Thermal effects of laser radiation in biological tissue

Corneal Sub-Basal Nerve Plexus in Non-Diabetic Small Fiber Polyneuropathies and the Diagnostic Role of In Vivo Corneal Confocal Microscopy

In vivo corneal confocal microscopy (IVCM) allows the immediate analysis of the corneal nerve quantity and morphology. This method became, an indispensable tool for the tropism examination, as it evaluates the small fiber plexus in the cornea. The IVCM provides us with direct information on the health of the sub-basal nerve plexus and indirectly on the peripheral nerve status. It is an important tool used to investigate peripheral polyneuropathies. Small-fiber neuropathy (SFN) is a group of neurological disorders characterized by neuropathic pain symptoms and autonomic complaints due to the selective involvement of thinly myelinated Aδ-fibers and unmyelinated C-fibers. Accurate diagnosis of SFN is important as it provides a basis for etiological work-up and treatment decisions. The diagnosis of SFN is sometimes challenging as the clinical picture can be difficult to interpret and standard electromyography is normal. In cases of suspected SFN, measurement of intraepidermal nerve fiber density through a skin biopsy and/or analysis of quantitative sensory testing can enable diagnosis. The purpose of the present review is to summarize the current knowledge about corneal nerves in different SFN. Specifically, we explore the correlation between nerve density and morphology and type of SFN, disease duration, and follow-up. We will discuss the relationship between cataracts and refractive surgery and iatrogenic dry eye disease. Furthermore, these new paradigms in SFN present an opportunity for neurologists and clinical specialists in the diagnosis and monitoring the peripheral small fiber polyneuropathies.

Electrodiagnostic Testing of Small Fiber Neuropathies: A Review of Existing Guidelines

This article reviews the literature on neurophysiological techniques for the diagnosis of small fiber neuropathy. The review is focused on clinical approach to suspected small fiber neuropathy, letting aside techniques whose clinical applicability is doubtful. We include, however, the special techniques required to examine C and Aδ fibers, which cannot be evaluated directly with conventional neurophysiological methods. The most relevant publications are summarized and recommendations for the clinical assessment of small fiber neuropathy are provided.

Penetrating effect of high-intensity infrared laser pulses through body tissue

Researchers have utilized infrared (IR) lasers as energy sources in laser therapy for curing skin diseases and skin injuries with remarkable effects. Preliminary experiments have also shown that high-intensity IR laser pulses could penetrate thick body tissues, resulting in remarkable effects for recovery from injuries in deep muscles and cartilage tissues. However, for deep-level IR laser therapy, it is unclear how much of the laser power density penetrates the body tissues at certain depths and which of the three major effects of laser irradiation, namely, laser-induced photo-chemical effect, photo-thermal effect and mechanical dragging effect, play a key role in the curing process. Thus, in this study, we developed micro-sized thin-film thermocouple (TFTC) arrays on freestanding Si₃N₄ thin-film windows as sensors for laser power density and local temperature. These devices showed excellent linear responses in output voltage to laser power density with wavelengths in the range of 325-1064 nm, and also indicated the local temperature at the laser spot. We systematically measured the penetrating effect and thermal effect through thick porcine tissues for high-intensity IR pulses with a laser system used in clinical treatment and subtracted the attenuation parameters for the porcine skin, fat and muscle tissue from the experimental data. The results offered reliable quantitative references for safe irradiation doses of high-intensity IR laser pulses in practical laser therapy.

Malignant central airway obstruction

This review comprehensively describes recent advances in the management of malignant central airway obstruction (CAO). Malignant CAO can be a dramatic and devastating manifestation of primary lung cancer or metastatic disease. A variety of diagnostic modalities are available to provide valuable information to plan a therapeutic intervention. Clinical heterogeneity in the presentation of malignant CAO provides opportunities to adapt and utilize endoscopic technology and tools in many ways. Mechanical debulking, thermal tools, cryotherapy and airway stents are methods and instruments used to rapidly restore airway patency. Delayed bronchoscopic methods, such as photodynamic therapy (PDT) and brachytherapy can also be utilized in specific non-emergent situations to establish airway patency. Although data regarding the success and complications of therapeutic interventions are retrospective and characterized by clinical and outcome measure variability, the symptoms of malignant CAO can often be successfully palliated. Assessment of risks and benefits of interventions in each individual patient during the decision-making process forms the critical foundation of the management of malignant CAO.

Temperature evolution in tissues embedded with large blood vessels during photo-thermal heating

During laser-assisted photo-thermal therapy, the temperature of the heated tissue region must rise to the therapeutic value (e.g., 43°C) for complete ablation of the target cells. Large blood vessels (larger than 500 micron in diameter) at or near the irradiated tissues have a considerable impact on the transient temperature distribution in the tissue. In this study, the cooling effects of large blood vessels on temperature distribution in tissues during laser irradiation are predicted using finite element based simulation. A uniform flow is assumed at the entrance and three-dimensional conjugate heat transfer equations in the tissue region and the blood region are simultaneously solved for different vascular models. A volumetric heat source term based on Beer-Lambert law is introduced into the energy equation to account for laser heating. The heating pattern is taken to depend on the absorption and scattering coefficients of the tissue medium. Experiments are also conducted on tissue mimics in the presence and absence of simulated blood vessels to validate the numerical model. The coupled heat transfer between thermally significant blood vessels and their surrounding tissue for three different tissue-vascular networks are analyzed keeping the laser irradiation constant. A surface temperature map is obtained for different vascular models and for the bare tissue (without blood vessels). The transient temperature distribution is seen to differ according to the nature of the vascular network, blood vessel size, flow rate, laser spot size, laser power and tissue blood perfusion rate. The simulations suggest that the blood flow through large blood vessels in the vicinity of the photothermally heated tissue can lead to inefficient heating of the target.

Numerical study on the thawing process of biological tissue induced by laser irradiation

Most of the laser applications in medicine and biology involve thermal effects. The laser-tissue thermal interaction has therefore received more and more attentions in recent years. However, previous works were mainly focused on the case of laser heating on normal tissues (37 degrees C or above). To date, little is known on the mechanisms of laser heating on the frozen biological tissues. Several latest experimental investigations have demonstrated that lasers have great potentials in tissue cryopreservation. But the lack of theoretical interpretation limits its further application in this area. The present paper proposes a numerical model for the thawing of biological tissues caused by laser irradiation. The Monte Carlo approach and the effective heat capacity method are, respectively, employed to simulate the light propagation and solid-liquid phase change heat transfer. The proposed model has four important features: (1) the tissue is considered as a nonideal material, in which phase transition occurs over a wide temperature range; (2) the solid phase, transition phase, and the liquid phase have different thermophysical properties; (3) the variations in optical properties due to phase-change are also taken into consideration; and (4) the light distribution is changing continually with the advancement of the thawing fronts. To this end, 15 thawing-front geometric configurations are presented for the Monte Carlo simulation. The least-squares parabola fitting technique is applied to approximate the shape of the thawing front. And then, a detailed algorithm of calculating the photon reflection/refraction behaviors at the thawing front is described. Finally, we develop a coupled light/heat transport solution procedure for the laser-induced thawing of frozen tissues. The proposed model is compared with three test problems and good agreement is obtained. The calculated results show that the light reflectance/transmittance at the tissue surface are continually changing with the progression of the thawing fronts and that lasers provide a new heating method superior to conventional heating through surface conduction because it can achieve a uniform volumetric heating. Parametric studies are performed to test the influences of the optical properties of tissue on the thawing process. The proposed model is rather general in nature and therefore can be applied to other nonbiological problems as long as the materials are absorbing and scattering media.

Factors influencing pricking pain threshold using a CO2 laser

The purpose of this study was the evaluation of the best experimental conditions in healthy subjects for the measurement of the minimal thermal energy density E1 which induced pricking pain on the volar surface of the left forearm by means of CO2 laser pulses. E1 was measured on a well-defined area, using laser pulses of different durations and constant power P. The dependence of E1 on the stimulus power P, the size A of the radiated area and the surface temperature T(e) were explored. In the first part of the study, these relations were obtained using a computer program, from the calculated spatio-temporal distribution of the skin temperature during, and following, a laser pulse which caused pricking pain. The second part studied a set of subsequent measurements carried out on a group of five healthy trained subjects and agreed only in part with the calculated data. We found that the measurement error on E(t) was less than 10% with P between 1.5 and 3 W, and A between 0.15 and 0.25 cm2, respectively. The influence of sensitization and adaptation phenomena on the measured data was also explored. We also show a rhythmic annual change of T(e) and E1.

Laser evoked potentials using the Nd:YAG laser

Pain-related cortical potentials were evoked by skin stimulation of the face and the limbs with 5-ns-duration laser pulses delivered by a Q-switched Nd:YAG laser. Such laser pulses, in the nanosecond range, were able to induce pinprick pain sensations and to evoke reproducible laser evoked potentials (LEPs) without visible skin lesions for an energy density of less than 18 mJ/mm(2). Low energy densities, around 10 mJ/mm(2), were sufficient to reach the pain threshold and to induce LEP. The mean conduction velocity of the stimulated afferent fibers was close to 20 m/s, consistent with the stimulation of Adelta fibers. The amplitude of LEP correlated with pain perception rather than with energy density. The differences, such as wavelength and stimulus duration, between the Q-switched Nd:YAG laser we used and the lasers that are currently used in LEP studies (i.e., CO(2), argon, or Tm:YAG lasers in the millisecond range) are discussed. Our study opens novel perspectives in the LEP field of research by using a new type of laser with a very short pulse duration.

Pain threshold changes following acupuncture, measured with cutaneous argon laser and electrical tooth pulp stimulation, a comparative study

1. The present study compared the argon laser technique for pain threshold measurements with the previously often used threshold measurements with electrical tooth pulp (TP) stimulation. 2. Conditioning stimuli with acupuncture was given since it previously has been shown to induce pain threshold changes. Acupuncture needles were inserted in the hands and arms and electrically stimulated. 3. The experiments were performed in a single blind fashion comparing pain threshold effects after either acupuncture or placebo. Pain threshold measurements with a method of limits were used with both electrical TP and the argon laser method. 4. In comparison to placebo the pain thresholds increased after acupuncture, both on the face and on the hand, with the argon laser method, while the TP thresholds were not influenced. No significant pain threshold change was detected with either the argon laser or the TP method following placebo treatment. 5. The results indicate that the argon laser used for sensory testing with a method of limits is a useful method for pain threshold measurements. The difference in pain threshold effects induced by acupuncture measured with the argon laser and the TP stimulation, are discussed and related to mechanisms that may differ between the two types of pain threshold measurements.

Computer simulation of heat and mass transfer in tissue during high-intensity long-range laser irradiation

Three-dimensional transient finite difference numerical model of the biological tissue irradiated by powerful laser beam is developed. It is used to simulate the thermal behavior of tissue assuming that radiation wavelength is chosen to give rise for volumetric heat sources. A three-dimensional seven-flow model is used to calculate radiation propagation. Evaporation and burn-out of tissue resulting in a through hole along the axis of the beam are taken into account. Besides the water boiling and corresponding changes of thermal and optical tissue properties the model takes into account one of the heat steam transfer mechanisms. Estimates are carried out for the effects of diffusion transfer and vaporization of water from the tissue surface. Kinetics of protein denaturation process are calculated by Arrenius equation. The problem is solved numerically using discrete grid technique and adaptive time-step control algorithm.

Current perspectives on direct myocardial revascularization

Direct myocardial revascularization (DMR), either surgical or catheter-based, uses lasers to create channels between ischemic myocardium and the left ventricular cavity to improve perfusion and decrease angina. This technique can also be used to deliver drugs to the damaged tissue. Candidates include patients with chronic, severe, refractory angina and those unable to undergo conventional surgical revascularization or angioplasty because remaining conduits or acceptable target vessels are lacking. Although the mechanism of action of DMR is still not known, several theories have been proposed, including stimulated angiogenesis. Late sequelae also remain to be determined. Channel characteristics differ depending on whether they were created by carbon dioxide or holmium/yttrium-aluminum-garnet (Ho: YAG) lasers. Catheter-based DMR obviates thoracotomy and anesthesia and, in systems that can create electromechanical maps, fluoroscopy. Phase I clinical trials are now under way to evaluate catheter-based DMR, with endpoints that include improvement in symptoms of angina, exercise capacity, and radionuclide myocardial perfusion.

Extensive damage to the end-plates as a complication of laser discectomy. An experimental study using an animal model

To date, there have been no reports of experiments demonstrating the effects of neodymium:YAG laser (Nd:YAG laser) on the vertebral end-plates. In this study the effect of Nd:YAG laser on end-plates was examined in 32 guinea pigs which were randomly divided into two groups. The first group was the control group, the second one the Nd:YAG laser group. All animals had experimental disc degeneration at three levels. Re-exploration was performed two months after the surgical ventral disc herniation. In the second group the same procedure was performed but at the end of the re-exploration, Nd:YAG laser irradiation of the degenerated discs was done. The wounds in both groups were closed again. Two months later all animals were sacrificed for histological and biochemical analysis. The cervical spine was excised en bloc and the overlying muscles were removed. Determination of hydroxyproline was done colorimetrically in the specimens harvested from each of these groups. Light microscopy was undertaken to evaluate the extent of morphological changes. The differences observed between the two groups were statistically significant (p < 0.05). From the results of this study, there is the question whether the Nd:YAG laser is a useful instrument in neurosurgery. Therefore, it remains to be proven whether or not this is of real benefit in the treatment of patients with degenerated disc disease.

Effect of Nd:YAG laser on experimental disc degeneration. Part I. Biochemical and radiographical analysis

Intervertebral disc herniation is an important health problem from both the social and economic aspect. It is often accompanied by a decrease in the content of water and proteoglycan (PG). The present study was undertaken to elucidate the effect of neodymium-yttrium-aluminum-garnet (Nd:YAG) laser on degenerated disc tissue. In this study a ventral disc herniation model in guinea pigs was performed to study the effects of ND:YAG laser on degenerated disc with low water and PG content. Effect of ND:YAG laser on degenerated cervical disc tissue is examined from the aspects of biochemistry and radiology. In the acute period water, PG, and collagen content decreased due to the ablative effect of ND:YAG laser on disc tissue. When changes in the degenerated disc in the post-laser chronic period were compared with degenerated disc findings, statistically significant changes could not be be found. From the results of this study, there is no question that the Nd:YAG laser offers many potential benefits, it remains to be proven whether or not this is of real benefit in the treatment of patients with degenerated disc disease.

Effect of Nd:YAG laser on experimental disc degeneration. Part II. Histological and MR imaging findings

The potential advantages of percutaneous procedures over traditional discectomy are multiple, but the use of laser energy to ablate disc tissue appears entirely empirical. To date, no experimental study exists investigating the results of laser on degenerated intervertebral disc. The present study was therefore undertaken to determine the histological and radiological changes induced by neodymium-yttrium-aluminum-garnet (Nd:YAG) laser on such disc tissue. It was shown that the vaporization of disc tissue was caused by Nd:YAG laser in early period, but this was gradually replaced by cartilaginous fibrous tissue at 60 days after laser irradiation as a result of the proliferation of cartilaginous cells and fibrous tissues. Accordingly the magnetic resonance (MR) imaging index histogram moved to the left in the early period, but it moved to the right again at 60 days after laser irradiation. In view of these data, we conclude that the use of laser in degenerated disc disease does not represent an effective treatment as an alternative to conventional surgical methods.

Thermal relaxation of port-wine stain vessels probed in vivo: the need for 1-10-millisecond laser pulse treatment

Although thermal relaxation times of cutaneous port-wine stain microvessels have been calculated and used to formulate laser selective photothermolysis, they have never been measured. A scheme to do so was devised by measuring the skin response to pairs of 585-nm dye laser pulses (250-360 microseconds each) as a function of the time interval between the two pulses, in five volunteers with port-wine stains. After a pump pulse delivering 80% of the fluence necessary for causing purpura, the fluence of a second probe pulse necessary to cause purpura was determined and was found to increase with the interval between the two pulses, in a manner consistent with thermal diffusion theory. Biopsy specimens were obtained from four of the five subjects to examine the nature and extent of vessel damage and to measure the port-wine stain vessel diameters. Using diffusion theory, the thermal relaxation time was calculated based on the measured vessel diameters. These calculated values are consistent with the increase in radiant exposure (fluence) of the probe pulse necessary to induce purpura for longer time delays. Two simple models for thermal relaxation of port-wine stain vessels are presented and compared with the data. The data and histologic assessment of the vessel injury strongly suggest that pulse durations for ideal laser treatment are in the 1-10-millisecond region and depend on vessel diameter. No dermatologic lasers presently used for port-wine stain treatment operate in this pulse width domain.

Minimally invasive palliative tumor therapy guided by imaging techniques: the UCLA experience

Imaging-guided palliative therapy of recurrent and/or inaccessible head and neck tumors may soon become clinically practical since sensitive and noninvasive monitoring techniques of energy deposition in tissues are now available. Interstitial tumor therapy (ITT) is a technique whereby a source of energy (laser, radiofrequency, ultrasonic, cryoenergy, etc.) is directly applied into tumors at various depths. Recent studies have demonstrated the efficiency of ultrasound (UTZ) and magnetic resonance imaging (MRI) for real and/or "near" real time tumor and vessel identification as well as monitoring and quantifying energy-induced tissue damage. We now report our initial clinical experience with patients in which UTZ and/or MRI-guided ITT techniques were successfully applied for the treatment of recurrent, nonresectable, local, and/or metastatic head and neck carcinomas. Patients were treated on an outpatient basis either in the operating room or in an upgraded specially equipped SIGNA 1.5T MR suite. Most patients tolerated these procedures well and were successfully palliated for periods ranging from 3 months to 5 years posttreatment. The upgrades introduced in a standard MRI suite, the clinical experience, and future perspectives will be reviewed.

Development and experimental in vivo validation of mathematical modeling of laser coagulation

Most clinical procedures using the laser are based on thermal laser-tissue interactions. The treatment often consists of inducing damage of given degree and extent by heating the tissue. The aim of this study was to develop a model called HELIOS. The ability of HELIOS to predict thermal coagulation was evaluated by comparison with in vivo experimental results. Conversion of laser light in tissue was studied using the beam-broadening model. Temperature was described by the heat conduction equation solved using the finite difference method. The tissue denaturation was modeled by the Henriques equation leading to the determination of the damage coefficient omega. For a given set of laser and tissue parameters, HELIOS makes a graphic representation of coagulation necrosis and temperature evolution in tissue. HELIOS was validated by experimental studies in vivo on rat liver using a CW Nd:YAG laser, a CO2 laser, and an argon laser. For given sets of laser parameters, temperature measurements were performed using an infrared camera. Histological examinations were carried out on samples to quantify the depth of coagulation necrosis. Experimental data obtained in vivo were compared with those calculated using HELIOS and similar sets of parameters. The difference between the predicted temperature evolution on tissue surface and that measured by the infrared camera was < 5 degrees C in all cases. The difference between the predicted coagulation necrosis depth and the corresponding experimental one was < 10%. In conclusion, HELIOS allows good prediction of tissue temperature and coagulation necrosis.

MRI and ultrasound guided interstitial Nd:YAG laser phototherapy for palliative treatment of advanced head and neck tumors: clinical experience

Interstitial laser phototherapy (ILP) is a technique whereby laser energy is directly applied into tumors at variable depths. This technique is attractive, since it is minimally invasive and carries a low morbidity. It may allow treatment of deep and difficult to reach tumors in the head and neck and other areas when improved noninvasive monitoring techniques of laser-tissue interactions are developed. Recent studies demonstrate, respectively, the efficiency of ultrasound (UTZ) and magnetic resonance imaging (MRI) for real time interstitial needle placement in tumors, identification of vessels, monitoring and quantifying laser-induced tissue damages. We present a case in which a patient with recurrent, metastatic base of skull carcinoma has managed successfully with repeat ILP using MRI and UTZ guidance. Under heavy sedation, needles were placed in the tumor using MRI or UTZ guidance. Tumors were treated with a 600 mum flexible Nd:YAG laser fiberoptic passed through the needles. Laser-induced tissue photoablation was monitored using real time color flow Doppler UTZ or near real time fast spin-echo T2-weighted MRI. Posttreatment fine needle aspiration cytologic study demonstrated the presence of cellular debris and no viable cancer cells. Posttreatment follow-up MRI scans showed significant reduction of tumor size, and positron emission tomography (PET) revealed interval decrease in tumor metabolism. Treatments were accompanied by pain relief and improved functional abilities. ILP has now evolved into minimally invasive outpatient surgical procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Interstitial photoablative laser therapy guided by magnetic resonance imaging for the treatment of deep tumors

The failure rate of cancer treatment remains unacceptably high, still being a leading cause of mortality in adults and children despite major advances over the past 50 years in the fields of surgery, radiation therapy, and, more recently, chemo and immunotherapy. In the United States, the 5-year survival rate for all cancers in the population has increased by only approximately 10% since 1960. Surgical access to some deep tumors of the head and neck and other areas often require extensive dissections with residual functional and cosmetic deformities. Repeated treatment is not possible after maximum dose radiotherapy and chemotherapy is still limited by its systemic toxicity. An attractive solution to these problems would be the development of a new adjunctive method combining the best features of interstitial laser phototherapy for selective tumor destruction via minimally invasive techniques for access and 3D-magnetic resonance imaging (MRI) as a monitoring system for laser-tissue interactions. Our experience with this new technique is reviewed.

Monoclonal antibody-coated magnetite particles as contrast agents for MR imaging and laser therapy of human tumors

Attempts to improve human tumor detection by non-radioactive magnetic resonance techniques have led several investigators to develop antibody-linked paramagnetic contrast agents. Initial studies focused on gadolinium conjugated to monoclonal antibodies. However, very high levels of this contrast agent were needed to significantly reduce proton relaxation times and obtain improved MR images. The use of magnetite (Fe 3O 4) as an MR contrast agent provides a magnetic moment that is approximately one order of magnitude larger than gadolinium. In this study monoclonal antibodies 44 x 14 (specific for squamous cell carcinoma) and 436G10 (specific for melanoma) were obtained from ammonium sulfate precipitation of tumor ascitic fluid. Equal volumes of magnetite solution (1.87 mg Fe/ml) and antibody solution 44 x 14 (5.24 mg protein/ml) and 436G10 (0.64 mg protein/ml) were mixed and sonicated. The 44 x 14-magnetite and 436G10-magnetite solutions were then added to equal volumes of M20 and P3 squamous cell carcinoma cell lines. T1 and T2 values were obtained on a Praxis II NMR spectrometer equipped with a 10 mm probe and 0.25 Tesla permanent magnet. The T2 relaxation times of the magnetite-antibody-cell mixtures were 31 ms with an R = 0.985 for both experimental samples. Our results demonstrate a significant decrease in T2 by binding of the magnetite-coated antibodies to these melanoma and carcinoma cells in vitro. The possibility of detecting subclinical local and metastatic disease with magnetite linked to monoclonal antibodies followed by MRI guided laser tumor ablation therapy may render this technique clinically attractive for treatment of deep-seated tumors.

Stereotactic laser therapy in cerebral gliomas

The 1.06 micron Nd:YAG laser and a new fiberoptic delivery system, the Interstitial Thermo-Therapy (ITT) laser fibre, allows stereotactic interstitial irradiation of cerebral tumours. In experimental rat brain studies we found typical laser-tissue effects with a central necrosis and a sharply demarcated oedema towards the normal brain. The size of the lesion depended on the energy and exposure time applied. In a pilot series we treated 5 patients with cerebral gliomas WHO grade II-III in functionally important regions and monitored the therapeutic effects by MR imaging and PET scan. Early post-operative results showed irreversible necrotic changes in the tumour centre and reversible oedematous changes at the tumour margin. Long-term results will show if stereotactic interstitial laser therapy is a useful supplementary method in the treatment of malignant cerebral tumours.

Comparison of four laser types for experimental pain stimulation on oral mucosa and hairy skin

The use of different lasers for stimulation in human experimental pain research has provided a sensitive method for evaluation of thin nerve fiber functions. In this study, sensory and pain thresholds were compared to argon-, copper vapour-, Nd:YAG-, and CO2 laser stimulation on hairy skin and on oral mucosa. The influence on thresholds with respect to laser type, stimulation site, surface colour, and stimulus parameters (laser beam diameter and pulse duration) was investigated. Significant differences in thresholds between the four lasers were found on both surfaces; however, no significant differences existed between thresholds on the skin and on the tongue when the same laser was used. The observations imply that wavelength-dependent optical properties of the stimulated tissue influence on threshold determinations. Furthermore, the results indicate that temporal and spatial summation mechanisms may exist for laser induced warmth and pain perceptions. Laser stimulation may be a new tool for the investigation of origin and genesis of various orofacial pain syndromes.

Effect of CO2 and blood media on laser probe temperature

Blood may limit laser ablation of arterial plaque by decreasing thermal energy transfer from metal-capped probes to arterial occlusions. Since a gas is a good insulator of heat, CO2 may be a better medium for laser recanalization. To study this possibility, a metal-capped fiber was positioned in a segment of blood-filled polyethylene tubing and activated with an argon laser. Probe temperatures were measured in blood and as the blood was displaced by flowing CO2 gas. Probe temperatures were higher at all powers studied in CO2 gas than in blood. Maximum probe temperatures averaged 518 +/- 24 degrees C after CO2 infusion versus 320 +/- 7 degrees C in blood, (P less than 0.0001). Blood aggregate formation was noted on the probe surface in blood but not in CO2 medium. Thus CO2 gas may be a preferable medium for laser recanalization, since higher probe temperatures are achieved, and the probe surface remains free of insulating blood coagulate.

Selective averaging of argon laser induced pre-pain and pain related cortical responses

The argon laser was found to be suitable for pre-pain and pain stimulation. The visible (488 and 515 nm) argon laser light penetrates the skin and is absorbed by melanin and haemoglobin. Argon laser stimuli of different intensities were perceived differently, and could be classified into 3 pre-pain and 3 pain classes. The pre-pain sensations were either perceived as warmth, weak pin prick, or weak pin prick followed by warmth. The pain sensations were perceived as painful pin pricks of different intensities. Single cortical responses to argon laser stimuli were averaged selectively, according to this perceptual classification, and characteristic pre-pain and pain related cortical responses were recorded. The sensation of warmth was related to a late cortical deflection, 700-800 ms after stimulus onset, whereas the pin prick related response appeared with a latency of 300-400 ms. Pre-pain related responses were only recorded when selective averaging according to perception was used. The amplitude of the selectively averaged pain related cortical responses correlated with the subjective sensation of pain. Selective averaging of pre-pain and pain related single responses may prove useful in studying the cortical projection of different perceptions or modality patterns, and to investigate the function of the thermal and nociceptive pathways and their interactions.

Effects of blood flow on laser probe temperature in human arteries

Laser recanalization using metal capped fibers occurs by thermal vaporization of occluding plaque. However, little is known about the effects of blood and flow on the temperature of the laser probe or the arterial wall during lasing. To study this, probe and arterial wall temperatures were measured while a metal capped fiber, activated by an argon laser, was held stationary in a stenotic human peripheral artery. Arteries were perfused with saline and blood, and flow was varied from 0 to 140 cc/min. Probe temperatures were significantly higher in blood than in saline. However, the increased probe temperature achieved in blood was not transferred to the arterial wall. Increasing flow decreased probe temperature in both media, but again arterial wall temperatures were minimally affected. Thus, the presence of blood and flow may significantly affect heat generation and heat transfer during arterial recanalization using metal capped fibers.

Sensory and pain threshold characteristics to laser stimuli

The clinical applications of thermal sensory and pain thresholds have been very limited due to large intra-individual variations. In the present paper CO2 and argon lasers were used as thermal stimulators, and the different factors (stimulus parameters and skin conditions) affecting the thresholds are described. The intra-individual variations obtained in sensory (9.3%) and pain (4.3%) thresholds were very low, which suggests that the method can be applied for clinical purposes.

Pain related cerebral potentials: late and ultralate components

Brief CO2 laser radiant heat pulses activate both A delta- and C-fibres. In the evoked potential (EP) late and ultralate components can be seen as correlates of first and second pain. Usually the ultralate EP appears to be suppressed. It could be uncovered by a preferential A-fibre block, and in two neurological patients with tabes dorsalis and with a polyneuropathy involving myelinated fibre loss. Due to a strong latency jittering the shape of the ultralate component is distorted in the conventional average. Latency corrected averaging, adaptive filters or parametric spectral estimators are needed to analyze these EP components. As a result the filtered ultralate waveforms look very similar to the late EP components. Clinical application of CO2 laser EPs promises to nonivasively assess A delta- and C-fibre function.

Use of pulsed energy delivery to minimize tissue injury resulting from carbon dioxide laser irradiation of cardiovascular tissues

The carbon dioxide (CO2) laser has been utilized for preliminary intraoperative cardiovascular applications, including coronary endarterectomy and ventricular endocardiectomy. CO2 lasers used for these applications have been operated in the continuous wave, chopped or pulsed mode at low peak powers. To evaluate the extent of boundary tissue injury, continuous, chopped and pulsed energy delivery of CO2 laser emission was used to bore through 192 5 mm thick myocardial slices in air. Continuous, chopped and pulsed delivery at a peak power of 500 W or less failed to eliminate light microscopic or ultrastructural signs of thermal injury. Only when a high energy CO2 laser (pulse energy 80 to 300 mJ, pulse duration 1 microseconds) was used at a peak power greater than 80 kW were all signs of thermal injury eliminated; furthermore, high peak power prevented thermal injury only when the beam was focused to achieve a peak power density greater than 60 kW/mm2. Under these conditions, pathologic findings were identical to those observed using excimer wavelengths. The results of these experiments indicate that: conventional CO2 lasers fail to minimize boundary tissue injury, elimination of thermal injury during intraoperative laser ablation requires that CO2 laser energy be focused to achieve a peak power density greater than 60 kW/mm2, and elimination of thermal injury can be achieved at a variety of wavelengths, provided that an appropriate energy profile is employed.

Reduction of laser-induced pathologic tissue injury using pulsed energy delivery

Continuous-wave (CW) laser irradiation of cardiovascular tissues is characterized by 2 distinctive histologic findings: a superficial zone of coagulation necrosis and a subjacent zone of polymorphous lacunae. The present investigation was designed to determine whether such injury could be eliminated by altering the temporal profile of laser energy delivery. One hundred forty-five myocardial slices were irradiated with an air-tissue interface using CW laser irradiation at wavelengths of 488 to 515 nm (argon), 1,064 nm (Nd-YAG) and 10,600 nm (CO2). Pulsed laser irradiation included 248 nm (excimer); 355, 532 and 1,064 nm (Nd-YAG); and 515 nm (mode-locked argon). Energy profiles in the pulsed mode included a range of repetition rates (1 Hz to 256 MHz), pulse duration (0.2 to 358 ns) and pulse energies (2 nJ to 370 mJ). Resultant average powers were 0.1 to 38 W. Grossly visible charring of myocardial tissue was observed at all laser wavelengths when the laser energy profile was CW or pulsed at high repetition rates (more than 2 KHz) and low pulse energies (less than 3 mJ) independent of the wavelengths used. In contrast, when laser energy was pulsed at low repetition rates (less than 200 Hz) and large pulse energies (more than 10 mJ), neither gross nor histologic signs of thermal injury were observed. Pathologic injury associated with laser-induced tissue ablation may thus be substantially reduced by use of pulsed energy delivery at low repetition rates. Potential advantages of pulsed laser energy include a more benign healing process, a less thrombogenic surface, and improved preservation of structural tissue integrity.

Histologic changes in rat brain tissue caused by neodymium-yttrium aluminum garnet laser irradiation. II. Cerebellum

Histologic changes after neodymium-yttrium aluminum garnet laser irradiation were evaluated in the rat cerebellum. Irradiation of 60 W (corresponds to 45.2 W/mm2) to the posterior fossa was dangerous even in adult rats, although this value was safe for the rat cerebral hemisphere as previously reported. The histologic changes caused by neodymium-yttrium aluminum garnet laser irradiation were similar to those caused by thermal energies. To the adult rat cerebellum, 45 W (35.2 W/mm2) can safely be applied. For the further use of the neodymium-yttrium aluminum garnet laser in neurosurgery, our findings should be taken into consideration.

Excimer laser ablation of the cornea and lens. Experimental studies

The pulsed ultraviolet excimer laser has been used to produce tissue ablation with a high degree of precision and with minimal thermal damage to adjacent structures. In comparative studies of excimer laser ablation of the cornea and crystalline lens using 193 nm and 248 nm radiation, threshold fluence for corneal and lens ablation was higher at 248 nm than at 193 nm. Ablation of corneal stroma at 193 nm produced the most precise cuts. When examined by transmission electron microscopy, a narrow zone of damaged tissue (0.1 to 0.3 micron) was seen immediately adjacent to the tissue removed by the laser. Ablation with 248 nm radiation produced incisions with ragged edges and with a wider and more severe zone of damage in adjacent stroma. Ultraviolet spectral transmission studies of the corneal stroma showed that absorption is 10 times greater at 193 nm than at 248 nm. The excimer laser was effective in producing well controlled ablation of the crystalline lens in vitro, with effects parallel to those seen in the cornea.

Effect of laser radiation on tissue during laser angioplasty

The thermal properties of adipose and ceramic atherosclerotic plaque deposits and normal arterial vessel wall were measured in the temperature range of 25-95 degrees C. In general, the data indicate that fatty plaques exhibit the lowest thermal conductivity and thermal diffusivity of the three types, whereas calcified plaques seem to have the highest values. By using a video scanning thermograph, temperature rise was recorded in normal vessel wall and plaque during ablation of tissue. Theoretical analysis suggested that realistic modeling of laser angioplasty should account for scattering of light, water content, and ablation. This paper is a preliminary report of these results.

Primary fluorescence of rat muscle after CO2 laser thermal injury

Observations are reported indicating that CO2 laser radiation induces the appearance of strong primary fluorescence in the tissues surrounding the incidence zone of the beam. The characteristics of this emission were studied by means of cytofluorometric techniques on rat muscles and compared with the fluorescence obtained by a heating procedure or by storage of tissue slices. Laser-induced primary fluorescence was found to be related to the thermal effect of CO2 laser radiation. Moreover, evidence is provided that the processes occurring during heating and those occurring during tissue decomposition most probably produce the same fluorescent products, albeit with different rates. From the results obtained, it is suggested that primary fluorescence can be used as a marker of the damage suffered by the irradiated tissues.