Functional Neurosurgery at Massachusetts General Hospital, is leading the way in providing patients suffering from epilepsy, movement and psychiatric disorders the opportunity to undergo minimally invasive, quality of life-improving surgeries. Dr. Richardson combines clinical and research expertise to conduct groundbreaking human neuroscience research.

His lab, which is funded through the National Institutes of Health (NIH) Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative, leads a new initiative with scientists at MIT to create the MGH-MIT InBRAIN (Intracranial Brain Recording, Analysis and Informed Neuromodulation) Partnership, focusing on collaborations in computational and cognitive neuroscience.

"The program and team is built around overlapping clinical and research areas," says Dr. Richardson. "By closely linking multidisciplinary clinical, computational and cognitive neuroscience expertise with a comprehensive architecture for data sharing, our patients have an opportunity to receive the most up-to-date treatments possible, while contributing to exciting new discoveries related to how our brains produce thought and action, and to how these processes are disrupted by disease."

Closed-loop Brain Stimulation

One method the team uses to treat epilepsy is responsive neurostimulation (RNS), which acts upon the patient's brain when seizure activity is measured. Their ultimate goal is to learn how RNS might teach itself the best way to respond to focal epileptic seizures.

"This objective approach could mean faster symptom improvements for patients." says Dr. Richardson.

Cognitive Neuroscience

Another effort is to understand how the brain produces speech, which can become severely disrupted in Parkinson's disease and other movement disorders. To do so, researchers simultaneously record from both the cortex and deeper structures targeted by DBS, like the subthalamic nucleus (STN), from which neurosurgeons must record in awake DBS surgery.

In addition to obtaining neural activity from speech experiments, his team also performs perceptual and cognitive tasks, in both DBS patients and in epilepsy patients temporarily implanted with brain recording electrodes to map their seizure circuits. Since both movement disorders and epilepsy surgeries are underutilized—only 10-15% of patients who would benefit from these surgeries actually receive them—the majority of patients treated are happy not only to have discovered these surgical options but also to have had the opportunity to participate in research.

Image-guided Neurosurgery

Mass General is at the forefront in the use of intraoperative-MRI (iMRI) for functional neurosurgery. Over the past decade, Dr. Richardson has pioneered the use of iMRI as an alternative to awake DBS, allowing patients to undergo DBS implantation under general anesthesia with real-time visual confirmation of accurate DBS lead placement.

These techniques also allow physicians to directly infuse viral vectors, for gene therapy, with exceptional precision. In a recent phase 1 clinical trial, Dr. Richardson targeted delivery of the aromatic L-amino acid decarboxylase enzyme into the putamen, which is needed to convert levodopa to dopamine, the neurotransmitter that it severely diminished in Parkinson's disease. The study sought to increase the putaminal coverage for patients with Parkinson's disease whom had medically refractory motor fluctuations. The findings suggest therapeutic improvement and a phase 2 study is currently underway.

"We also use iMRI to perform ablation of epileptic seizure foci using laser-induced thermal therapy (LITT)," says Dr. Richardson. "iMRI LITT is a minimally-invasive and valuable alternative in patients for whom open surgery or craniotomy is contraindicated or not preferred. It safely targets abnormal tissue while sparing normal tissue."

Clinical Innovation: Addressing Patient Needs Earlier

"Often, utilization of surgery is hindered because it seems scary and that something could go wrong. In reality, surgery is on more of a continuum with medication, rather than another dimension," says Dr. Richardson. "If someone's epilepsy or movement disorder symptoms are worsening, it is worth investigating whether surgery could provide real benefit with minimal risk."

For appropriately selected patients who are medically intractable, quality of life improvement through functional neurosurgery is almost always possible.

"On average it takes 18 years for someone with epilepsy to be referred to a surgeon," says Dr. Richardson. "They have likely lost years and years of life quality."

Such advancements have shown to positively affect epilepsy and movement disorders, including awake DBS, interventional-MRI DBS, and gene therapy. In partnership with referring providers, Dr. Richardson and his team also offer functional neurosurgery as another means of improving the quality of life for patients.

Visit the Functional Neurosurgery Center

Refer a patient to the Department of Neurosurgery