Les Mlakar has practiced law in Pennsylvania for more than 55 years, mostly municipal and estate work. For the much of his career, he wasn’t the type of lawyer who stayed behind closed doors – he often attended public meetings in the evenings and loved the energy of the courtroom. At 80 years old, he has no plans to quit: “I’ve seen too many people become stagnant,” he says. But over the past few decades, he’s retreated from trial law and public life more generally, all because of his essential tremor.
Essential tremor is a common neurological condition characterized by involuntary shaking of the hands, head, voice, or legs. Mlakar says these symptoms made him feel ineffective in front of a jury; his words garbled and his hands shaking.
“They thought I was nervous,” he says. “Like I had a bad case.”
He quit his main hobby, golf, because he couldn’t hold the putter still enough. He made up excuses for why he couldn’t attend social events, too embarrassed to eat or drink in public.
“I had to rely on other people to do so much for me,” Mlakar said. “It really affected my overall quality of life.”
Les Mlakar
Today, Mlakar’s right hand is steady, thanks to a procedure called focused ultrasound performed at UPMC Presbyterian by Dr. Ajay Niranjan, associate director of the UPMC Center for Image-Guided Neurosurgery and director of the UPMC Brain Mapping Center.
His experience mirrors what other UPMC patients describe as nothing short of transformational.
The incisionless technique uses 30-40 focused ultrasound beams to heat and destroy a tiny, pinpointed area deep in the brain that drives tremors. Patients are awake in an MRI while clinicians check their progress in real time and give commands to draw circles, write their name or hold up their hands. At the same time, the team finetunes the target to millimeter precision. The lesion itself is only about two to three millimeters wide and the effect can be immediate.
Mlakar says when the team finally slid him out of the MRI for the last time and asked him to extend his right hand, he stared at it in disbelief. “It was totally solid,” he says. “I didn’t think it would work that well.”
For Dr. Jorge González-Martínez, director of Epilepsy and Functional Services in the Department of Neurological Surgery at the University of Pittsburgh, watching these transformations never loses its impact. He says many patients come to him after years or even decades of embarrassment, shame and isolation. Focused ultrasound gives them a chance at immediate relief without an incision, implant, or general anesthesia.
“After so many years of suffering, to be able to perform a procedure that will take a couple of hours, with no incision, and have the tremor completely subside – it’s just incredible,” he says.
Not every patient with essential tremor is a candidate for focused ultrasound, and the durability of the treatment may not match the decade plus benefit that deep brain stimulation can provide. But for older adults, those with cardiac conditions or blood thinner requirements, or people simply unwilling to undergo open surgery, focused ultrasound is an excellent option.
Focused ultrasound at UPMC is part of the Center for Image Guided Neurosurgery (CIGNS), a multidisciplinary program that brings together neurosurgeons, neurologists, imaging specialists and engineers to develop and deliver some of the most precise brain therapies available. Real-time image guidance and advanced navigation allow clinicians to target tiny areas deep within the brain with millimeter accuracy, while continuously monitoring patient response.
This infrastructure not only supports focused ultrasound for essential tremor but also serves as a foundation for testing and refining other minimally invasive and incisionless approaches to treating complex conditions. Researchers at UPMC are studying how focused ultrasound might be applied to the treatment of Alzheimer’s disease, epilepsy, brain tumors, cerebrovascular disorders, as well as addiction and psychiatric disorders. These possibilities remain early and will require extensive clinical trials, but the opportunity to treat the brain without invasive surgery is already transforming lives.
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