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Brain probe eases patient's tremors
Neurosurgeon Donald Whiting asked her to take a pen in her right hand and write something. It didn't matter what.
He only wanted to know if the probe planted in her thalamus, the inner portion of the brain, was doing its job - blocking the misfiring neurons within her brain caused by her multiple sclerosis. Four tiny electrodes on the tip of the probe were supposed to control the tremors in her right hand, which had shaken so badly that she couldn't hold a pen to paper or apply lipstick.
"I'm naturally right-handed. I hadn't written anything with my right hand in seven years," said Vdrale, 26, who had her doubts when doctors handed her a pen. "I was writing and I was like, `Oh my gosh.' I wrote my name and I drew a house. I cried."
The surgery in late July at Allegheny General Hospital did so much more than give Vdrale back her right hand.
"This is amazing, they brought our Nada back to us," said her mother, Myra, of Penn Township, Westmoreland County, as the two of them waited last week in a hospital exam room for a check-up with Whiting.
Vdrale hoped he would tell her she could return to medical school next month. Because of the tremors, she struggled with depression last year and barely made it through the last few months of school.
The technology implanted in her, known as deep brain stimulation, is in its infancy. It has yet to be approved by the U.S. Food and Drug Administration for use on patients with multiple sclerosis tremors, Whiting said. Some health experts argue its effectiveness varies greatly from patient to patient.
The government approved the procedure for use on patients with general tremors and tremors due to Parkinson's disease, but Whiting said he has no idea when the FDA will consider it for patients with multiple sclerosis.
Dr. Stephen Reingold, vice president of research for the National Multiple Sclerosis Society, said there have been studies on thalamic stimulation that raise questions about its effectiveness.
The studies indicate the procedure helps some, but just how much depends on the individuals and the seriousness of the tremors, he said.
"In virtually all cases, stimulation that works for a time tends to wane in effectiveness over time, and it is not always possible to adjust current to accommodate the adaptation," Reingold said.
Last week, as Whiting checked to see if the 4.5 volt current flowing into Vdrale's thalamus was enough, Vdrale demonstrated her deep brain stimulator, waving a blue magnet across a 4-inch scar on her chest.
Beneath the scar, near her collarbone, is a palm-sized generator that sends electric pulses along a wire just beneath her skin to her brain.
"This was me," she said, her right hand waving wildly after she deactivated the device.
She took a pen and tried to write her name, but the effort looked more like an electrocardiogram read-out than a signature.
THE TREMORS BEGIN
In the summer of 1994, Vdrale had just finished her sophomore year studying civil engineering at the University of Pittsburgh. She was visiting relatives in Yugoslavia when she first noticed the tremors.
"My coffee was everywhere on my lap," said Vdrale.
At first, she hid the tremors from her family, thinking it was carpal tunnel syndrome. But in September of that year, she was diagnosed with multiple sclerosis.
Often called MS, multiple sclerosis is a disease that affects more than 300,000 working-age Americans and causes vision problems, fatigue, loss of balance and muscle coordination, slurred speech and, in severe cases, paralysis.
But the symptoms that plagued Vdrale were the tremors in her right hand.
Because of the disease, she decided to drop out of Pitt and begin the six-year medical program in Belgrade.
"Maybe it's a tap on the shoulder saying civil engineering isn't for you. Maybe you should be a doctor," she remembers thinking.
But her disease worsened.
When she could no longer hold a pen in her right hand, she taught herself to write left-handed.
"Imagine not having a right hand," she said. "That's what it was like."
She couldn't take notes or button a lab coat. She couldn't shampoo her hair or paint her nails.
"It was interesting. When I went on a date, I had to ask my date to cut my meat," she said.
Eventually, Vdrale started losing muscle control in her left hand and in her legs.
"She would just drop to the floor," her mother said.
Life was hard. Medical school was impossible.
"When I was doing clinical work, I needed my hands for that," she said.
When her hands didn't work, she made excuses to patients.
"I lied. I told them I banged my hand on the drawer," Vdrale said. "I fell into depression."
OUT OF THE HOLE
While on break from school at home in Penn Township, she learned about deep brain stimulation, but was skeptical because she also has endured diabetes since she was 10. Doctors had told her of a diabetes patient who proceeded with deep brain stimulation and later developed meningitis.
She returned to school only a shell of her bubbly self. Her mother visited in January.
"Something had to be done," Myra Vdrale said. "It was not our Nada. Our Nada had crawled into a hole."
She returned to Pennsylvania in June and had the surgery on July 30.
Since the surgery, she has progressively gained muscle control in her right hand. The only noticeable sign of her multiple sclerosis is a hitch in her right leg.
"I have a little limp," she said.
A few days ago, Vdrale helped her family paint the kitchen of their Penn Township home.
"I wrote my name on every wall," she said. "Now I've moved on to the garage door."
During a meeting with Whiting last week, he explained it would be at least a year before he could determine how much control she'll have over her tremors.
"Then we'll know where you're going to be at," he told her.
"She still needs precision," her mother responded.
Questions followed for Whiting.
Can she do Tae Bo? Can she snorkel? Can she dye her hair? Can she still pick up her mother in a big bear hug?
Then the most important: Can she return to medical school this month?
She still hasn't decided what speciality to get into, maybe epidemiology, maybe neuroscience.
Go, Whiting said. Be a neurosurgeon.
"As soon as I can get a plane ticket," she said. "I'm so happy."
Marc Lukasiak can be reached at mlukasiak@tribweb.com or (412) 320-7939.
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