Dr. Robert Fahed was more excited than nervous when he headed to an angiogram suite at The Ottawa Hospital’s Civic campus on the morning of Nov. 14. If all went as planned, something momentous was about to happen.
First, though, the 36-year-old neurosurgeon put on his lucky cap. “This is the one I wear on special days,” he said during an interview, pulling the surgical cap off his head to reveal rows of multicoloured brain-eating zombies. “Every surgeon is superstitious.”
It was a moment specialized brain surgeons like Fahed had long dreamed of.
He was about to perform a medical procedure that would make history: the first real-world use of a microscopic camera designed to see inside a patient’s brain. The new technology, called a MicroAngioScope, could pave the way for new treatment of strokes, aneurysms and more.
Fahed would later describe the moment the camera came on as akin to what Neil Armstrong must have felt when he walked on the moon on July 20, 1969.
“(I was) seeing something that everybody had always imagined, that everybody had always pictured in their minds, but nobody had ever seen,” Fahed said. “I was seeing inside of the brain vessels and I can’t even describe the feeling, but it was fantastic.”
The still unlicensed technology represents a potential medical breakthrough that had long existed only in the realm of science fiction. It was originally conceived by two University of Waterloo mechanical engineering students as an undergraduate capstone project. They developed it further as part of the medical technology startup they founded after graduation, Vena Medical.
Their MicroAngioScope is slightly thicker than a strand of hair, just one-third of a millimetre in diameter. It is designed to be small enough to navigate the looping, delicate blood vessels of the brain and flexible enough to do so safely. The device has a microscopic camera and light at its tip, which become eyes into the brain.
Its development was closely watched by Fahed and others working in the highly specialized field of interventional neuroradiology (INR) — doctors who diagnose and treat conditions such as strokes from inside blood vessels.
When he learned such a device was in the works, Fahed said he knew immediately that it had huge potential. “I knew they were going to change the world.”
Until Nov. 14, it had never been used on a person.
The work interventional neuroradiologists like Fahed do on a daily basis is remarkable. They perform brain surgery from inside blood vessels, pulling blood clots out of brains and treating aneurysms using delicate tools guided by X-ray images through the patient’s femoral artery near the groin and into the brain. The minimally invasive procedures are often done urgently in the middle of the night. They can save lives and change lives, including giving patients back their independence after strokes.
But, until now, surgeons have been doing that work with a less-than-perfect understanding of what they are seeing, Fahed said.
“Our understanding of cerebralvascular diseases has always been limited because it is like looking at an image through a cracked mirror,” he said. “You are seeing something that is distorted. You are making assumptions that you are seeing a painting of a forest with a sunset, but you are actually not seeing the whole picture, so you can only make hypotheses.”
Currently, what interventional neuroradiologists see is a pattern of blood flow through the brain. Dye is injected into a patient. Live X-ray images show any blockages caused by clots or other barriers. But it can be difficult to understand the exact cause and how best to remove or treat it. That can cost time, which can mean loss of brain function. “Time is brain,” Fahed said.
Co-designers Michael Phillips and Phillip Cooper won a $50,000 award for their graduation capstone project in 2017, allowing them to co-found Vena Medical and to continue working on the MicroAngioScope. They took the device containing the microscopic camera from a proof of concept to a high-tech medical device designed to work in the real world.
After years of development and testing, Health Canada approved the use of the still-unlicensed technology on a patient at The Ottawa Hospital who had a series of strokes. Doctors had been unable to diagnose the source of the man’s ongoing health issues with existing technology. The man, in his 40s, agreed to become the first person to undergo a procedure using the tiny camera after other diagnostic tools failed. A date for the procedure was set.
On the morning of Nov.14, Fahed used the device in its first real-world test at The Ottawa Hospital. The room behind him was packed with medical and technical experts. Medical professionals from throughout the hospital and beyond were among those peering through windows from an adjacent control room.
“I’m glad I didn’t turn around to see all those people because I would have freaked out,” Fahed said.
A catheter had been inserted into the patient’s femoral artery through a small incision in the groin, standard for the non-invasive procedure. The patient, who had asked to be put under general anesthesia, was injected with dye. X-ray machines positioned by his head relayed images of blood flowing and bumping into the as-yet-undiagnosed barrier in his brain.
Fahed placed the MicroAngioScope inside the blue catheter in the patient’s artery and pushed it toward the brain. Live images from the camera began to appear on a large screen, at first showing the blue from inside the catheter.
“At first you are inside the blue tunnel. You can’t wait to get out. You see the dark circle at the end and you exit the catheter and then you see the brain vessel,” Fahed recalled.
Once the camera was in the brain vessel, the crowded room went silent.
“We didn’t say anything. Our minds were blown,” Fahed said.
Phillips, the Vena CEO who co-created the device, remembers that moment, too.
“I remember reminding myself to soak it all in. It is pretty crazy to see that many people just kind of awestruck. Everybody was dead silent for 10 to 20 seconds,” Phillips said.
Within seconds, doctors could see what they had been unable to see before: the cause of the patient’s strokes. There was a bulge of fibrotic tissue into the blood vessel resulting in clots. The solution was immediately clear: a stent to restore blood flow.
The treatment was straightforward and life-changing. The patient hasn’t had a stroke since.
After the procedure, Fahed told him: “You were the very first patient of something that is going to change everybody’s life.” The patient, who has asked to remain anonymous, thanked Fahed, saying he was glad he could somehow help others. “And I hope you will be able to use that technology on as many patients as possible.”
Fahed believes the technological breakthrough will be life-changing for many more people, but first it requires research to better understand its capabilities.
Thrombectomies, in which stroke-causing blood clots are removed from the brain, make up about half of what physicians like Fahed do. “That is the most life-changing procedure.”
But doctors only remove the clot on the first attempt in 35 per cent of cases — they call that a “home run.” In 50 per cent of cases, it takes more than one attempt. In around 15 per cent, the procedure is not successful at all.
Patients have a 60-70 per cent of continuing to function independently if the clot is removed on the first try, but after that the chances of living independently go down to between 40 and 50 per cent if it takes more than one attempt and to less than 20 per cent if doctors are unable to remove the clot.
Fahed believes the use of the microscopic camera will enable doctors to remove clots on the first try more frequently because they will know immediately which tool is best. As well, new tools will be developed based on what they can see.
“I hope we get to zero (failures to remove clots) in a few years,” he said.
The concept of seeing inside the human body with a tiny camera is not new. It has long been in the public imagination, visualized in television and movies such as the 1966 film Fantastic Voyage, in which a submarine and its crew are miniaturized and travel to a scientist’s brain to destroy a blood clot. And the animated kids television show Magic School Bus — which device co-creator Phillips said he watched as a kid — devoted an episode to having teacher Ms. Frizzle and her students shrink down in order to travel through the human body, including blood vessels.
“Think about doctors having the ability to miniaturize themselves and go through our arteries to understand health issues,” was how Phillips described the new invention.
Tiny cameras are already used to navigate inside lungs, stomachs, colons and other organs to help doctors diagnose and treat patients. They have even been used inside some larger blood vessels in the leg or the arm.
But not in the blood vessels of the brain, until now, which is why the microscopic camera is being heralded as a significant development in the field of neurovascular care.
“There are lots of loops and turns, so, if you use a camera that is too big and too still, you can rupture the vessel. If you rupture the vessel in the brain, it is basically game over,” Fahed said.
When the procedure was finished, around 12:30 p.m. on Nov. 14, there were congratulations and chatter. Then Fahed sat with Vena Medical officials to brainstorm about what would come next.
“Immediately after (the procedure), we knew we were on to something new and big. Immediately a billion questions pop into your head because now you finally have the possibility to visualize anything you want and there are so many questions to answer,” he said.
“It is like finally turning on the light in a dark room. You finally know what you are seeing.”
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