Design of patient-specific focused ultrasound arrays for non-invasive brain therapy with increased trans-skull transmission and steering range

The role of focused ultrasound for pediatric brain tumors: current insights and future implications on treatment strategies

INTRODUCTION

Focused ultrasound (FUS) is an innovative and emerging technology for the treatment of adult and pediatric brain tumors and illustrates the intersection of various specialized fields, including neurosurgery, neuro-oncology, radiation oncology, and biomedical engineering.

OBJECTIVE

The authors provide a comprehensive overview of the application and implications of FUS in treating pediatric brain tumors, with a special focus on pediatric low-grade gliomas (pLGGs) and the evolving landscape of this technology and its clinical utility.

METHODS

The fundamental principles of FUS include its ability to induce thermal ablation or enhance drug delivery through transient blood-brain barrier (BBB) disruption, emphasizing the adaptability of high-intensity focused ultrasound (HIFU) and low-intensity focused ultrasound (LIFU) applications.

RESULTS

Several ongoing clinical trials explore the potential of FUS in offering alternative therapeutic strategies for pathologies where conventional treatments fall short, specifically centrally-located benign CNS tumors and diffuse intrinsic pontine glioma (DIPG). A case illustration involving the use of HIFU for pilocytic astrocytoma is presented.

CONCLUSION

Discussions regarding future applications of FUS for the treatment of gliomas include improved drug delivery, immunomodulation, radiosensitization, and other technological advancements.

Generating Patient-Specific Acoustic Simulations for Transcranial Focused Ultrasound Procedures Based on Optical Tracking Information

Optical tracking is a real-time transducer positioning method for transcranial focused ultrasound (tFUS) procedures, but the predicted focus from optical tracking typically does not incorporate subject-specific skull information. Acoustic simulations can estimate the pressure field when propagating through the cranium but rely on accurately replicating the positioning of the transducer and skull in a simulated space. Here, we develop and characterize the accuracy of a workflow that creates simulation grids based on optical tracking information in a neuronavigated phantom with and without transmission through an ex vivo skull cap. The software pipeline could replicate the geometry of the tFUS procedure within the limits of the optical tracking system (transcranial target registration error (TRE): 3.9 ± 0.7 mm). The simulated focus and the free-field focus predicted by optical tracking had low Euclidean distance errors of 0.5±0.1 and 1.2±0.4 mm for phantom and skull cap, respectively, and some skull-specific effects were captured by the simulation. However, the TRE of simulation informed by optical tracking was 4.6±0.2, which is as large or greater than the focal spot size used by many tFUS systems. By updating the position of the transducer using the original TRE offset, we reduced the simulated TRE to 1.1 ± 0.4 mm. Our study describes a software pipeline for treatment planning, evaluates its accuracy, and demonstrates an approach using MR-acoustic radiation force imaging as a method to improve dosimetry. Overall, our software pipeline helps estimate acoustic exposure, and our study highlights the need for image feedback to increase the accuracy of tFUS dosimetry.

Current and Emerging Systems for Focused Ultrasound-Mediated Blood-Brain Barrier Opening

With an ever-growing list of neurological applications of focused ultrasound (FUS), there has been a consequent increase in the variety of systems for delivering ultrasound energy to the brain. Specifically, recent successful pilot clinical trials of blood-brain barrier (BBB) opening with FUS have generated substantial interest in the future applications of this relatively novel therapy, with divergent, purpose-built technologies emerging. With many of these technologies at various stages of pre-clinical and clinical investigation, this article seeks to provide an overview and analysis of the numerous medical devices in active use and under development for FUS-mediated BBB opening.

Influence of Plastination on Ultrasound Transmission Through the Human Skull

Development, optimization and validation of transcranial ultrasound methods require the use of fresh human or animal skulls. However, to avoid fresh skull degradation over time, fixation methods are required for conservation, such as formaldehyde buffer solution. This method allows for conservation of the skull properties over a relatively long period, but requires specific conditioning (de-gassing) and storage conditions, such that its practical use is limited. Plastination appears to be a unique solution for the preservation and transportation of body parts without constraints. However, the influence of this conservation process has yet to be characterized with respect to ultrasound transmission to verify that the acoustic and mechanical properties of the skulls are not altered by the plastination process. The objective of the study described here was to quantify the effect of plastination on ultrasound transmission through the temporal and parietal areas of the human skull between 200 kHz and 2 MHz. To achieve this, transmission measurements were performed on three different skulls and four areas before and after plastination. It was found that the plastination process results in a transmission loss of 5 dB. Moreover, results indicate that the plastination process does not induce any phase shift in the transmitted signal, validating the proper use of plastinated skulls for in vitro measurements and development of new transcranial ultrasound methods.

Effect of skull porosity on ultrasound transmission and wave mode conversion at large incidence angles

BACKGROUND

Transcranial ultrasound imaging and therapy depend on the efficient transmission of acoustic energy through the skull. Multiple previous studies have concluded that a large incidence angle should be avoided during transcranial-focused ultrasound therapy to ensure transmission through the skull. Alternatively, some other studies have shown that longitudinal-to-shear wave mode conversion might improve transmission through the skull when the incidence angle is increased above the critical angle (i.e., 25° to 30°).

PURPOSE

The effect of skull porosity on the transmission of ultrasound through the skull at varying incidence angles was investigated for the first time to elucidate why transmission through the skull at large angles of incidence is decreased in some cases but improved in other cases.

METHODS

Transcranial ultrasound transmission at varying incidence angles (0°-50°) was investigated in phantoms and ex vivo skull samples with varying bone porosity (0% to 28.54% ± 3.36%) using both numerical and experimental methods. First, the elastic acoustic wave transmission through the skull was simulated using micro-computed tomography data of ex vivo skull samples. The trans-skull pressure was compared between skull segments having three levels of porosity, that is, low porosity (2.65% ± 0.03%), medium porosity (13.41% ± 0.12%), and high porosity (26.9%). Next, transmission through two 3D-printed resin skull phantoms (compact vs. porous phantoms) was experimentally measured to test the effect of porous microstructure alone on ultrasound transmission through flat plates. Finally, the effect of skull porosity on ultrasound transmission was investigated experimentally by comparing transmission through two ex vivo human skull segments having similar thicknesses but different porosities (13.78% ± 2.05% vs. 28.54% ± 3.36%).

RESULTS

Numerical simulations indicated that an increase in transmission pressure occurs at large incidence angles for skull segments having low porosities but not for those with high porosity. In experimental studies, a similar phenomenon was observed. Specifically, for the low porosity skull sample (13.78% ± 2.05%), the normalized pressure was 0.25 when the incidence angle increased to 35°. However, for the high porosity sample (28.54% ± 3.36%), the pressure was no more than 0.1 at large incidence angles.

CONCLUSIONS

These results indicate that the skull porosity has an evident effect on the transmission of ultrasound at large incidence angles. The wave mode conversion at large, oblique incidence angles could enhance the transmission of ultrasound through parts of the skull having lower porosity in the trabecular layer. However, for transcranial ultrasound therapy in the presence of highly porous trabecular bone, transmission at a normal incidence angle is preferable relative to oblique incidence angles due to the higher transmission efficiency.

Technical Comparison of Treatment Efficiency of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy and Pallidotomy in Skull Density Ratio-Matched Patient Cohorts

Objective

MR-guided focused ultrasound (MRgFUS) is increasingly being used to treat patients with essential tremor (ET) and Parkinson's disease (PD) with thalamotomy and pallidotomy, respectively. Pallidotomy is performed off-center within the cranium compared to thalamotomy and may present challenges to therapeutic lesioning due to this location. However, the impact of target location on treatment efficiency and ability to create therapeutic lesions has not been studied. This study aimed to compare the physical efficiency of MRgFUS thalamotomy and pallidotomy.

Methods

Treatment characteristics were compared between patients treated with thalamotomy (n = 20) or pallidotomy (n = 20), matched by skull density ratios (SDR). Aspects of treatment efficiency were compared between these groups. Demographic and comparative statistics were conducted to assess these differences. Acoustic field simulations were performed to compare and validate the simulated temperature profile for VIM and GPi ablation.

Results

Lower SDR values were associated with greater energy requirement for thalamotomy (R² = 0.197, p = 0.049) and pallidotomy (R² = 0.342, p = 0.007). The impact of low SDR on efficiency reduction was greater for pallidotomy, approaching significance (p = 0.061). A nearly two-fold increase in energy was needed to reach 50°C in pallidotomy (10.9kJ) than in thalamotomy (5.7kJ), (p = 0.002). Despite lower energy requirement, the maximum average temperature reached was higher in thalamotomy (56.7°C) than in pallidotomy (55.0°C), (p = 0.017). Mean incident angle of acoustic beams was lesser in thalamotomy (12.7°) than in pallidotomy (18.6°), (p < 0.001). For all patients, a lesser mean incident angle correlated with a higher maximum average temperature reached (R² = 0.124, p = 0.026), and less energy needed to reach 50°C (R²=0.134, p = 0.020). Greater skull thickness was associated with a higher maximum energy for a single sonication for thalamotomy (R² = 0.206, p = 0.045) and pallidotomy (R² = 0.403, p = 0.003). An acoustic and temperature field simulation validated similar findings for thalamotomy and pallidotomy in a single patient.

Conclusion

The centrally located VIM offers a more efficient location for therapeutic lesioning compared to GPi pallidotomy in SDR matched cohort of patients. The impact on therapeutic lesioning with lower SDR may be greater for pallidotomy patients. As newer off-center targets are investigated, these findings can inform patient selection and treatment requirements for lesion production.

Lesion location and lesion creation affect outcomes after focused ultrasound thalamotomy

MRI-guided focused ultrasound thalamotomy has been shown to be an effective treatment for medication refractory essential tremor. Here, we report a clinical-radiological analysis of 123 cases of MRI-guided focused ultrasound thalamotomy, and explore the relationships between treatment parameters, lesion characteristics and outcomes. All patients undergoing focused ultrasound thalamotomy by a single surgeon were included. The procedure was performed as previously described, and patients were followed for up to 1 year. MRI was performed 24 h post-treatment, and lesion locations and volumes were calculated. We retrospectively evaluated 118 essential tremor patients and five tremor-dominant Parkinson's disease patients who underwent thalamotomy. At 24 h post-procedure, tremor abated completely in the treated hand in 81 essential tremor patients. Imbalance, sensory disturbances and dysarthria were the most frequent acute adverse events. Patients with any adverse event had significantly larger lesions, while inferolateral lesion margins were associated with a higher incidence of motor-related adverse events. Twenty-three lesions were identified with irregular tails, often extending into the internal capsule; 22 of these patients experienced at least one adverse event. Treatment parameters and lesion characteristics changed with increasing surgeon experience. In later cases, treatments used higher maximum power (normalized to skull density ratio), accelerated more quickly to high power, and delivered energy over fewer sonications. Larger lesions were correlated with a rapid rise in both power delivery and temperature, while increased oedema was associated with rapid rise in temperature and the maximum power delivered. Total energy and total power did not significantly affect lesion size. A support vector regression was trained to predict lesion size and confirmed the most valuable predictors of increased lesion size as higher maximum power, rapid rise to high-power delivery, and rapid rise to high tissue temperatures. These findings may relate to a decrease in the energy efficiency of the treatment, potentially due to changes in acoustic properties of skull and tissue at higher powers and temperatures. We report the largest single surgeon series of focused ultrasound thalamotomy to date, demonstrating tremor relief and adverse events consistent with reported literature. Lesion location and volume impacted adverse events, and an irregular lesion tail was strongly associated with adverse events. High-power delivery early in the treatment course, rapid temperature rise, and maximum power were dominant predictors of lesion volume, while total power, total energy, maximum energy and maximum temperature did not improve prediction of lesion volume. These findings have critical implications for treatment planning in future patients.

Focused ultrasound: growth potential and future directions in neurosurgery

Over the past two decades, vast improvements in focused ultrasound (FUS) technology have made the therapy an exciting addition to the neurosurgical armamentarium. In this time period, FUS has gained US Food and Drug Administration (FDA) approval for the treatment of two neurological disorders, and ongoing efforts seek to expand the lesion profile that is amenable to ultrasonic intervention. In the following review, we highlight future applications for FUS therapy and compare its potential role against established technologies, including deep brain stimulation and stereotactic radiosurgery. Particular attention is paid to tissue ablation, blood-brain-barrier opening, and gene therapy. We also address technical and infrastructural challenges involved with FUS use and summarize the hurdles that must be overcome before FUS becomes widely accepted in the neurosurgical community.

Implementation of a Skull-Conformal Phased Array for Transcranial Focused Ultrasound Therapy

OBJECTIVE

To implement a skull-conformal phased array for ultrasound-guided transcranial focused ultrasound therapy with improved patient comfort.

METHODS

Using patient-specific computed tomography and MRI neuroimaging data, tightly-conforming helmet scaffolds were designed computationally. The helmet scaffolds were designed to hold reusable transducer modules at near-normal incidence in an optimal configuration for the treatment location(s) of interest. Numerical simulations of trans-skull ultrasound propagation were performed to evaluate different conformal array designs and to compare with hemispherical arrays similar to those employed clinically. A 4096-element phased array was constructed by 3D printing a helmet scaffold optimised for an ex vivo human skullcap, and its performance was evaluated via benchtop and in vivo experiments.

RESULTS

Acoustic field measurements confirmed the system's ability to focus through human skull bone using simulation-based transcranial aberration corrections. Preliminary in vivo testing demonstrated safe trans-human skull blood-brain barrier (BBB) opening in rodents.

CONCLUSION

Patient-specific conformal ultrasound phased arrays appear to be a feasible and safe approach for conducting transcranial BBB opening procedures.

SIGNIFICANCE

Skull-conformal phased arrays stand to improve patient comfort and have the potential to accelerate the adoption of transcranial FUS therapy by improving access to the technology.

Opening doors with ultrasound and microbubbles: Beating biological barriers to promote drug delivery

Apart from its clinical use in imaging, ultrasound has been thoroughly investigated as a tool to enhance drug delivery in a wide variety of applications. Therapeutic ultrasound, as such or combined with cavitating nuclei or microbubbles, has been explored to cross or permeabilize different biological barriers. This ability to access otherwise impermeable tissues in the body makes the combination of ultrasound and therapeutics very appealing to enhance drug delivery in situ. This review gives an overview of the most important biological barriers that can be tackled using ultrasound and aims to provide insight on how ultrasound has shown to improve accessibility as well as the biggest hurdles. In addition, we discuss the clinical applicability of therapeutic ultrasound with respect to the main challenges that must be addressed to enable the further progression of therapeutic ultrasound towards an effective, safe and easy-to-use treatment tailored for drug delivery in patients.

Visualizing tumour self-homing with magnetic particle imaging

Due to their innate tumour homing capabilities, in recent years, circulating tumour cells (CTCs) have been engineered to express therapeutic genes for targeted treatment of primary and metastatic lesions. Additionally, previous studies have incorporated optical or PET imaging reporter genes to enable noninvasive monitoring of therapeutic CTCs in preclinical tumour models. An alternative method for tracking cells is to pre-label them with imaging probes prior to transplantation into the body. This is typically more sensitive to low numbers of cells since large amounts of probe can be concentrated in each cell. The objective of this work was to evaluate magnetic particle imaging (MPI) for the detection of iron-labeled experimental CTCs. CTCs were labeled with micro-sized iron oxide (MPIO) particles, administered via intra-cardiac injection in tumour bearing mice and were detected in the tumour region of the mammary fat pad. Iron content and tumour volumes were calculated. Ex vivo MPI of the tumours and immunohistochemistry were used to validate the imaging data. Here, we demonstrate for the first time the ability of MPI to sensitively detect systemically administered iron-labeled CTCs and to visualize tumour self-homing in a murine model of human breast cancer.

Therapeutic Agent Delivery Across the Blood-Brain Barrier Using Focused Ultrasound

Specialized features of vasculature in the central nervous system greatly limit therapeutic treatment options for many neuropathologies. Focused ultrasound, in combination with circulating microbubbles, can be used to transiently and noninvasively increase cerebrovascular permeability with a high level of spatial precision. For minutes to hours following sonication, drugs can be administered systemically to extravasate in the targeted brain regions and exert a therapeutic effect, after which permeability returns to baseline levels. With the wide range of therapeutic agents that can be delivered using this approach and the growing clinical need, focused ultrasound and microbubble (FUS+MB) exposure in the brain has entered human testing to assess safety. This review outlines the use of FUS+MB-mediated cerebrovascular permeability enhancement as a drug delivery technique, details several technical and biological considerations of this approach, summarizes results from the clinical trials conducted to date, and discusses the future direction of the field.

Design of a Versatile Angle-Rotatable Skull-Shaped Conformal Transcranial Focused Ultrasound Transducer for Noninvasive Brain Therapy

Phase-controlled focused ultrasound transducers have opened up a new way to noninvasively treat brain diseases. However, due to the geometry and the heterogeneous medium of the human skull, the currently used hemispherical transducers cannot guarantee that the ultrasound emitted by the transducer penetrates the skull normally; consequently, the impact of the shear wave on the treatment area has to be considered. The usual approach is to turn off elements in the transducer with excessively large incident angles, but this approach reduces the efficiency of the transducer. This article presents the design of a novel transducer that can be rotated according to the different geometric shapes of the skull. The incident angles of the elements in the transducer are modified so that the effect of the shear wave on the treatment area can be ignored and the efficiency of the transducer is improved. The results of computed tomography (CT) model simulation of nine skulls verify the versatility and feasibility of the new transducer. We believe that this kind of rotatable transducer has clinical and engineering significance.

An efficient and accurate parallel hybrid acoustic signal correction method for transcranial ultrasound

Phased-control focused ultrasound transducers provide a new and noninvasive treatment method for brain disease. However, improving the accuracy of phase correction and reducing the calculation time during treatment have always been contradictory constraints. In this paper, a hybrid acoustic signal correction (HASC) method combined with k-Wave stage and holography stage was introduced for phase correction and simulation of transcranial focused ultrasound. The k-Wave stage is mainly used to calculate the sound field in a heterogeneous medium (skull), which divides the sound field calculation process into paths that can be calculated in parallel, and the transcranial correction phase can also be obtained during the calculation. The holography stage is sufficient to simulate the acoustic field in the homogenous intracranial medium after ultrasound transmitting through the skull. The agreement of the k-space corrected pseudospectral time domain method and HASC method was assessed by statistical methods: linear regression between the two methods provided a slope of 0.9735, intercept of 0.0078, and R ² of 0.9982. The Bland-Altman method provided a bias of 0.0015 and 95% limits of agreement 0.065 apart. We demonstrated that the difference in sound intensity at the focal point corrected by HASC and time reversal phase correction method was 0.2% and 0.5% in the results of simulation and experiment, respectively. Not only that, the phase calculation time by the HASC phase correction method can be reduced to 11 min on a multi GPU array, which has clinical potential for ultrasound treatment of brain therapy.

Applications of focused ultrasound in the brain: from thermoablation to drug delivery

Focused ultrasound (FUS) is a disruptive medical technology, and its implementation in the clinic represents the culmination of decades of research. Lying at the convergence of physics, engineering, imaging, biology and neuroscience, FUS offers the ability to non-invasively and precisely intervene in key circuits that drive common and challenging brain conditions. The actions of FUS in the brain take many forms, ranging from transient blood-brain barrier opening and neuromodulation to permanent thermoablation. Over the past 5 years, we have seen a dramatic expansion of indications for and experience with FUS in humans, with a resultant exponential increase in academic and public interest in the technology. Applications now span the clinical spectrum in neurological and psychiatric diseases, with insights still emerging from preclinical models and human trials. In this Review, we provide a comprehensive overview of therapeutic ultrasound and its current and emerging indications in the brain. We examine the potential impact of FUS on the landscape of brain therapies as well as the challenges facing further advancement and broader adoption of this promising minimally invasive therapeutic alternative.

Numerical Evaluation of the Influence of Skull Heterogeneity on Transcranial Ultrasonic Focusing

In transcranial penetration, ultrasound undergoes refraction, diffraction, multi-reflection, and mode conversion. These factors lead to phase aberration and waveform distortion, which impede the realization of transcranial ultrasonic imaging and therapy. Ray tracing has been used to correct the phase aberration and is computationally more efficient than traditional full-wave simulation. However, when ray tracing has been used for transcranial investigation, it has generally been on the premise that the skull medium is homogeneous. To find suitable homogeneity that balances computational speed and accuracy, the present work investigates how the focus deviates after phase-aberration compensation with ray tracing using time-reversal theory. The waveforms are synthetized with ray tracing for phase aberration, by which the properties of the skull bone are simplified for refraction calculation as those of either (i) the cortical bone or (ii) the mean of the entire skull bone, and the focusing accuracy is evaluated for each hypothesis. The propagation of ultrasound for transcranial focusing is simulated with the elastic model using the k-space pseudospectral method. Unlike the fluid model, the elastic model does not omit shear waves in the skull bones, and the influence of that omission is investigated, with the fluid model resulting in a focal deflection of 0.5 mm. The focusing deviations are huge when the properties of the skull bone are idealized with ray tracing as those of the mean of the entire skull bone. The focusing accuracy improves when the properties of the skull bone are idealized as those of the cortical bone. The results reveal minimal deviation (8.6, 3.9, and 3.2% in the three Cartesian coordinates) in the focal region and suggest that transcranial focusing deflections are caused mostly by ultrasonic refraction on the surface of the skull bone. A heterogeneous skull bone causes wave bending but minimal focusing deflection. The proposed simplification of a homogeneous skull bone is more accurate for transcranial ultrasonic path estimation and offers promising applications in transcranial ultrasonic focusing and imaging.

A Noninvasive Ultrasound Resonance Method for Detecting Skull Induced Phase Shifts May Provide a Signal for Adaptive Focusing

OBJECTIVE

There may be a need to perform dynamic skull aberration corrections during the non-invasive high-intensity transcranial treatment with magnetic resonance imaging (MRI) -guided focused ultrasound in order to accurately and rapidly restore the focus in the brain.

METHODS

This could possibly be accomplished by using an ultrasound-based correction method based on the skulls' thickness resonance frequencies. The focus of a 500 kHz transducer was centered in the ex vivo human skull caps at different temperatures. The pulse-echoed signals reflected from the skulls were analyzed in the frequency domain to reveal the resonance frequencies for the phase shift calculation. The accuracy was compared to both hydrophone and computed tomography (CT) based analytical methods.

RESULTS

Around 73% of the measurements (n = 784) were in the optimal constructive interference region, with a 15° decrease in the average phase error compared to the previous study. In the best implementation, it performed approximately the same or better than the CT based analytical method currently in clinical use. Linear correlation was found between the resonance frequencies or skull induced phase shifts and the skull temperature with an average rate of -0.4 kHz/°C and 2.6 deg/°C, respectively.

CONCLUSION

The ultrasound based resonance method has shown the feasibility of detecting heating-induced changes of skull phase shift non-invasively and accurately.

SIGNIFICANCE

Since the technique can be made MRI compatible and integrated in the therapy arrays, it may enable temperature tracking and adaptive focusing during high-intensity transcranial ultrasound treatments, to prevent skull overheating and preserve the transcranial focusing integrity.

Wavefield finite time focusing with reduced spatial exposure

Wavefield focusing is often achieved by time-reversal mirrors, where wavefields emitted by a source located at the focal point are evaluated at a closed boundary and sent back, after time-reversal, into the medium from that boundary. Mathematically, time-reversal mirrors are derived from closed-boundary integral representations of reciprocity theorems. In heterogeneous media, time-reversal focusing theoretically involves in- and output signals that are infinite in time and the resulting waves propagate through the entire medium. Recently, integral representations have been derived for single-sided wavefield focusing. Although the required input signals for this approach are finite in time, the output signals are not and, similar to time-reversal mirroring, the resulting waves propagate through the entire medium. Here, an alternative solution for double-sided wavefield focusing is derived. This solution is based on an integral representation where in- and output signals are finite in time, and where the energy of the waves propagating in the layer embedding the focal point is smaller than with time-reversal focusing. The potential of the proposed method is explored with numerical experiments involving a head model consisting of a skull enclosing a brain.

Enhanced Numerical Method for the Design of 3-D-Printed Holographic Acoustic Lenses for Aberration Correction of Single-Element Transcranial Focused Ultrasound

The correction of transcranial focused ultrasound aberrations is a relevant issue for enhancing various non-invasive medical treatments. The emission through multi-element phased arrays has been the most widely accepted method to improve focusing in recent years; however, the number and size of transducers represent a bottleneck that limits the focusing accuracy of the technique. To overcome this limitation, a new disruptive technology, based on 3-D-printed acoustic lenses, has recently been proposed. As the submillimeter precision of the latest generation of 3-D printers has been proven to overcome the spatial limitations of phased arrays, a new challenge is to improve the accuracy of the numerical simulations required to design this type of ultrasound lens. In the study described here, we evaluated two improvements in the numerical model applied in previous works for the design of 3-D-printed lenses: (i) allowing the propagation of shear waves in the skull by means of its simulation as an isotropic solid and (ii) introduction of absorption into the set of equations that describes the dynamics of the wave in both fluid and solid media. The results obtained in the numerical simulations are evidence that the inclusion of both s-waves and absorption significantly improves focusing.

Sonopermeation to improve drug delivery to tumors: from fundamental understanding to clinical translation

INTRODUCTION

Ultrasound in combination with microbubbles can make cells and tissues more accessible for drugs, thereby achieving improved therapeutic outcomes. In this review, we introduce the term 'sonopermeation', covering mechanisms such as pore formation (traditional sonoporation), as well as the opening of intercellular junctions, stimulated endocytosis/transcytosis, improved blood vessel perfusion and changes in the (tumor) microenvironment. Sonopermeation has gained a lot of interest in recent years, especially for delivering drugs through the otherwise impermeable blood-brain barrier, but also to tumors.

AREAS COVERED

In this review, we summarize various in vitro assays and in vivo setups that have been employed to unravel the fundamental mechanisms involved in ultrasound-enhanced drug delivery, as well as clinical trials that are ongoing in patients with brain, pancreatic, liver and breast cancer. We summarize the basic principles of sonopermeation, describe recent findings obtained in (pre-) clinical trials, and discuss future directions.

EXPERT OPINION

We suggest that an improved mechanistic understanding, and microbubbles and ultrasound equipment specialized for drug delivery (and not for imaging) are key aspects to create more effective treatment regimens by sonopermeation. Real-time feedback and tools to predict therapeutic outcome and which tumors/patients will benefit from sonopermeation-based interventions will be important to promote clinical translation.