Visualase Laser Therapy

What is Visualase laser therapy?

Visualase ® laser therapy is a minimally invasive surgical procedure performed in our interventional MRI suite that can treat seizures, certain types of brain tumors, and/or tremors. Visualase uses an MRI-guided, laser ablation system (Figure 1), which allows close monitoring of the surgery in real time. The system is FDA-cleared for use in neurosurgery.

Figure 1 (Courtesy of Medtronic) The Visualase System:
Figure 1

This technique allows patients who have brain tumors, epilepsy, or tremors to be treated in a minimally invasive way, under general anesthesia, and even if other treatments have failed.

Visualase works by delivering a highly concentrated amount of heat via a thin laser into a brain lesion. Depending on the patient’s particular illness, the brain lesion may be a primary or a metastatic brain tumor, or another diseased brain area that is causing seizures, tremors, or another problem. The fiberoptic laser is placed directly into the lesion to deliver laser light energy within the desired region of treatment (Figure 2).

Figure 2 (Courtesy of Medtronic) The Visualase Laser:
Figure 2

Visualase is performed through a small scalp incision and hole in the skull as opposed to an extensive scalp incision and large cranial opening that is typical of standard open brain surgery (Figure 3). The treatment time and recovery time are both dramatically faster. In the event that the procedure incompletely treats a patient’s disease, repeat treatment is possible and generally well-tolerated a few months later.

Figure 3 - Small incision in posterior scalp after Visualase laser therapy:
Figure 3

For certain patients, using laser ablation for treating brain disease can be as or more effective than other therapeutic options, with less risk. MR-guided Visualase laser therapy is an exciting new option for patients with brain tumors, seizures, and tremors that may increase both safety and efficacy. Patients who undergo a Visualase procedure generally recover faster than with open brain surgery and show few signs of having gone through a surgical procedure. Using the MRI to guide the laser in real time during the procedure offers a high degree of accuracy and protects the surrounding normal tissue from harm.

Patients are currently being treated with Visualase in over 70 centers across the nation. To date, there have been over 1,500 tumor and epilepsy Visualase procedures completed (Figure 4).

Figure 4 (Courtesy of Medtronic) Visualase cases nationally 2011-2015:
Figure 4

Who is a good candidate for the Visualase therapy?

Patients with difficult-to-reach brain tumors

The Visualase laser can be inserted under careful MRI-guidance into most regions of the brain without major morbidity given its small size and the accuracy of MRI scans (Figure 5). Visualase is a good option for patients with deep brain tumors that are close to important brain structures like the brain stem. Traditionally these lesions have been difficult to treat with open brain surgery, making the laser therapy a potentially safer option.

Figure 5 (Courtesy of Medtronic) The Visualase laser can be inserted under careful MRI-guidance into many discrete areas of the brain without major morbidity given its small size and the accuracy of MRI scans:
Figure 5

Patients with seizures originating from the mesial temporal lobe

The Visualase laser can be inserted under careful MRI-guidance along the long axis of the temporal lobe without major morbidity given its small size and the accuracy of MRI scans (Figure 6). Visualase is a good option for patients who have seizures that originate from the mesial temporal lobe and who have ongoing seizures despite regularly taking anti-seizure medications. Unlike traditional open brain surgery called “temporal lobectomy,” Visualase may be able to destroy the seizure-causing part of the temporal lobe without a large incision or major surgical procedure. In addition, Visualase may cause less post-operative problems with thinking and memory than traditional open surgery.

Figure 6 (Courtesy of Medtronic) The Visualase laser can be inserted under careful MRI-guidance along the long axis of the temporal lobe without major morbidity given its small size and the accuracy of MRI scans:
Figure 6

Patients with seizures originating from another discrete area of the brain

The Visualase laser can be inserted under careful MRI-guidance into many discrete areas of the brain without major morbidity given its small size and the accuracy of MRI scans (Figure 5). Visualase is a good option for patients who have seizures that originate from a discrete brain region and who have ongoing seizures despite regularly taking anti-seizure medications. Unlike traditional open brain surgery, Visualase may be able to destroy the seizure-causing part of the brain without a large incision or major surgical procedure. In addition, Visualase may cause less post-operative problems with thinking and memory than traditional open surgery.

Patients with brain tumors that have been radiated and are still growing

The Visualase laser can be inserted under careful MRI-guidance into most regions of the brain without major morbidity given its small size and the accuracy of MRI scans (Figure 5). Visualase is a good option for patients with primary or metastatic brain tumors that have been treated with radiation but are still growing. Traditionally patients have had very few options, if any, if they had a brain tumor that continued to grow after receiving chemotherapy and radiation. Visualase is now a minimally invasive option for patients with brain tumors that have not responded to other more classic therapies and who do not desire a large open brain surgery for resection due to general health, social or cosmetic concerns.

Patients with tremors

Many patients have severe hand tremor due to Essential Tremor (ET), Parkinson’s disease (PD) or another illness. Unfortunately not all patients are appropriate for the “brain pacemaker,” or deep brain stimulation, which is a therapy commonly used to treat tremors. Patients may be too fragile to be implanted with a pacemaker due to age or other major medical illness, like being prone to infections. Additionally, from a social standpoint, not all patients are able to make the repeated visits to the doctor for adjustment of a deep brain stimulator and therefore defer this therapy.

An alternative procedure for tremor is called “thalamotomy.” A thalamotomy is a small destruction of a central brain region called the VIM thalamus, which is known to generate tremors. In other words, the VIM thalamus sends bad signals to the body muscles, causing tremors of the hands, legs, face, and/or voice. When this small brain area of the VIM thalamus is destroyed, tremor can improve immediately after surgery. There have been many different methods used to accomplish destruction of the diseased area of the thalamus over the years, including using a heat probe inserted into the brain (e.g.- known as “radiofrequency lesioning”), Gamma Knife radiation therapy, or even focused ultrasonic waves.

More recently, we have been using the Visualase laser therapy to accomplish a controlled destruction of the VIM thalamus in patients with tremor. Tremor decreases immediately after the surgery and there is no implanted hardware that is left behind. That being said, unlike deep brain stimulation, the therapy is “one and done” and cannot be titrated over time like the brain pacemaker. However, the laser procedure could be repeated if necessary down the road if tremor recurs or worsens.

How does Visualase compare to open brain surgery?

Many neurosurgical procedures are performed through a highly invasive craniotomy (e.g.-open brain surgery):

  • 5-7 day hospital stay
  • 1-2 nights in Intensive Care Unit (ICU)
  • Moderate incisional pain
  • Nausea/vomiting
  • Large area of hair shaved with C-shaped incision several cm long (Figure 3)
  • 4-8 weeks recovery

For some patients, minimally invasive neurosurgery with Visualase, MRI-guided laser procedure might be an option:

  • 1-2 day hospital stay
  • No time spent in Intensive Care Unit (ICU)
  • Minimal incisional pain
  • Minimal nausea
  • Minimal hair shaved and < 1 cm incision (Figure 3)
  • Rapid recovery in 1-2 weeks

What are other additional advantages of the Visualase procedure in the MRI suite?

  • The actual laser ablation treatment time is on the order of minutes. Set-up time and laser fiber placement is~ 3-4 hours.
  • Destruction of targeted tissue through a minimally invasive technique instead of a craniotomy
  • Quick surgical procedure
  • Efficient post-op follow-up
  • Short hospital stay
  • Minimal pain, one stitch closure and rapid
  • Staged or planned treatments for recurrent tumor are well tolerated and prolong quality life

Visualase In the National News

When was the current Visualase system first used in Shreveport?

Dr. Wilden’s team used the Visualase technology in January of 2017 on a patient diagnosed with a brain tumor. The patient, a 57-year-old man, had a symptomatic tumor in the temporal lobe of the brain that was near the brain stem. The location of the tumor made it difficult and dangerous to resect using open brain surgery. Using the Visualase technology in the interventional MRI suite at Willis-Knighton North Medical Center, we were able to access and destroy the tumor through a small ~5 mm incision using a laser fiber. The patient was discharged the following day feeling well.

Willis-Knighton Health System recently acquired the Visualase technology as a continuing effort to grow the interventional MRI (iMRI) surgery program. The iMRI surgery program was started through a partnership between Willis-Knighton Health System, Dr. Wilden-an expert in MRI-based surgery, and other critical team members in radiology, engineering, and neurology in 2013.

Surgery in the sterile MRI suite under general anesthesia provides enhanced accuracy, safety, and comfort for the patient compared to more traditional techniques in the regular operating room. We are the only site in Louisiana and in the Ark-La-Tex with an iMRI suite, which is used on a weekly basis to perform highly specialized procedures, including deep brain stimulation and laser therapy. Dr. Wilden’s team was the first to use the Visualase laser technology in this region in combination with the iMRI suite.

What is the benefit of Visualase laser therapy in an interventional MRI (iMRI) suite?

In other institutions, the Visualase laser is placed into the patient’s brain in the regular operating room using a metal head clamp. The laser is then secured to the scalp using a special bone anchor and the patient is transported through the hospital to a non-sterile diagnostic MRI scanner where the laser procedure takes place.

At Willis-Knighton North, our entire procedure is performed in an operative MRI suite under sterile conditions from start to finish. There is thus no need to place the patient in a metal head clamp or transport the patient from one area of the hospital to another while under general anesthesia. All of the necessary surgery tools are inside the interventional MRI suite, making it straightforward to place the laser fiber accurately, promptly activate the laser, and heat the desired brain lesion with MRI guidance—all done in a continuously sterile, safe environment.

Learn more with this PowerPoint presentation courtesy of Dr. Wilden.