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Zhu S, Meng B, Jiang J, Wang X, Luo N, Liu N, Shen H, Wang L, Li Q. The Updated Role of Transcranial Ultrasound Neuromodulation in Ischemic Stroke: From Clinical and Basic Research. Front Cell Neurosci 2022; 16:839023. [PMID: 35221926 PMCID: PMC8873076 DOI: 10.3389/fncel.2022.839023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/17/2022] [Indexed: 12/31/2022] Open
Abstract
Ischemic stroke is a common cause of death and disability worldwide, which leads to serious neurological and physical dysfunction and results in heavy economic and social burdens. For now, timely and effective dissolution of thrombus, and ultimately improvement in the recovery of neurological functions, is the treatment strategy focus. Recently, many studies have reported that transcranial ultrasound stimulation (TUS), as a non-invasive method, can dissolve thrombus, improve cerebral blood circulation, and exert a neuroprotective effect post-stroke. TUS can promote functional recovery and improve rehabilitation efficacy among patients with ischemic stroke. This mini-review summarizes the potential mechanism and limitation of TUS in stroke aims to provide a new strategy for the future treatment of patients with ischemic stroke.
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Affiliation(s)
- Shuiping Zhu
- Department of Geriatric Medicine, Rongjun Hospital, Jiaxing, China
| | - Bin Meng
- Department of Ultrasound, Rongjun Hospital, Jiaxing, China
| | - Jianping Jiang
- Department of Geriatric Medicine, Rongjun Hospital, Jiaxing, China
| | - Xiaotao Wang
- Department of Ultrasound, Rongjun Hospital, Jiaxing, China
| | - Na Luo
- Department of Ultrasound, Rongjun Hospital, Jiaxing, China
| | - Ning Liu
- Department of Ultrasound, Rongjun Hospital, Jiaxing, China
| | - Huaping Shen
- Department of Ultrasound, Rongjun Hospital, Jiaxing, China
| | - Lu Wang
- Starbody Plastic Surgery Clinic, Hangzhou, China
| | - Qian Li
- Department of Ultrasound, Rongjun Hospital, Jiaxing, China
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Stern JM, Spivak NM, Becerra SA, Kuhn TP, Korb AS, Kronemyer D, Khanlou N, Reyes SD, Monti MM, Schnakers C, Walshaw P, Keselman I, Cohen MS, Yong W, Fried I, Jordan SE, Schafer ME, Engel J, Bystritsky A. Safety of focused ultrasound neuromodulation in humans with temporal lobe epilepsy. Brain Stimul 2021; 14:1022-1031. [PMID: 34198105 DOI: 10.1016/j.brs.2021.06.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE Transcranial Focused Ultrasound (tFUS) is a promising new potential neuromodulation tool. However, the safety of tFUS neuromodulation has not yet been assessed adequately. Patients with refractory temporal lobe epilepsy electing to undergo an anterior temporal lobe resection present a unique opportunity to evaluate the safety and efficacy of tFUS neuromodulation. Histological changes in tissue after tFUS can be examined after surgical resection, while further potential safety concerns can be assessed using neuropsychological testing. METHODS Neuropsychological functions were assessed in eight patients before and after focused ultrasound sonication of the temporal lobe at intensities up to 5760 mW/cm2. Using the BrainSonix Pulsar 1002, tFUS was delivered under MR guidance, using the Siemens Magnetom 3T Prisma scanner. Neuropsychological changes were assessed using various batteries. Histological changes were assessed using hematoxylin and eosin staining, among others. RESULTS With respect to safety, the histological analysis did not reveal any detectable damage to the tissue, except for one subject for whom the histology findings were inconclusive. In addition, neuropsychological testing did not show any statistically significant changes in any test, except for a slight decrease in performance on one of the tests after tFUS. SIGNIFICANCE This study supports the hypothesis that low-intensity Transcranial Focused Ultrasound (tFUS) used for neuromodulation of brain circuits at intensities up to 5760 mW/cm2 may be safe for use in human research. However, due to methodological limitations in this study and inconclusive findings, more work is warranted to establish the safety. Future directions include greater number of sonications as well as longer exposure at higher intensity levels to further assess the safety of tFUS for modulation of neuronal circuits.
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Affiliation(s)
- John M Stern
- Department of Neurology, UCLA School of Medicine, USA
| | - Norman M Spivak
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, USA; Department of Neurosurgery, UCLA School of Medicine, USA
| | - Sergio A Becerra
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, USA
| | - Taylor P Kuhn
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, USA
| | - Alexander S Korb
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, USA; BrainSonix Inc., Los Angeles, CA, USA
| | - David Kronemyer
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, USA
| | - Négar Khanlou
- Department of Pathology and Laboratory Medicine, UCLA School of Medicine, USA
| | - Samuel D Reyes
- Department of Neurosurgery, UCLA School of Medicine, USA
| | - Martin M Monti
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, USA; Department of Neurosurgery, UCLA School of Medicine, USA; Department of Psychology, UCLA College of Letters and Science, USA; Brain Research Institute, UCLA, USA
| | | | - Patricia Walshaw
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, USA
| | - Inna Keselman
- Department of Neurology, UCLA School of Medicine, USA
| | - Mark S Cohen
- Department of Neurology, UCLA School of Medicine, USA; Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, USA; Department of Psychology, UCLA College of Letters and Science, USA; Department of Radiology, UCLA School of Medicine, USA; Department of Biomedical Physics, UCLA School of Medicine, USA; Department of Bioengineering, UCLA School of Engineering, USA; California Nanosystems Institute, UCLA, USA; Brain Research Institute, UCLA, USA
| | - William Yong
- Department of Pathology and Laboratory Medicine, UCLA School of Medicine, USA
| | - Itzhak Fried
- Department of Neurosurgery, UCLA School of Medicine, USA; Brain Research Institute, UCLA, USA
| | - Sheldon E Jordan
- Neurology Management Associates- Los Angeles, Santa Monica, CA, USA
| | - Mark E Schafer
- BrainSonix Inc., Los Angeles, CA, USA; School of Biomedical Engineering, Drexel University, Philadelphia, PA, USA
| | - Jerome Engel
- Department of Neurology, UCLA School of Medicine, USA; Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, USA; Department of Neurobiology, UCLA School of Medicine, USA; Brain Research Institute, UCLA, USA
| | - Alexander Bystritsky
- Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, USA; BrainSonix Inc., Los Angeles, CA, USA.
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Masomi-Bornwasser J, Fabrig O, Krenzlin H, König J, Tanyildizi Y, Kempski O, Ringel F, Keric N. Systematic Analysis of Combined Thrombolysis Using Ultrasound and Different Fibrinolytic Drugs in an in Vitro Clot Model of Intracerebral Hemorrhage. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1334-1342. [PMID: 33549380 DOI: 10.1016/j.ultrasmedbio.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 06/12/2023]
Abstract
Adequate removal of blood clots by minimally invasive surgery seems to correlate with a better clinical outcome in patients with intracerebral hemorrhages (ICHs). Moreover, neurotoxic effects of recombinant tissue plasminogen activator have been reported. The aim of this study was to improve fibrinolysis using an intra-clot ultrasound application with tenecteplase and urokinase in our established ICH clot model. One hundred thirty clots were produced from 25 or 50 mL of human blood, incubated for different periods and equipped with drainage, through which an ultrasound catheter was placed in 65 treatment clots for 1 h, randomly allocated into three groups: administration of ultrasound, administration of 60 IU of tenecteplase or administration of 30,000 IU urokinase. Relative end weights were compared. This study found a significant increase in thrombolysis caused by a combination of ultrasound and fibrinolytic drugs, whereas ultrasound and tenecteplase are significantly more effective in the treatment of larger and aged clots.
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Affiliation(s)
- Julia Masomi-Bornwasser
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
| | - Oliver Fabrig
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Harald Krenzlin
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Yasemin Tanyildizi
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Oliver Kempski
- Institute for Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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Intrahematomal Ultrasound Enhances RtPA-Fibrinolysis in a Porcine Model of Intracerebral Hemorrhage. J Clin Med 2021; 10:jcm10040563. [PMID: 33546160 PMCID: PMC7913235 DOI: 10.3390/jcm10040563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 11/30/2022] Open
Abstract
Catheter-based ultrasound-thrombolysis has been successfully used in a small clinical trial in order to enhance recombinant tissue plasminogen activator (rtPA)-fibrinolysis, for the treatment of spontaneous intracerebral hemorrhages (ICHs). The aim of this study was to investigate the ultra-early effects of ultrasound on hematoma and the surrounding brain tissue in a porcine ICH-model. To achieve this, 21 pigs with a right frontal ICH were randomly assigned to four groups: (1) drainage (n = 3), (2) drainage + rtPA (n = 6), (3) drainage + ultrasound (n = 6), and (4) drainage + ultrasound + rtPA (n = 6). The hematoma volume assessment was performed using cranial MRI before and after the treatments. Subsequently, the brain sections were analyzed using HE-staining and immunohistochemistry. The combined treatment using rtPA and ultrasound led to a significantly higher hematoma reduction (62 ± 5%) compared to the other groups (Group 1: 2 ± 1%; Group 2: 30 ± 12%; Group 3: 18 ± 8% (p < 0.0001)). In all groups, the MRI revealed an increase in diffusion restriction but neither hyper- or hypoperfusion, nor perihematomal edema. HE stains showed perihematomal microhemorrhages were equally distributed in each group, while edema was more pronounced within the control group. Immunohistochemistry did not reveal any ultra-early side effects. The combined therapy of drainage, rtPA and ultrasound is a safe and effective technique for hematoma-reduction and protection of the perihematomal tissue in regard to ultra-early effects.
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Schafer ME, Spivak NM, Korb AS, Bystritsky A. Design, Development, and Operation of a Low-Intensity Focused Ultrasound Pulsation (LIFUP) System for Clinical Use. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2021; 68:54-64. [PMID: 32746201 DOI: 10.1109/tuffc.2020.3006781] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Noninvasive low-intensity focused ultrasound pulsation (LIFUP) neuromodulation provides a unique approach to both investigating and treating the brain. This work describes a well-calibrated, simple-to-use ultrasound stimulation system for neuromodulation studies. It provides a single-element 650-kHz transducer design and a straightforward control mechanism, with extensive calibration and internal electronic monitoring to prevent unwanted over or under treatment. One goal of this approach is to relieve researchers of many of the details associated with developing their own exposure equipment. A unique transducer positioning system and distinctive MRI fiducial targets simplify alignment and targeting. The system design, control software, calibration, and alignment techniques are described in detail. Examples of transducer targeting and neurostimulation using the system are provided.
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Keric N, Döbel M, Krenzlin H, Kurz E, Tanyildizi Y, Heimann A, König J, Kempski O, Ringel F, Masomi-Bornwasser J. Comparative analysis of fibrinolytic properties of Alteplase, Tenecteplase and Urokinase in an in vitro clot model of intracerebral haemorrhage. J Stroke Cerebrovasc Dis 2020; 29:105073. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 06/14/2020] [Accepted: 06/15/2020] [Indexed: 12/11/2022] Open
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Masomi-Bornwasser J, Winter P, Neulen A, Kantelhardt SR, König J, Kempski O, Ringel F, Keric N. Doppler sonography enhances rtPA-induced fibrinolysis in an in vitro clot model of spontaneous intracerebral hemorrhages. PLoS One 2019; 14:e0210810. [PMID: 30653589 PMCID: PMC6336417 DOI: 10.1371/journal.pone.0210810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 01/02/2019] [Indexed: 01/25/2023] Open
Abstract
Background Transcranial Doppler (TCD) was shown to enhance intravascular fibrinolysis by rtPA in ischemic stroke. Studies revealed that catheter-based administration of rtPA induces lysis of intracerebral hemorrhages (ICH). However, it is unknown whether TCD would be suitable to enhance rtPA-induced fibrinolysis in patients with ICH. The aim of this study was to assess the potential of TCD to enhance rtPA-induced fibrinolysis in an in vitro clot system. Methods Reproducible human blood clots of 25 ml were incubated in a water bath at 37°C during treatments. They were weighed before and after 6 different treatments: (I) control (incubation only), (II) rtPA only, (III) one Doppler probe, (IV) two Doppler probes placed vis-à-vis, (V) one probe and rtPA and (VI) two probes and rtPA. To quantify lysis of the blood clots and attenuation of the Doppler through a temporal squama acoustic peak rarefaction pressure (APRP) was measured in the field of the probes. Temperature was assessed to evaluate possible side effects. Results Clot weight was reduced in all groups. The control group had the highest relative end weight of 70.2%±7.2% compared to all other groups (p<0,0001). Most efficient lysis was achieved using (VI) 2 probes and rtPA 36.3%±4.4% compared to (II, III, IV) (p<0.0001; p = 0.0002; p = 0.048). APRP was above lysis threshold (535.5±7.2 kPa) using 2 probes even through the temporal squama (731.6±32.5 kPa) (p = 0.0043). There was a maximal temperature elevation of 0.17±0.07°C using both probes. Conclusions TCD significantly enhances rtPA-induced lysis of blood clots, and the effect is amplified by using multiple probes. Our results indicate that bitemporal TCD insonation of hematomas could be a new and safe approach to enhance fibrinolysis of ICH´s treated with intralesional catheter and rtPA.
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Affiliation(s)
- Julia Masomi-Bornwasser
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- * E-mail:
| | - Philipp Winter
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Sven R. Kantelhardt
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Oliver Kempski
- Institute of Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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Mueller JK, Ai L, Bansal P, Legon W. Numerical evaluation of the skull for human neuromodulation with transcranial focused ultrasound. J Neural Eng 2018; 14:066012. [PMID: 28777075 DOI: 10.1088/1741-2552/aa843e] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Transcranial focused ultrasound is an emerging field for human non-invasive neuromodulation, but its dosing in humans is difficult to know due to the skull. The objective of the present study was to establish modeling methods based on medical images to assess skull differences between individuals on the wave propagation of ultrasound. APPROACH Computational models of transcranial focused ultrasound were constructed using CT and MR scans to solve for intracranial pressure. We explored the effect of including the skull base in models, different transducer placements on the head, and differences between 250 kHz or 500 kHz acoustic frequency for both female and male models. We further tested these features using linear, nonlinear, and elastic simulations. To better understand inter-subject skull thickness and composition effects we evaluated the intracranial pressure maps between twelve individuals at two different skull sites. MAIN RESULTS Nonlinear acoustic simulations resulted in virtually identical intracranial pressure maps with linear acoustic simulations. Elastic simulations showed a difference in max pressures and full width half maximum volumes of 15% at most. Ultrasound at an acoustic frequency of 250 kHz resulted in the creation of more prominent intracranial standing waves compared to 500 kHz. Finally, across twelve model human skulls, a significant linear relationship to characterize intracranial pressure maps was not found. SIGNIFICANCE Despite its appeal, an inherent problem with the use of a noninvasive transcranial ultrasound method is the difficulty of knowing intracranial effects because of the skull. Here we develop detailed computational models derived from medical images of individuals to simulate the propagation of neuromodulatory ultrasound across the skull and solve for intracranial pressure maps. These methods allow for a much better understanding of the intracranial effects of ultrasound for an individual in order to ensure proper targeting and more tightly control dosing.
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Affiliation(s)
- Jerel K Mueller
- Department of Rehabilitation Medicine, Division of Physical Therapy and Division of Rehabilitation Science, Medical School, University of Minnesota, Minneapolis, MN, United States of America
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Masomi-Bornwassser J, Freguia F, Müller-Werkmeister H, Kempski O, Giese A, Keric N. Effect of irrigation on fibrinolytic rtPA therapy in a clot model of intracerebral haemorrhage: a systematic in vitro study. Acta Neurochir (Wien) 2018; 160:1159-1165. [PMID: 29564653 DOI: 10.1007/s00701-018-3517-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 03/09/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Although fibrinolytic therapy is an upcoming treatment for intracerebral haemorrhage (ICH), standard guidelines are lacking, and some clinical issues persist. Here, we used our recently devised clot model of ICH to systematically analyse effects of irrigation and cerebrospinal fluid (CSF) on fibrinolysis. METHODS In vitro clots of human blood (25 ml) were generated and a catheter irrigation system was applied to deliver fluid/treatment. Clots were weighed before and after treatment and compared to rtPA treatment alone. First various drainage periods (15, 30 and 60 min; n = 3 each) and irrigation rates (0, 15, 90 and 180 ml/h; n = 3-5 each) were tested, followed by rtPA administration (1 mg, 15 min incubation) at each irrigation rate. Potential fibrinolytic effect of CSF was examined by incubation with 5 ml healthy vs. haemorrhagic CSF (n = 3 each). To assess a washout effect treatment with saline (0.9%), rtPA (1 mg) and high-rate irrigation (180 ml/h) were compared with measuring plasminogen level before and after. Furthermore clots were treated with a combination of plasminogen (150% serum concentration) and rtPA (1 mg). RESULTS Relative clot end weights after 60 min irrigation system treatments were 66.3 ± 3.8% (0 ml/h), 46.3 ± 9.5% (15 ml/h), 46.5 ± 7.1% (90 ml/h) and 53.3 ± 4.1% (180 ml/h). At a lower irrigation rate (15 ml/h), relative end weights were lowest (49.5 ± 4.6%) after 60 min (15 min: 62 ± 4.3%, p = 0.016; 30 min: 62.90 ± 1.88%, p = 0.012). The combination of rtPA and irrigation produced following relative end weights: 0 ml/h, 35 ± 3.2%; 15 ml/h, 32.1 ± 5.7%; 90 ml/h, 36.7 ± 6.3% and 180 ml/h, 41.9 ± 7.5%. No irrigation (0 ml/h) versus rtPA alone showed a significant difference (p < 0.0001) in higher clot weight reduction by rtPA. Similar rtPA+15 ml/h irrigation achieved a significant higher weight reduction compared to 15 ml/h irrigation alone (p = 0.0124). No differences were evident at 90 and 180 ml/h irrigation rates with and without rtPA. Healthy (55.1 ± 5%) or haemorrhagic (65.2 ± 6.2%) CSF showed no fibrinolytic activity. Plasminogen levels in clots declined dramatically (> 80% initially to < 10%) after 1 mg single rtPA dosing and high-rate (180 ml/h) irrigation. The fibrinolytic benefit of adding plasminogen to rtPA was marginal. CONCLUSIONS In our in vitro clot model, irrigation combined with rtPA (vs. rtPA alone) conferred no added lytic benefit. Likewise, exposure to haemorrhagic CSF did not increase clot lysis.
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Affiliation(s)
- Julia Masomi-Bornwassser
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Fabio Freguia
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
- Department of Neuropathology, University- and Knappschaft- Hospital Bochum, Bochum, Germany
| | - Hendrik Müller-Werkmeister
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Asklepios Klinikum Harburg, Hamburg, Germany
| | - Oliver Kempski
- Institute of Neurosurgical Pathophysiology, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Alf Giese
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
- OrthoCentrum Hamburg, Hansastr. 1-3, Hamburg, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Centre of the Johannes Gutenberg University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
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Combination of ultrasound and rtPA enhances fibrinolysis in an In Vitro clot system. PLoS One 2017; 12:e0188131. [PMID: 29145482 PMCID: PMC5690612 DOI: 10.1371/journal.pone.0188131] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/01/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Catheter-based lysis with recombinant tissue plasminogen activator (rtPA) is a well-established therapy for spontaneous intracerebral hemorrhage (ICH). The effectiveness of this therapy can be increased with ultrasound, but the optimal conditions are not yet clearly established. Using a novel in vitro system of blood clots previously developed by our group, we investigated various parameters of intralesional sonothrombolysis using an endosonography catheter in combination with rtPA. METHODS Standardized human blood clots were equipped with a drainage catheter and weighed before and after 4 treatments: control (drainage only), rtPA only, ultrasound only and the combination of rtPA+ultrasound. The effectiveness of ultrasound was further analysed in terms of optimal frequency, duration and distance to the probe. Temperature and acoustic peak rarefaction pressure (APRP) were assessed to analyse potential adverse effects and quantify lysis. Histo-morphological analysis of the treated clots was performed by H&E staining and confocal laser scanning microscopy using fluorescent fibrinogen. RESULTS The combined treatment rtPA+ultrasound achieved the highest lysis rates with a relative weight of 30.3%±5.5% (p≤0.0001) compared to all other groups. Similar results were observed when treating aged clots. Confocal fluorescent microscopy of the treated clots revealed a rarefied fibrin mesh without cavitations. No relevant temperature increase occurred (0.53±0.75°C). The optimal insonation treatment time was 1 hour. APRP measurements showed a lysis threshold of 515.5±113.4 kPa. Application of 10 MHz achieved optimal lysis and lysis radius, while simultaneously proving to be the best frequency for morphologic imaging of the clot and surrounding tissue. CONCLUSIONS These promising data provide the basis for an individualized minimal invasive ICH therapy by rtPA and sonothrombolysis independent of ICH age.
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Wang Z, Komatsu T, Mitsumura H, Nakata N, Ogawa T, Iguchi Y, Yokoyama M. An uncovered risk factor of sonothrombolysis: Substantial fluctuation of ultrasound transmittance through the human skull. ULTRASONICS 2017; 77:168-175. [PMID: 28242510 DOI: 10.1016/j.ultras.2017.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 06/06/2023]
Abstract
Sonothrombolysis is one of the most feasible methods for enhancing clot lysis with a recombinant tissue plasminogen activator (rt-PA) in cases of acute ischemic strokes. For safe and efficient clinical practices of sonothrombolysis, accurate estimation of ultrasound transmittance through the human skull is critical. Previously, we reported substantial and periodic fluctuation of ultrasound transmittance through a bone-phantom plate following changes to ultrasound frequency, the thickness of the bone-phantom plate, and the distance between a transducer and the bone-phantom plate. In the present study, we clarify the transmittance behavior of medium-frequency ultrasound (from 400kHz to 600kHz) through the human skull, and examine reduction of the transmittance fluctuation. For the study, we measured transmittance of sinusoidal ultrasound waves at 400kHz, 500kHz, and 600kHz at 13 temple spots on 3 human skulls by changing the distance between a transducer and the skull bone, and found substantial and periodic fluctuation in the transmittance behaviors for these sinusoidal voltage excitations. Degrees of the fluctuation varied depending on the measurement spots. A fluctuation ratio between the maximum transmittance and the minimum transmittance reached 3 in some spots. This large transmittance fluctuation is considered to be a risk factor for sonothrombolysis therapies. We examined a modulated ultrasound wave to reduce the fluctuation, and succeeded in obtaining considerable reduction. The average fluctuation ratios for 400-kHz, 500-kHz, and 600-kHz waves were 2.38, 2.38, and 2.07, respectively. We successfully reduced the ratio to 1.72 by using a periodic selection of random frequency (PSRF)-type of modulation wave. The thus obtained results indicate that attention to the fluctuation in ultrasound transmittance through the skull is necessary for safe and effective sonothrombolysis therapies, and that modulated ultrasound waves constitute a powerful method for reducing the risk of fluctuation.
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Affiliation(s)
- Zuojun Wang
- Division of Ultrasound Development and Application, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Teppei Komatsu
- Department of Neurology, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Hidetaka Mitsumura
- Department of Neurology, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Norio Nakata
- Division of Ultrasound Development and Application, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Takeki Ogawa
- Department of Emergency Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Masayuki Yokoyama
- Division of Medical Engineering, Research Center for Medical Sciences, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan.
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Ebrahim S, Montoya L, Kamal El Din M, Sohani ZN, Agarwal A, Bance S, Saquib J, Saquib N, Ioannidis JPA. Randomized trials are frequently fragmented in multiple secondary publications. J Clin Epidemiol 2016; 79:130-139. [PMID: 27387965 DOI: 10.1016/j.jclinepi.2016.05.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 04/19/2016] [Accepted: 05/06/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To assess the frequency and features of secondary publications of randomized controlled trials (RCTs). STUDY DESIGN AND SETTING For 191 RCTs published in high-impact journals in 2009, we searched for secondary publications coauthored by at least one same author of the primary trial publication. We evaluated the probability of having secondary publications, characteristics of the primary trial publication that predict having secondary publications, types of secondary analyses conducted, and statistical significance of those analyses. RESULTS Of 191 primary trials, 88 (46%) had a total of 475 secondary publications by 2/2014. Eight trials had >10 (up to 51) secondary publications each. In multivariable modeling, the risk of having subsequent secondary publications increased 1.32-fold (95% CI 1.05-1.68) per 10-fold increase in sample size, and 1.71-fold (95% CI 1.19-2.45) in the presence of a design article. In a sample of 197 secondary publications examined in depth, 193 tested different hypotheses than the primary publication. Of the 193, 43 tested differences between subgroups, 85 assessed predictive factors associated with an outcome of interest, 118 evaluated different outcomes than the original article, 71 had differences in eligibility criteria, and 21 assessed different durations of follow-up; 176 (91%) presented at least one analysis with statistically significant results. CONCLUSIONS Approximately half of randomized trials in high-impact journals have secondary publications published with a few trials followed by numerous secondary publications. Almost all of these publications report some statistically significant results.
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Affiliation(s)
- Shanil Ebrahim
- Stanford Prevention Research Center, Department of Medicine, Stanford University, 1265 Welch Road, Stanford, CA 94305, USA; Meta-Research Innovation Center at Stanford (METRICS), School of Medicine, Stanford University, 1265 Welch Road, Stanford, CA 94305, USA; Department of Clinical Epidemiology & Biostatistics, McMaster University, 1200 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Anesthesia, McMaster University, 1200 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Prevention Lab and Systematic Overviews through advancing Research Technology (SORT), SickKids Research Institute, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Luis Montoya
- Department of Trauma and Orthopaedics, University Health Network, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
| | - Mostafa Kamal El Din
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1200 Main Street West, Hamilton, Ontario L8S 4K1, Canada
| | - Zahra N Sohani
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1200 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Population Genomics Program, Faculty of Health Sciences, McMaster University, 1200 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Faculty of Medicine, 1 King's College Circle, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Arnav Agarwal
- Faculty of Medicine, 1 King's College Circle, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Sheena Bance
- Department of Applied Psychology and Human Development, Ontario Institute for Studies in Education, 252 Bloor Street West, Toronto, Ontario M5S 1V6, Canada
| | - Juliann Saquib
- Department of Family and Community Medicine, Qassim University, Buraydah, Saudi Arabia
| | - Nazmus Saquib
- College of Medicine, Sulaiman AlRajhi Colleges, Al Bukayriyah, Saudi Arabia
| | - John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, Stanford University, 1265 Welch Road, Stanford, CA 94305, USA; Meta-Research Innovation Center at Stanford (METRICS), School of Medicine, Stanford University, 1265 Welch Road, Stanford, CA 94305, USA; Department of Health Research and Policy, Stanford University School of Medicine, 150 Governor's Ln, Stanford, CA 94305, USA; Department of Statistics, Stanford University School of Humanities and Sciences, Building 1, Main Quad, Stanford, CA 94305, USA.
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Abstract
Thrombo-occlusive disease is a leading cause of morbidity and mortality. In this chapter, the use of ultrasound to accelerate clot breakdown alone or in combination with thrombolytic drugs will be reported. Primary thrombus formation during cardiovascular disease and standard treatment methods will be discussed. Mechanisms for ultrasound enhancement of thrombolysis, including thermal heating, radiation force, and cavitation, will be reviewed. Finally, in-vitro, in-vivo and clinical evidence of enhanced thrombolytic efficacy with ultrasound will be presented and discussed.
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Affiliation(s)
- Kenneth B Bader
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Guillaume Bouchoux
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Christy K Holland
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
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Thrombolytic therapy with rt-PA and transcranial color Doppler ultrasound (TCCS) combined with microbubbles for embolic thrombus. Thromb Res 2015; 136:1027-32. [DOI: 10.1016/j.thromres.2015.08.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/29/2015] [Accepted: 08/29/2015] [Indexed: 11/22/2022]
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Saito O, Wang Z, Mitsumura H, Ogawa T, Iguchi Y, Yokoyama M. Substantial fluctuation of acoustic intensity transmittance through a bone-phantom plate and its equalization by modulation of ultrasound frequency. ULTRASONICS 2015; 59:94-101. [PMID: 25702201 DOI: 10.1016/j.ultras.2015.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Revised: 12/20/2014] [Accepted: 01/28/2015] [Indexed: 06/04/2023]
Abstract
For safe and efficient sonothrombolysis therapies, accurate estimation of ultrasound transmittance through the human skull is essential. The present study clarifies uncertainty surrounding this transmittance and experimentally verifies the equalization of transmittance through the modulation of ultrasound frequency. By changing three factors (ultrasound frequency, the thickness of a bone-phantom plate, and the distance between a transducer and a bone-phantom plate), we measured the intensity of ultrasound passing through the plate. Two activating methods, sinusoidal waves at 500 kHz and modulated waves, were compared. When we changed (1) the distance between a transducer and a bone-phantom plate and (2) the thickness of the bone-phantom plate, ultrasound transmittance through the plates substantially fluctuated. The substantial fluctuation in transmittance was observed also for a cut piece of human temporal skull bone. This fluctuation significantly declined for the modulated wave. In conclusion, modulation of ultrasound frequency can equalize the transmittance with an approximately 30-65% fluctuation drop and an approximately 40% fluctuation drop for a bone-phantom plate and for a cut piece of skull bone, respectively. By using modulated waves, we can develop safer and more effective sonothrombolysis therapies.
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Affiliation(s)
- Osamu Saito
- Division of Medical Engineering, Research Center for Medical Sciences, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Zuojun Wang
- Division of Medical Engineering, Research Center for Medical Sciences, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Hidetaka Mitsumura
- Department of Neurology, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Takeki Ogawa
- Department of Emergency Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Masayuki Yokoyama
- Division of Medical Engineering, Research Center for Medical Sciences, The Jikei University School of Medicine, 3-25-8, Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan.
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Bouchoux G, Shivashankar R, Abruzzo TA, Holland CK. In silico study of low-frequency transcranial ultrasound fields in acute ischemic stroke patients. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:1154-66. [PMID: 24631377 PMCID: PMC4012005 DOI: 10.1016/j.ultrasmedbio.2013.12.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 11/21/2013] [Accepted: 12/29/2013] [Indexed: 05/08/2023]
Abstract
Ultrasound in the sub-megahertz range enhances thrombolysis and may be applied transcranially to ischemic stroke patients. The consistency of transcranial insonification needs to be evaluated. Acoustic and thermal simulations based on computed-tomography (CT) scans of 20 patients were performed. An unfocused 120-kHz transducer allowed homogeneous insonification of the thrombus, and positioning based on external landmarks performed similarly to an optimized placement based on CT data. With a weakly focused 500-kHz transducer, the landmark-based positioning underperformed. The predicted inter-patient variation of in situ acoustic pressure was similar with both the 120 and 500-kHz transducers for the optimized placement (18.0-26.4% relative standard deviation). The simulated maximum acoustic pressure in intervening tissues was 2.6 ± 0.6 and 2.0 ± 0.7 times the pressure in the thrombus for the 120-kHz and 500-kHz transducers, respectively. A 1 W/cm(2) insonification of the thrombus caused a 3.8 ± 2.2 °C increase in the bone for the 120-kHz transducer, and a 13.4 ± 3.3 °C increase for the 500-kHz transducer. Contralateral local maxima up to 1.1 times the pressure amplitude in the targeted zone were predicted for the 120-kHz transducer. We established two transducer placement approaches, one based on analysis of a head CT and the other using simple external, visible landmarks. Both approaches allowed consistent insonification of the thrombus.
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Affiliation(s)
- Guillaume Bouchoux
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | | | - Todd A Abruzzo
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Christy K Holland
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Biomedical Engineering Program, College of Engineering and Applied Sciences, University of Cincinnati, Cincinnati, OH, USA.
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Barlinn K, Barreto AD, Sisson A, Liebeskind DS, Schafer ME, Alleman J, Zhao L, Shen L, Cava LF, Rahbar MH, Grotta JC, Alexandrov AV. CLOTBUST-hands free: initial safety testing of a novel operator-independent ultrasound device in stroke-free volunteers. Stroke 2013; 44:1641-6. [PMID: 23598523 PMCID: PMC4156594 DOI: 10.1161/strokeaha.113.001122] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to evaluate safety and tolerability of a novel operator-independent ultrasound device among stroke-free volunteers. METHODS A headframe containing 18 ultrasound transducers (each operating at 2 MHz, pulsed-wave) was used to expose both temporal windows and the suboccipital window. The transmission characteristics were set to emulate the acoustic characteristics of the exposure levels in the Combined Lysis of Thrombus in Brain Ischemia using Transcranial Ultrasound and Systemic tPA (CLOTBUST) trial and to never exceed Food and Drug Administration mandated diagnostic ultrasound exposure limits. Volunteers underwent 2 hours of insonation with transducer activation one at a time. Safety was captured using serial neurological examinations and pre- and postinsonation MRI for detection of the blood brain barrier permeability. RESULTS A total of 15 volunteers (40% men; 49 ± 16 years; 27% black; all pre-exposure National Institutes of Health Stroke Scale scores 0) were enrolled. Five volunteers received pulsed-wave ultrasound via the best pair temporal transducers, 5 via sequential activation of the suboccipital transducers, and 5 via sequential activation of all bilateral temporal and suboccipital transducers. All subjects were safely insonated with no adverse effects as indicated by the neurological examinations during, immediately after the exposure, and at 24 hours, and no abnormality of the blood brain barrier was found on any of the MRIs. CONCLUSIONS Our novel device was well tolerated by stroke-free volunteers and did not cause any neurological dysfunction nor did it affect blood brain barrier integrity. The safety and efficacy of the device are now being tested in stroke patients receiving intravenous tissue-type plasminogen activator in phase II-III clinical trials.
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Affiliation(s)
- Kristian Barlinn
- Department of Neurology, Comprehensive Stroke Center, The University of Alabama at Birmingham, RWUH M226, 619 19th St South, Birmingham, AL 35249-3280, USA
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Abstract
OPINION STATEMENT Acute ischemic stroke remains one of the most devastating diseases when it comes to morbidity and mortality, not to mention the personal and economic burden that occurs in long-term. Intravenous thrombolysis with tissue plasminogen activator (tPA) is the only effective acute stroke therapy that improves outcome if given up to 4.5 hours from symptom onset. However, recanalization rates are meager and the majority of treated patients still have residual disability after stroke, emphasizing the need for further treatment options that may facilitate or even rival the only approved therapy. Sonothrombolysis, the adjuvant continuous ultrasound sonication of an intra-arterial occlusive thrombus during thrombolysis, enhances the clot-dissolving capabilities of intravenous tPA presumably by delivering acoustic pressure to the target brain vessel. Higher recanalization rates produce a trend towards better functional outcomes that could be safely achieved with the combination of high-frequency ultrasound and intravenous tPA. However, data on ultrasound targeting of intracranial proximal occlusive lesions other than those in the middle cerebral arteries are sparse. Moreover, recent sonothrombolysis trials were exclusively conducted with operator-dependent hand-held technology hindering its further testing in clinical sonothrombolysis trials. An operator-independent 2-MHz transcranial Doppler device has been developed allowing health care professionals not formally trained in ultrasound apparatus to provide therapeutic ultrasound as needed. Currently, this operator-independent device covering 12 proximal intracranial segments that most commonly contain thrombo-embolic occlusions enters testing in a pivotal multicenter sonothrombolysis efficacy trial. If this trial demonstrates safety and efficacy, adjuvants, such as gaseous microbubbles that further potentiate the thrombolytic effect of intravenous tPA, could be tested along with this device.
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