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“It doesn’t make sense to get hardware implanted in my body.”

It was the week after Thanksgiving, and Vibhor Krishna listened intently as a patient recalled the moment her favorite holiday turned into her family’s greatest fear. A retired woman well into her 80s, nothing could disrupt the joy of uniting her family over a home-cooked meal — and a decade of severe hand tremors was no exception.

But one accidental kitchen fire had her loved ones, and her physician, considering what came next. When Krishna raised the possibility of surgical intervention, he met firm resistance.

That conversation stayed with him long after the appointment ended. It wasn’t just one patient’s hesitation — it reflected a broader reality. For many people with neurological conditions, the idea of brain surgery feels too invasive, too permanent, or simply too frightening to consider.

It raised a question that now drives much of the UNC-Chapel Hill physician’s work: How can neurosurgeons treat neurological disease without ever opening the skull?

After seeing the success of incision-less approaches in other neurological disorders, Krishna began leading Carolina’s efforts to extend focused ultrasound to epilepsy.

Epilepsy causes bursts of abnormal electrical activity in the brain, leading to unprovoked, recurring seizures. For some, it stems from genetics, brain injury, or autoimmune disorders. For others, the causes remain unknown. Sleep deprivation, stress, illness, and various other factors can all trigger seizures. One in 26 people will develop epilepsy in their lifetime. 

And it’s notoriously difficult to study and treat. 

“Tremendous progress has been made in discovering new anti-epileptic medications to control seizures,” Krishna says. “For those who don’t respond, there is surgical dissection or stimulation by electrodes to reduce seizure activity.”

For the 15 million people whose seizures don’t respond to medication, called refractory epilepsy, the stakes are even higher — and the options far more limited.

That’s where Krishna’s work comes in. He’s spent the past 15 years exploring whether focused ultrasound could offer something new: a way to target the specific brain tissue causing seizures without invasive surgery. 

The beginning of something big

Long before he knew his way around the human brain, Krishna was drawn to its mysteries. In conversations with his mother, a psychologist, he picked up snippets of neuroscience history — foundational ideas and unanswered questions — sensing a story still being written.

Through library books, he met the field’s most influential figures and learned how they pushed its boundaries. But it wasn’t until medical school that Krishna encountered his own mentors, who shaped not just how he thought about the brain, but how he cared for patients.

“I was drawn to the work ethic of being a team player and having ownership from start to finish,” Krishna says. “Of being in situations where, with empathy and care, you could make a difference during a tough time in your patients’ lives.”

After graduating medical school in India, Krishna came to the United States to pursue that vision. Upon completing his master’s in epidemiology at Harvard University, he matched into a neurosurgery residency at the Medical University of South Carolina. His growing interest in neuroimaging landed him a fellowship in neurosurgery at the University of Toronto.

It was there that Krishna first encountered focused ultrasound and began following its evolution in clinical practice. That training would shape how he saw the future of the field — not only who surgeons could treat, but how.

Precision without incision

For functional neurosurgeons in the 1960s, a procedure called brain ablation was a mainstay. A small, heated probe inserted into the brain could destroy small swaths of affected tissue, reducing abnormal activity and helping patients with tremors or Parkinson’s disease regain control. But the approach carried risks — bleeding, swelling, and unintended neurological effects — and gradually fell out of favor as reversible techniques emerged.

Deep brain stimulation (DBS) replaced ablation as the favored approach. Instead of destroying tissue, surgeons implanted electrodes to modulate brain activity through electrical signals. DBS became a standard treatment for many movement disorders and is now being studied in psychiatric conditions like depression and bipolar disorder.

Then, in the early 2010s, focused ultrasound entered the scene.

The new technology produced similar results to ablation but did so in an entirely new way. Instead of opening the skull, physicians could deliver energy from outside the body, aiming over a thousand ultrasound beams at a target deep in the brain. Together, they generate enough heat to alter tissue with millimeter precision — without incision.

When a mentor encouraged Krishna to attend a treatment for a patient with tremors, he was blown away by its accuracy.

“I realized that you could make a profound impact in patients’ symptoms without ever touching their head,” he recalls.

A groundbreaking treatment

Like Parkinson’s disease, epilepsy often involves abnormal activity originating from specific regions of the brain and hijacking routine neural circuits. But epilepsy poses unique challenges. Seizure networks can be harder to map, and the consequences of targeting the wrong area can be significant. But advances in imaging and years of experience with ultrasound technology gave Krishna and his colleagues a reason to try.

Patients lie in an MRI scanner wearing a specialized helmet that delivers hundreds of ultrasound beams through the skull. They remain awake as physicians monitor both the machine’s aim and the patient’s memory in real time, gradually increasing the energy until the tissue’s proteins are permanently deformed.

There are no incisions, no implanted hardware, and typically, a much shorter recovery time. For patients who have spent years weighing the risks of surgery, the difference can be profound.

Krishna is leading a small Phase 1 clinical trial at UNC Health with 10 patients, three of which have been treated so far with encouraging results. One patient, who previously experienced around six seizures a month, has been seizure-free for nearly five years. Another, who had close to 100 seizures monthly, now experiences only a few.

For patients, those outcomes are measured not just in numbers, but in daily life: the ability to leave home without fear, to regain a sense of independence, and to imagine a future not defined by uncertainty. The consistent results of this trial have positioned Carolina as a leader in this emerging field — and given Krishna’s team confidence that they are moving in the right direction.

That idea, expanding not just treatment options but the choices patients feel able to make, returns him to his 80-year-old patient who just wanted to host Thanksgiving dinner for her family. For patients like her who once rejected surgery, the possibility of treating the brain without opening the skull may change the conversation entirely.

And for those who have spent years without answers, it may offer something just as important as the treatment itself: a new sense of hope.