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Vital Signs with Dr. Sanjay Gupta

Neurosurgery Called Deep Brain Stimulation Examined; Patient with Tourette's Syndrome Undergoes Deep Brain Stimulation Procedure. Aired 2:30-3p ET

Aired July 11, 2015 - 14:30   ET


[14:30:06] DR. SANJAY GUPTA, CNN CHIEF MEDICAL CORRESPONDENT: The brain is probably the most vital organ in our body, the center of all of our motor skills, our thoughts, even our emotions. In essence, it's who we are. And yet while stunning new discoveries have allowed researchers to look deeper and deeper into how the brain works, much of why it works is still a mystery.

This is "VITAL SIGNS." I'm Dr. Sanjay Gupta.

Today, researchers and doctors across the globe are racing to unlock the brain's secrets. In a way, it's like human genome project. In this case, the goal is to map the activity of every neuron in the human brain. It's a daunting task. There are billions of these neurons firing inside our brains. Trying to understand their structure and function is going to require collaborative teams of doctors, scientists, even patients, all relying on innovative neuro- technologies, many of which have not yet been invented.

Two doctors at the university of Florida have already begun this partnership as they push the boundaries of brain mapping. They specialize in a treatment called DBS, deep brain stimulation. It uses electricity to relieve their patients from the debilitating effects of movement disorders. Through their quest to fix the brain, they're discovering new ways to control the brain.


DR. MICHAEL OKUN, NEUROLOGIST, UF HEALTH: Your brain controls everything. And we can control your brain.


GUPTA: Dr. Michael Okun and Dr. Kelly Foote are not mad scientists, but they are a very rare breed of doctors, a neurologist and a neurosurgeon who get along.

DR. KELLY FOOTE, NEUROSURGEON, UF HEALTH: Medicine and speaking in broad terms is divided into surgeons and people who aren't surgeons.

OKUN: He's never kicked me out of the operating room, and you always hear about surgeons kicking neurologists and other people out of the operating room.

GUPTA: In 2002, they combined their two interests to set up the center for movement disorders and neuro-restoration at the University of Florida. Their goal, bring together teams of doctors, researchers, and scientists to push the boundaries of deep brain stimulation, or DBS.

OKUN: It's honestly a typical Wednesday for us, which is three deep brain stimulation lead implantations.

What an audience here.

When we go into the operating room, I often say it's a bunch of cool cats in that operating room. That is not a typical operating room.

You feel all right? Lean your head back. Let me hold your head. Just relax your head. It's not painful, but it's stressful. And a lot of what we do that may seem a little weird to see in an operating room is really designed to alleviate that stress.


OKUN: We focus on the music to try to take their focus off the fact that I'm drilling a hole in their head and cutting their scalp.

GUPTA: One of the things that may surprise you about deep brain stimulation surgery is that the patient remains awake.

OKUN: The way sedatives work is by suppressing brain activity, right. So we'll get better recording if we don't use any sedatives.

GUPTA: The brain is often described as an incredible interconnected circuit. And the delivery of electricity is at the root of what makes DBS work. By introducing electrical impulses to circuits in the brain associated with specific motor skills, the doctors believe they are helping reroute, or possibly replace the rhythmic connections between neurons.

The doctors admit they are not entirely sure why DBS works, but they do know how it works, and that the exact placement of the electrical leads is the key to a successful implant.

FOOTE: And we learn that these operations are really specific. And if you miss by a millimeter or two, it's like the difference between, you know, ending up in Florida or ending up in Australia. It's a big deal.

The next couple of millimeters might start to see a transition.

So what we then do is we put a tiny little lead into the brain called a microelectrode and we listen to the cells and they sing a song. The song that they sing allows us to tell where they are. And so as you get to different areas, it's like driving through Europe, as you pass through different countries or different borders, the language changes.

[14:35:00] GUPTA: Drs. Okun and Foote point out that DBS is not an option with everyone, but in patients with severe disorders, where medication and other treatments have failed, DBS may be their only remaining option.

UNIDENTIFIED FEMALE: Do your best to try and spread your fingers out.

GUPTA: This video taken in Dr. Okun's office shows a little boy suffering from dystonia. It's a condition where muscles lock up due to conflicting messages from the brain. Now look, after DBS, an amazing transformation. DBS is also being tested as a treatment for major depression, Alzheimer's, even obsessive-compulsive disorder.

OKUN: Your brain controls everything. We can control your brain. I think you should get a little bit uncomfortable with that notion, and it should remind us about the responsibility that we have to have an ethically guiding principle when we do these sorts of operations. And that principle is always that we've agreed with patients, it's to alleviate human suffering.

UNIDENTIFIED FEMALE: Slow it down just a little bit. OK?

GUPTA: Trying to heal a patient with one of the most perplexing brain disorders will put everything they know about the brain to the test.

AMBER COMFORT: Without medication, I am one of the worst cases that doctors have ever seen in the United States.



GUPTA: Since deep brain stimulation was first approved for tremors in 1997, more than 100,000 patients have been implanted with deep brain stimulators.

Dr. Okun and Dr. Foote's team at the University of Florida implant about 150 leads a year in patients suffering from movement disorders like Parkinson's and essential tremor. The success of DBS in helping patients return to normal lives has been overwhelming.

[14:40:012] But that's not the case with Tourette's syndrome. Unlike many of the disorders which affect, Tourette's also afflicts centers of the brain that control emotion. Another challenge, the uncontrollable urges to tic in Tourette's patients are unpredictable and therefore hard to regulate with standard DBS. But with the help of their patient, Amber, and a new experimental device, these doctors hope to change that.



COMFORT: I love to sing. Singing is what gets me through a lot of hard days.


COMFORT: When I'm on the computer, when I'm driving, when I write poetry, basically, anything with a sense of focus, I used to play in a pool league. When I shoot pool, I don't tic. You'll see me completely at ease when I'm doing those things, because I'm in my comfort zone, and I'm not really caring about anything else. When I worry about my tics, I do just that, I worry about my tics.

GUPTA: Amber Comfort is 25-years-old. She suffered from Tourette's syndrome. It's a neurological disorder that usually starts at a young age.

COMFORT: I don't remember any parts of ever being tic-free. I was five when the symptoms started happening, six when I was diagnosed. It's not a day that's come by I don't remember moving or making noise when I couldn't help it. It's been lovely.

Sitting in class, second grade, teachers would put me outside the hallway because I'd be ticking so loud. I was a distraction. So teachers would walk back and forth and say you better stop that before you get in my class next year, things that were just completely obscene that you would never expect the world to be, but I had to deal with it on a daily basis.

GUPTA: Although Amber's condition has shaped every moment of her life, she has not let it dictate how she lives.

OKUN: OK, deep breath.

GUPTA: After years of unsuccessful therapies and only limited results, Amber was referred to Dr. Okun at the University of Florida center for movement disorders.

OKUN: Turn around again for me. OK.

GUPTA: Dr. Okun and Dr. Foote have chosen Amber for an experimental DBS surgery. They will implant the new gridlock device on top of her brain in addition to the standard leads, which go deep inside the brain. By combining both, they hope to gather information from Amber's brain that will not only lessen her tics, but maybe someday stop them.

FOOTE: The difference in Tourette is the movement disorder isn't there all the time. When you get a tic, it comes on. And the patients that have tics, they get this buildup. They call it a premonitory urge, that's what the scientists call it, and they feel like they need to move. And until they move, they don't feel better. So they get a sense of relief.

GUPTA: That sensation, the urge to tic, is what Amber suffers from every day.

COMFORT: It's like I'm having 15,000 mosquito bites that you can't itch. You can't itch it. And they come out and you have no control and you cannot take them away.

OKUN: One of the most scientifically exciting things about deep brain stimulation is that it offers the really uncommon opportunity to record the electrical activity from a living human being's brain. GUPTA: It's the cutting edge of what is known as neural network

modulation. Through their extensive work with Parkinson's and other movement disorders, the doctors are honing in on a particular area deep in the brain known as the basal ganglia. It's an area that can control both movement and emotion.

I've been invited to observe Amber's groundbreaking surgery. I'll be joining a team of doctors flying in around the world for this unique chance to listen to the brain and to learn from it.

COMFORT: Fifteen tics or less a day would be fine with me. Anything less would be perfect in my eyes, just to have some relief.

[14:45:00] They told me it could get rid of potentially all of my vocals within a year, and half, if not more than half of my motor tics.

GUPTA: Amber has placed a lot of hope in the outcome of this intensive day-long operation.

COMFORT: It's a chance to change my life for the better, and to make sure that I don't have to deal with this anymore, which is grueling almost every day. I'm up for it. I've had this 20 years and I think I've done my time.




FOOTE: I'm going to size it up first and see how it fits.

GUPTA: The day of Amber's brain surgery has finally arrived. After a lifetime of living with the debilitating effects of Tourette's syndrome, she and her family are hoping today's operation is finally provide some relief.

How important is today for you guys?

UNIDENTIFIED FEMALE: A new beginning. For her to have the same opportunities if life that everyone else has, as bright as she is, and as social and outgoing, for it to be her own, her own choices, not something that she was given that she can't help.

UNIDENTIFIED MALE: There she is, the guest of honor.

UNIDENTIFIED MALE: We should put a pillow. Can we?

UNIDENTIFIED MALE: How does one pick music for surgery? What are you looking for?

COMFORT: I like country.

UNIDENTIFIED MALE: You like country? You understand everything that's being done today?


UNIDENTIFIED MALE: OK. How are you feeling about it?

COMFORT: As good as I can be.

UNIDENTIFIED MALE: OK. You get to stay awake through the whole thing.

COMFORT: Yes, I heard.


FOOTE: You just watch the internal capsule and watch the boundaries of these structures. So that is what we think looks like a pretty safe trajectory to get there.

[14:50:07] GUPTA: Dr. Okun and Dr. Foote expect the operation to last at least 12 hours.

FOOTE: Axial is negative 12.

GUPTA: Before any incision is made, the entire surgery is mapped out virtually.

FOOTE: We're going to attach to this arc to her head ring and use this to aim.

GUPTA: When you to talk to her ahead of time, patients always ask, how likely is to this work? How do you answer that question for them?

FOOTE: Well, any time it's an experimental procedure, I always say the price you pay for an experimental procedure is that no one in the world can say I've done this 100 times and give you statistics and say it works X percent of the time.

GUPTA: She was good with that. She was at that point in her life where --

FOOTE: Yes. You can imagine living her life. You would be willing to try something if you could be convinced that it was reasonably safe and had the potential to minimize your tics.

All right, here we go. So what I'm about to do is not painful at all. It's not a painful procedure. It's just really loud. All right, here we go.

GUPTA: To begin, four holes are drilled into her skull.

FOOTE: One down, so you're now a member of an elite club. Very few people can say they've had a hole drilled in their skull while they're awake.

GUPTA: Dr. Foote and his team have performed measure 1,000 deep brain stimulation procedures. But the additional contacts they are placing on top of Amber's brain are new and still being tested.

FOOTE: So we said left cortical first, right?

OKUN: We want to split the contacts so that we have got some over the pre-motor region so we can sense the tics before they happen when they get premonitory urges, but also in the motor region.

GUPTA: What is so interesting here is when you think about Tourette's, you're thinking about something that is almost half motor movements and almost half emotion. So you take a look at what they're trying to do, they're actually going right in the middle. You've got motor on one side, emotion on the other. And look at that line. That goes right down the middle of both.

To make sure they found the right location, they stimulate the leads on Amber's motor cortex. That involuntary twitch, that's a good sign.

COMFORT: Is this going to change?

GUPTA: Next, the deep brain electrodes are lowered into place to capture neuronal activity.

OKUN: What we're listening to now is three channels. It's like an orchestra. It's like an ensemble.

GUPTA: Okun gradually drives the electrodes deeper and deeper, listening as the cells talk to him.

OKUN: All three channels are up, guys. Got a burst coming out of the posterior channel.

GUPTA: They are telling him the best place to implant the remaining leads.

OKUN: When you hear that crisp sound, that means you're really close to a group of neurons here. It's total blow your mind kind of stuff. We really have no idea until we get in there and we really start to look at the data.

GUPTA: Does it surprise you that we do these procedures without having the knowledge of the how or the why?

OKUN: It does. It really does. The operating room is the experimental laboratory for the human.

Let's go ahead and have you tic. Don't suppress your tics. Let them come.

GUPTA: You can see when she's having her tics, you're seeing activity in the brain, not just in the more superficial areas. Take a look over here.

With the new leads successfully implanted on top and inside Amber's brain, the doctors have essentially created a new network. It's an early version of what they hope will someday become a tic detector.

OKUN: So we're recording from 16 different locations in her brain right now.

GUPTA: And what you're describing really hasn't been done before.

OKUN: Right. But we're also trying to figure out what causes this. So in some ways, she's sacrificing for kids in the future.

GUPTA: Right.

Dr. Okun and Dr. Foote now believe they've given Amber the best shot at leading a normal life. But keep in mind it's just day one of six to 12 months of return visits, recalibration, and tweaking before she could potentially get there, and, also, before they can really understand what's happening inside her brain.


[14:55:10] FOOTE: You were a trooper. I mean, you did great, because that's a long operation. And honestly, we do this on people who are awake all the time. But we don't do this much.

OKUN: She came into the operating room at 8:00 a.m. and we brought her out of the operating room at 8:00 p.m., which during that time, she had, depending on how you count it, one, two, three, four, five, six operations. She did great. She did great.

GUPTA: After an exhaustive surgery, Amber knows she's been given an incredible chance at a new life.

COMFORT: I feel honored. I do. My niece and my nephew are what's really pushing me right now, because I want them to see -- I want them to grow up and see me, you know, being a productive member of society, and that to me is not ticking.

I cannot express how grateful I am that this surgery has worked for me in a positive way. I am completely content with my life as it is now. And I can't imagine it getting any better. But I look forward to it getting better.