In vitro and in vivo high-intensity focused ultrasound thrombolysis

Investigating the potential of catheter-assisted pulsed focused ultrasound ablation for atherosclerotic plaques

BACKGROUND

Atherosclerosis is a condition in which an adhesive substance called plaque accumulates over time inside the arteries. Plaque buildup results in the constriction of arteries, causing a shortage of blood supply to tissues and organs. Removing atherosclerotic plaques controls the development of acute ischemic stroke and heart diseases. It remains imperative for positive patient outcomes.

PURPOSE

This study sought to develop a minimally invasive technique for removing arterial plaques by applying focused ultrasound (FUS) energy on the metal surface of a nitinol catheter wire to induce inertial cavitation. The induced cavitation can deplete plaque mechanically inside the arteries, leading towards improved recanalization of blood vessels.

METHODS

The enhanced cavitation effect induced by combining FUS with a metal catheter was first verified by exposing agar phantom gels with or without a 0.9-mm diameter nitinol wire to an acoustic field produced by a 0.5-MHz FUS transducer. The phenomenon was further confirmed in pork belly fat samples with or without a 3-mm diameter nitinol catheter wire. Cavitation was monitored by detecting the peaks of emitted ultrasound signals from the samples using a passive cavitation detector (PCD). Cavitation threshold values were determined by observing the jump in the peak amplitude of signals received by the PCD when the applied FUS peak negative pressure (PNP) increased. To simulate arterial plaque removal, FUS with or without a catheter was used to remove tissues from pork belly fat samples and the lipid cores of human atherosclerotic plaque samples using 2500-cycle FUS bursts at 10% duty cycle and a burst repetition rate of 20 Hz. Treatment outcomes were quantified by subtracting the weight of samples before treatment from the weight of samples after treatment. All measurements were repeated 5 times (n = 5) unless otherwise indicated, and paired t-tests were used to compare the means of two groups. A p-value of <0.05 will be considered significant.

RESULTS

Our results showed that with a nitinol wire, the cavitation threshold in agar phantoms was reduced to 2.6 MPa from 4.3 MPa PNP when there was no nitinol wire in the focal region of FUS. For pork belly fat samples, cavitation threshold values were 1.0 and 2.0 MPa PNP, with and without a catheter wire, respectively. Pork belly fat tissues and lipid cores of atherosclerotic plaques were depleted at the interface between a catheter and the samples at 2 and 4 MPa FUS PNP, respectively. The results showed that with a catheter wire in the focal region of a 3-min FUS treatment session, 24.7 and 25.6 mg of lipid tissues were removed from pork belly fat and human atherosclerotic samples, respectively. In contrast, the FUS-only group showed no reduction in sample weight. The differences between FUS-only and FUS-plus-catheter groups were statistically significant (p < 0.001 for the treatment on pork belly samples, and p < 0.01 for the treatment on human atherosclerotic samples).

CONCLUSION

This study demonstrated the feasibility of catheter-assisted FUS therapy for removing atherosclerotic plaques.

Inducing cavitation within hollow cylindrical radially polarized transducers for intravascular applications

Thrombotic occlusions of large blood vessels are increasingly treated with catheter based mechanical approaches, one of the most prominent being to employ aspiration to extract clots through a hollow catheter lumen. A central technical challenge for aspiration catheters is to achieve sufficient suction force to overcome the resistance of clot material entering into the distal tip. In this study, we examine the feasibility of inducing cavitation within hollow cylindrical transducers with a view to ultimately using them to degrade the mechanical integrity of thrombus within the tip of an aspiration catheter. Hollow cylindrical radially polarized PZT transducers with 3.3/2.5 mm outer/inner diameters were assessed. Finite element simulations and hydrophone experiments were used to investigate the pressure field distribution as a function of element length and resonant mode (thickness, length). Operating in thickness mode (∼5 MHz) was found to be associated with the highest internal pressures, estimated to exceed 23 MPa. Cavitation was demonstrated to be achievable within the transducer under degassed water (10 %) conditions using hydrophone detection and high-frequency ultrasound imaging (40 MHz). Cavitation clouds occupied a substantial portion of the transducer lumen, in a manner that was dependent on the pulsing scheme employed (10 and 100 μs pulse lengths; 1.1, 11, and 110 ms pulse intervals). Collectively the results support the feasibility of achieving cavitation within a transducer compatible with mounting in the tip of an aspiration format catheter.

Sonothrombolysis: State-of-the-Art and Potential Applications in Children

In recent years, advances in ultrasound therapeutics have been implemented into treatment algorithms for the adult population; however, the use of therapeutic ultrasound in the pediatric population still needs to be further elucidated. In order to better characterize the utilization and practicality of sonothrombolysis in the juvenile population, the authors conducted a literature review of current pediatric research in therapeutic ultrasound. The PubMed database was used to search for all clinical and preclinical studies detailing the use and applications of sonothrombolysis, with a focus on the pediatric population. As illustrated by various review articles, case studies, and original research, sonothrombolysis demonstrates efficacy and safety in clot dissolution in vitro and in animal studies, particularly when combined with microbubbles, with potential applications in conditions such as deep venous thrombosis, peripheral vascular disease, ischemic stroke, myocardial infarction, and pulmonary embolism. Although there is limited literature on the use of therapeutic ultrasound in children, mainly due to the lower prevalence of thrombotic events, sonothrombolysis shows potential as a noninvasive thrombolytic treatment. However, more pediatric sonothrombolysis research needs to be conducted to quantify the safety and ethical considerations specific to this vulnerable population.

Distinct thermal effect on biological tissues using subwavelength ultrasound metalens at megahertz

Ultrasound focusing plays an important role in biomedical therapy and diagnosis. Acoustic metalens has showcased remarkable focusing performance but yet to be implemented to the practical ultrasound therapeutic applications. We design a planar metalens operating at megahertz and experimentally demonstrate the distinct thermal effect on biological tissues induced by the high-resolution focusing. A prominent temperature rise of 50°C is experimentally observed in the biological phantom, with a much lower input ultrasound power of 4 W compared with the traditional methods. We further study the thermal effect on fresh porcine liver and investigate the morphological changes under different physical parameters. Visible lesions are observed in in vitro tissues at the lowest input ultrasound power of 2.6 W within 10 s. This study facilitates the practical biomedical application of acoustic metalens, providing a feasible approach for the precise, safe, and reliable therapeutic ultrasound with the simple and compact metalens.

Focused Ultrasound, an Emerging Tool for Atherosclerosis Treatment: A Comprehensive Review

Focused ultrasound (FUS) has emerged as a promising noninvasive therapeutic modality for treating atherosclerotic arterial disease. High-intensity focused ultrasound (HIFU), a noninvasive and precise modality that generates high temperatures at specific target sites within tissues, has shown promising results in reducing plaque burden and improving vascular function. While low-intensity focused ultrasound (LIFU) operates at lower energy levels, promoting mild hyperthermia and stimulating tissue repair processes. This review article provides an overview of the current state of HIFU and LIFU in treating atherosclerosis. It focuses primarily on the therapeutic potential of HIFU due to its higher penetration and ability to achieve atheroma disruption. The review summarizes findings from animal models and human trials, covering the effects of FUS on arterial plaque and arterial wall thrombolysis in carotid, coronary and peripheral arteries. This review also highlights the potential benefits of focused ultrasound, including its noninvasiveness, precise targeting, and real-time monitoring capabilities, making it an attractive approach for the treatment of atherosclerosis and emphasizes the need for further investigations to optimize FUS parameters and advance its clinical application in managing atherosclerotic arterial disease.

Miniaturized Stacked Transducer for Intravascular Sonothrombolysis With Internal-Illumination Photoacoustic Imaging Guidance and Clot Characterization

Thromboembolism in blood vessels can lead to stroke or heart attack and even sudden death unless brought under control. Sonothrombolysis enhanced by ultrasound contrast agents has shown promising outcome on effective treatment of thromboembolism. Intravascular sonothrombolysis was also reported recently with a potential for effective and safe treatment of deep thrombosis. Despite the promising treatment results, the treatment efficiency for clinical application may not be optimized due to the lack of imaging guidance and clot characterization during the thrombolysis procedure. In this paper, a miniaturized transducer was designed to have an 8-layer PZT-5A stacked with an aperture size of 1.4 × 1.4 mm2 and assembled in a customized two-lumen 10-Fr catheter for intravascular sonothrombolysis. The treatment process was monitored with internal-illumination photoacoustic tomography (II-PAT), a hybrid imaging modality that combines the rich contrast of optical absorption and the deep penetration of ultrasound detection. With intravascular light delivery using a thin optical fiber integrated with the intravascular catheter, II-PAT overcomes the penetration depth limited by strong optical attenuation of tissue. In-vitro PAT-guided sonothrombolysis experiments were carried out with synthetic blood clots embedded in tissue phantom. Clot position, shape, stiffness, and oxygenation level can be estimated by II-PAT at clinically relevant depth of ten centimeters. Our findings have demonstrated the feasibility of the proposed PAT-guided intravascular sonothrombolysis with real-time feedback during the treatment process.

Robotic system for magnetic resonance imaging-guided high-intensity focus ultrasound application: Feasibility of breast fibroadenoma treatment

PURPOSE

This paper presents a high-intensity focus ultrasound (HIFU) robotic system for treating breast fibroadenoma under the guidance of magnetic resonance imaging (MRI). Based on the thermal and mechanical effects of ultrasound, the system aims to deliver ultrasound energy to a target precisely without damaging the normal tissue. The temperature elevation can be monitored in real time by MRI, and the treatment plan can be adjusted during the procedure. The requirements, design specifications, control system and registration of the robotic system are specified.

METHODS

The robotic system was designed with a 3 degrees of freedom manipulator with limit switches and encoders, a customised MRI-compatible breast coil, a water bladder with sets of breast-conforming brackets, and a probe capable of generating ultrasound. Twenty volunteers were recruited for this study, and their data were analysed to provide more precise data for the design. The accuracy of the robot was evaluated in free space using a coordinate measuring machine, phantom and ex vivo porcine tissue in MRI room. The study also verified the signal-to-noise ratio (SNR) of the MRI with the effect of the robotic system.

RESULTS

The research findings revealed that the manipulator exhibited a translational precision of 0.10 ± 0.14 mm, a rotational fidelity around the X direction of 0.11 ± 0.09°, and an oscillatory exactness around the Y direction of 0.10 ± 0.08°. The investigation of positioning accuracy demonstrated that the robot's error in free space was 0.26 ± 0.07 mm. When subjected to MRI room with agar-silica phantom and ex vivo porcine tissue, the positioning accuracy amounted to 1.11 ± 0.47 mm and 1.57 ± 0.52 mm. In the presence of the robotic system, the SNR of the MRI experienced a 4.2% reduction, which had a negligible impact on image quality.

CONCLUSIONS

The conducted experiments validate the efficacy of the proposed MRI-guided HIFU robotic system in executing agar-silica phantom and ex vivo porcine tissue investigations with adequate positioning accuracy. Consequently, this system exhibits certain feasibility for the treatment of breast fibroadenomas.

Estimating Thrombus Elasticity by Shear Wave Elastography to Evaluate Ultrasound Thrombolysis for Thrombus With Different Stiffness

OBJECTIVE

There is uncertainty about deep vein thrombosis standard treatment as thrombus stiffness alters each case. Here, we investigated thrombus' stiffness of different compositions and ages using shear wave elastography (SWE). We then studied the effectiveness of ultrasound-thrombolysis on different thrombus compositions.

METHODS

Shear waves generated through mechanical shaker and traveled along thrombus of different hematocrit (HCT) levels, whereas 18-MHz ultrasound array used to detect wave propagation. Thrombus' stiffness was identified by the shear wave speed (SWS). In thrombolysis, a 3.2 MHz focused transducer was applied to different thrombus compositions using different powers. The thrombolysis rate was defined as the percentage of weight loss.

RESULTS

The estimated average SWS of 20%, 40%, and 60% HCT thrombus were 0.75 m/s, 0.44 m/s, and 0.32 m/s, respectively. For Thrombolysis, the percentage weight loss at 8 MPa Negative pressure for the same HCT groups were 23.1%, 35.29%, and 39.66% respectively.

CONCLUSION

SWS is inversely related to HCT level and positively related to thrombus age. High HCT thrombus had higher weight loss compared to low HCT. However, the difference between 20% and 40% HCT was more significant than between 40% and 60% HCT in both studies. Our results suggest that thrombus with higher SWS require more power to achieve the same thrombolysis rate as thrombus with lower SWS.

SIGNIFICANCE

Characterizing thrombus elastic property undergoing thrombolysis enables evaluation of ultrasound efficacy for fractionating thrombus and reveals the appropriate ultrasound parameters selection to achieve a certain thrombolysis rate in the case of a specific thrombus stiffness.

A robotic MR-guided high-intensity focused ultrasound platform for intraventricular hemorrhage: assessment of clot lysis efficacy in a brain phantom

OBJECTIVE

Intraventricular hemorrhage (IVH) is a neurovascular complication due to premature birth that results in blood clots forming within the ventricles. Magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) has been investigated as a noninvasive treatment to lyse clots. The authors designed and constructed a robotic MRgHIFU platform to treat the neonatal brain that facilitates ergonomic patient positioning. The clot lysis efficacy of the platform is quantified using a brain phantom and clinical MRI system.

METHODS

A thermosensitive brain-mimicking phantom with ventricular cavities was developed to test the clot lysis efficacy of the robotic MRgHIFU platform. Whole porcine blood was clotted within the phantom's cavities. Using the MRgHIFU platform and a boiling histotripsy treatment procedure (500 W, 10-msec pulse duration, 1.0% duty cycle, and 40-second duration), the clots were lysed inside the phantom. The contents of the cavities were vacuum filtered, and the remaining mass of the solid clot particles was used to quantify the percentage of clot lysis. The interior of the phantom's cavities was inspected for any collateral damage during treatment.

RESULTS

A total of 9 phantoms were sonicated, yielding an average (± SD) clot lysis of 97.0% ± 2.57%. Treatment resulted in substantial clot lysis within the brain-mimicking phantoms that were apparent on postsonication T2-weighted MR images. No apparent collateral damage was observed within the phantom after treatment. The results from the study showed the MRgHIFU platform was successful at lysing more than 90% of a blood clot at a statistically significant level.

CONCLUSIONS

The robotic MRgHIFU platform was shown to lyse a large percentage of a blood clot with no observable collateral damage. These results demonstrate the platform's ability to induce clot lysis when targeting through simulated brain matter and show promise toward the final application in neonatal patients.

A narrative review on the application of high-intensity focused ultrasound for the treatment of occlusive and thrombotic arterial disease

Objectives

High-intensity focused ultrasound (HIFU) is a noninvasive therapeutic modality with a variety of applications. It is approved for the treatment of essential tremors, ablation of prostate, hepatic, breast, and uterine tumors. Although not approved for use in the treatment of atherosclerotic arterial disease, there is a growing body of evidence investigating applications of HIFU. Currently, percutaneous endovascular techniques are predominant for the treatment of arterial pathology; however, there are no endovascular techniques of HIFU available. This study aims to review the state of current evidence for the application of HIFU in atherosclerotic arterial disease.

Methods

All English-language articles evaluating the effect of HIFU on arterial occlusive and thrombotic disease until 2021 were reviewed. Both preclinical and human clinical studies were included. Study parameters such as animal or clinical model and outcomes were reviewed. In addition, details pertaining to settings on the HIFU device used were also reviewed.

Results

In preclinical models, atherosclerotic plaque progression was inhibited by HIFU, through decreases in oxidized low-density lipoprotein cholesterol and increases in macrophage apoptosis. Additionally, HIFU promotes angiogenesis in hindlimb ischemic models by the upregulation of angiogenic and antiapoptotic factors, with increased angiogenesis at higher line densities of HIFU. HIFU also promotes thrombolysis and conversely induces platelet activation at low frequencies and higher intensities. Various clinical studies have attempted to translate some of these properties and demonstrated positive clinical outcomes for arterial recanalization after thrombotic stroke, decreased atherosclerotic plaque burden in carotid arteries, increase in tissue perfusion and a decrease in diameter stenosis in patients with atherosclerotic arterial disease.

Conclusions

In current preclinical and clinical data, the safety and efficacy of HIFU shows great promise in the treatment of atherosclerotic arterial disease. Future focused studies are warranted to guide the refinement of HIFU settings for more widespread adoption of this technology.

Transcranial ultrasound stimulation applied in ischemic stroke rehabilitation: A review

Ischemic stroke is a serious medical condition that is caused by cerebral vascular occlusion and leads to neurological dysfunction. After stroke, patients suffer from long-term sensory, motor and cognitive impairment. Non-invasive neuromodulation technology has been widely studied in the field of stroke rehabilitation. Transcranial ultrasound stimulation (TUS), as a safe and non-invasive technique with deep penetration ability and a tiny focus, is an emerging technology. It can produce mechanical and thermal effects by delivering sound waves to brain tissue that can induce the production of neurotrophic factors (NFs) in the brain, and reduce cell apoptosis and the inflammatory response. TUS, which involves application of an acoustic wave, can also dissolve blood clots and be used to deliver therapeutic drugs to the ischemic region. TUS has great potential in the treatment of ischemic stroke. Future advancements in imaging and parameter optimization will improve the safety and efficacy of this technology in the treatment of ischemic stroke.

A Review of Imaging Methods to Assess Ultrasound-Mediated Ablation

Ultrasound ablation techniques are minimally invasive alternatives to surgical resection and have rapidly increased in use. The response of tissue to HIFU ablation differs based on the relative contributions of thermal and mechanical effects, which can be varied to achieve optimal ablation parameters for a given tissue type and location. In tumor ablation, similar to surgical resection, it is desirable to include a safety margin of ablated tissue around the entirety of the tumor. A factor in optimizing ablative techniques is minimizing the recurrence rate, which can be due to incomplete ablation of the target tissue. Further, combining focal ablation with immunotherapy is likely to be key for effective treatment of metastatic cancer, and therefore characterizing the impact of ablation on the tumor microenvironment will be important. Thus, visualization and quantification of the extent of ablation is an integral component of ablative procedures. The aim of this review article is to describe the radiological findings after ultrasound ablation across multiple imaging modalities. This review presents readers with a general overview of the current and emerging imaging methods to assess the efficacy of ultrasound ablative treatments.

High-Pressure Low-Frequency Lateral Mode Phased-Array Transducer System for the Treatment of Deep Vein Thrombosis: An In Vitro Study

Deep vein thrombosis (DVT) can lead to a fatal disease known as pulmonary embolism. Application of high-power ultrasound has been successful in studies to mechanically fragment the clots. Single-element ultrasound transducers were used in most of the studies. Challenges associated with phased arrays, such as high electrical impedance and element breakdown at high voltages, were addressed in the previous study, and a high-power 64-element transducer module was designed and fabricated. In this study, a cylindrical array of 16 modules with the frequency of 260 kHz was modeled and constructed for DVT thrombolysis. The maximum pressure, focal size, and steering ability of the array were examined. In vitro experiments were conducted to assess the performance of the array. The simulated pressure amplitude of 34 MPa at the depth of 55 mm (average femoral vein (FV) distance from the inner surface of the thigh) was in consistent with the experiments and satisfied the purpose of this study. Moreover, the employed module distribution resulted in a focal spot dimension of 2.4×2.8×7.3 mm³ (at the 75% pressure amplitude level) that can be confined in a human FV with the average diameter of 12 mm. In vitro experiments manifested a partial and complete clot breakdown at 11.5- and 15-MPa pressure at the focus. The design and engineering of the array system was succeeded in maintaining the desired pressure and focal size even when steered. The results presented in this study suggest the potential of the designed array system for clinical applications.

Dissolution Effect of Alteplase on Arterial Blood Clot Model of Hypertensive Intracerebral Hemorrhage Patients in vitro

Objective

To explore the dissolution effect of alteplase (rt-PA) on arterial blood clots of patients with hypertensive cerebral hemorrhage in vitro and analyze the optimal concentration and action time of rt-PA for intracranial hematomas.

Methods

The arterial blood of 35 patients with confirmed hypertensive cerebral hemorrhage were collected, centrifuged, and the serum was aspirated to prepare the blood clot model. The 0.125, 0.25, 0.5, 1, 2, and 3 mg t-PA, 20,000 U, and 40,000 U urokinase (u-PA) were taken for the corresponding blood clot for dissolution test. The blood clot volume and dissolution volume was measured at 0, 30, 60, 90, 120, and 150 min.

Results

Without intervention, the blood clot volume of men was higher than that of women at 0, 30, 60, and 90 min (P &lt; 0.05). Without intervention, hematocrit (HCT) was correlated with blood clot volume and the correlation decreased with time. The 30, 60, and 90 min dissolution curves of each group showed an upward trend (P &lt; 0.05), and the dissolution curves tended to be flat at 120 min and 150 min. The dissolution volume of.125 mg/3 ml, 0.25 mg/3 ml, 0.5 mg/3 ml rt-PA, 20,000 U, 40,000 U u-PA was higher than that of 1, 2, 3 mg/ml rt-PA (P &lt; 0.05). The dissolution volume of.125 mg/3 ml, 0.25 mg/3 ml, 0.5 mg/3 ml rt-PA was not significantly different from 20,000 and 40,000 U u-PA (P &gt; 0.05). Gender differences did not affect the effects of the above drugs.

Conclusion

In vitro, low-concentration rt-PA has a better dissolution effect, and it shows a time-dependent effect, reaching the highest effect in 90 min.

Safety Evaluation of a Forward-Viewing Intravascular Transducer for Sonothrombolysis: An in Vitro and ex Vivo Study

Recent in vitro work has revealed that a forward-viewing intravascular (FVI) transducer has sonothrombolysis applications. However, the safety of this device has yet to be evaluated. In this study, we evaluated the safety of this device in terms of tissue heating, vessel damage and particle debris size during sonothrombolysis using microbubbles or nanodroplets with tissue plasminogen activator, in both retracted and unretracted blood clots. The in vitro and ex vivo sonothrombolysis tests using FVI transducers revealed a temperature rise of less than 1°C, no vessel damage as assessed by histology and no downstream clot particles >500 µm. These in vitro and ex vivo results indicate that the FVI transducer poses minimal risk for sonothrombolysis applications and should be further evaluated in animal models.

A multi-pillar piezoelectric stack transducer for nanodroplet mediated intravascular sonothrombolysis

We aim to develop a nanodroplet (ND)-mediated intravascular ultrasound (US) transducer for deep vein thrombosis treatments. The US device, having an efficient forward directivity of the acoustic beam, is capable of expediting the clot dissolution rate by activating cavitation of NDs injected onto a thrombus. We designed and prototyped a multi-pillar piezoelectric stack (MPPS) transducer composed of four piezoelectric stacks. Each stack was made of five layers of PZT-4 plates, having a dimension of 0.85 × 0.85 × 0.2 mm3. The transducer was characterized by measuring the electrical impedance and acoustic pressure, compared to simulation results. Next, in-vitro tests were conducted in a blood flow mimicking system using the transducer equipped with an ND injecting tube. The miniaturized transducer, having an aperture size of 2.8 mm, provided a high mechanical index of 1.52 and a relatively wide focal zone of 3.4 mm at 80 Vpp, 0.96 MHz electric input. The mass-reduction rate of the proposed method (NDs + US) was assessed to be 4.1 and 4.6 mg/min with and without the flow model, respectively. The rate was higher than that (1.3-2.7 mg/min) of other intravascular ultrasound modalities using micron-sized bubble agents. The ND-mediated intravascular sonothrombolysis using MPPS transducers was demonstrated with an unprecedented lysis rate, which may offer a new clinical option for DVT treatments. The MPPS transducer generated a high acoustic pressure (~3.1 MPa) at a distance of approximately 2.2 wavelengths from the small aperture, providing synergistic efficacy with nanodroplets for thrombolysis without thrombolytic agents.

The feasibility of ultrasound-assisted endovascular laser thrombolysis in an acute rabbit thrombosis model

PURPOSE

This study aimed to test the feasibility of combined ultrasound and laser technique, namely, ultrasound-assisted endovascular laser thrombolysis (USELT), for thrombolysis by conducting in vivo tests in a rabbit thrombosis model.

MATERIALS AND METHODS

An acute thrombus was created in the right jugular vein of rabbit and then was treated with ultrasound only, laser only, and USELT to dissolve the blood clot. A total of 20 rabbits were used. Out of which, the first three rabbits were used to titrate the laser and ultrasound parameters. Then, five rabbits were treated with ultrasound only, five rabbits were treated with laser only, and seven rabbits were treated with USELT. During USELT, 532-nm laser pulses were delivered endovascularly directly to the clot through a fiber optic, and 0.5 MHz ultrasound pulses were applied noninvasively to the same region. A laser fluence of 4 to 12 mJ/cm² and ultrasound amplitude of 1 to 2 MPa were used. Recanalization of the jugular vein was assessed by performing ultrasound Doppler imaging immediately after the treatment. The maximum blood flow speed after the treatment as compared to its value before the treatment was used to calculate the blood flow recovery in vessel.

RESULTS

The blood flow was fully recovered (100%) in three rabbits, partially recovered in two rabbits (more than 50% and less than 100%) with mean percentage recovery of 69.73% and poorly recovered in two rabbits (<50%) with mean percentage recovery of 6.2% in the USELT group. In contrast, the treatment group with ultrasound or laser alone did not show recanalization of vein in any case, all the five rabbits were poorly/not recovered with a mean percentage recovery of 0%.

CONCLUSIONS

The USELT technology was shown to effectively dissolve the blood clots in an acute rabbit jugular vein thrombosis model.

The promising shadow of microbubble over medical sciences: from fighting wide scope of prevalence disease to cancer eradication

Microbubbles are typically 0.5-10 μm in size. Their size tends to make it easier for medication delivery mechanisms to navigate the body by allowing them to be swallowed more easily. The gas included in the microbubble is surrounded by a membrane that may consist of biocompatible biopolymers, polymers, surfactants, proteins, lipids, or a combination thereof. One of the most effective implementation techniques for tiny bubbles is to apply them as a drug carrier that has the potential to activate ultrasound (US); this allows the drug to be released by US. Microbubbles are often designed to preserve and secure medicines or substances before they have reached a certain area of concern and, finally, US is used to disintegrate microbubbles, triggering site-specific leakage/release of biologically active drugs. They have excellent therapeutic potential in a wide range of common diseases. In this article, we discussed microbubbles and their advantageous medicinal uses in the treatment of certain prevalent disorders, including Parkinson's disease, Alzheimer's disease, cardiovascular disease, diabetic condition, renal defects, and finally, their use in the treatment of various forms of cancer as well as their incorporation with nanoparticles. Using microbubble technology as a novel carrier, the ability to prevent and eradicate prevalent diseases has strengthened the promise of effective care to improve patient well-being and life expectancy.

Ultrasound-assisted laser thrombolysis with endovascular laser and high-intensity focused ultrasound

PURPOSE

The combination of laser and ultrasound can significantly improve the efficiency of thrombolysis through an enhanced cavitation effect. We developed a fiber optics-based laser-ultrasound thrombolysis device and tested the feasibility and efficiency of this technology for restoring blood flow in an in vitro blood clot model.

METHODS

An in vitro blood flow-clot model was setup, and then an endovascular laser thrombolysis system was combined with high-intensity focused ultrasound to remove the clot. The laser and ultrasound pulses were synchronized and delivered to the blood clot concurrently. The laser pulses of 532 nm were delivered to the blood clot endovascularly through an optical fiber, whereas the ultrasound pulses of 0.5 MHz were applied noninvasively to the same region. Effectiveness of thrombolysis was evaluated by the ability to restore blood flow, which was monitored by ultrasound Doppler.

RESULTS

As laser powers increased, the ultrasound threshold pressures for effective thrombolysis decreased. For laser fluence levels of 0, 2, and 4 mJ/cm² , the average negative ultrasound threshold pressures were 1.26 ± 0.114, 1.05 ± 0.181, and 0.59 ± 0.074 MPa, respectively. The periods of time needed to achieve effective thrombolysis were measured at 0.8, 2, and 4 mJ/cm² laser fluence levels and 0.42, 0.70, and 0.98 MPa negative ultrasound pressures. In general, thrombolysis could be achieved more rapidly with higher laser powers or ultrasound pressures.

CONCLUSIONS

Effective thrombolysis can be achieved by combining endovascular laser with noninvasive ultrasound at relatively low power and pressure levels, which can potentially improve both the treatment efficiency and safety.

High-Power Phased-Array Transducer Module for the Construction of a System for the Treatment of Deep Vein Thrombosis

Blood clot can be disintegrated by high-intensity focused ultrasound alone through inertial cavitation. There are limitations in using single-element ultrasound transducers for this purpose such as lack of steerability and control of the focus in terms of shape and location. Phased-array transducers being able to rapidly scan over the clots can alleviate this problem. A full 3-D control of the ultrasound beam can be achieved by 2-D electronically steerable arrays. However, the required high-pressure amplitude has not been possible with such arrays. In this work, a 2-D 64-element fully populated phased-array transducer module was designed and fabricated for the high-pressure amplitude required for deep vein thrombosis (DVT). Lateral coupling was considered for the transducer design to decrease the electrical impedance and eliminate the need for electrical matching circuit. PZT-4 with a thickness of 0.35 mm, an element surface area of [Formula: see text] mm, and a length of 6 mm showed a mean electrical impedance of 60.4 ± 11.5 measured for each transducer element facilitating effective electric power transfer from the driving electronics. No breakdown was observed when the voltage was increased gradually to 180 ± 3 V_pp. Operation at 180 V_pp was found to be safe over 10,000 repetitions without reduction in the power, resulting in the average pressure amplitude of 1.01 ± 0.09 MPa at 2 mm from the element surface. These pressure amplitude values indicate that an array of eight modules (80 [Formula: see text] mm) is required to reach to the pressure amplitude needed for DVT. Such arrays are practical with the current technology.

Non-invasive recanalization of deep venous thrombosis by high frequency ultrasound in a swine model with follow-up

AIMS

Pulsed cavitational ultrasound therapy (thombotripsy) allows the accurate fractionation of a distant thrombus. We aimed to evaluate the efficacy and safety of non-invasive thrombotripsy using a robotic assisted and high frequency ultrasound approach to recanalize proximal deep venous thrombosis (DVT) in a swine model.

METHODS

Occlusive thrombosis was obtained with a dual jugular and femoral endoveinous approach. The therapeutic device was composed of a 2.25 MHz focused transducer centered by a linear ultrasound probe, and a robotic arm. The feasibility, security, and efficacy (venous channel patency) assessment after thrombotripsy was performed on 13 pigs with acute occluded DVT. To assess the mid-term efficacy of this technique, 8 pigs were followed up for 14 days after thrombotripsy and compared with 8 control pigs. The primary efficacy endpoint was the venous patency. Safety was assessed by the search for local vessel wall injury and pulmonary embolism.

RESULTS

We succeeded in treating all pigs except two with no accessible femoral vein. After median treatment duration of 23 minutes of cavitation, all treated DVT were fully recanalized acutely. At 14 days, in the treated group, six of the eight pigs had a persistent patent vein and two pigs had a venous reocclusion. In the control group all pigs had a persistent venous occlusion. At sacrifice, no local vein nor arterial wall damage were observed as well as no evidence of pulmonary embolism in all pigs.

CONCLUSION

High frequency thrombotripsy seems to be effective and safe for non-invasive venous recanalization of DVT.

Enhanced cavitation activity in a slab-shaped optical absorber during photo-mediated ultrasound therapy

Recently, new studies have shown that combined laser and ultrasound, or photo-mediated ultrasound therapy (PUT), can enhance cavitation in optically absorptive targets to disrupt tissues through photoacoustic (PA) effect. These studies, including both experimental and theoretical investigations, have largely focused on blood vessels, which are modeled as cylindrically-shaped optical absorbers for PA wave generation and propagation. However, in many clinical situations, target tissues may not be cylindrically-shaped. In this paper we investigated the effect of PUT on a slab-shaped optical absorber, much larger than the size of the laser beam or the ultrasound focal point. Our results demonstrated that laser light could generate a PA wave that could enhance cavitation not only at the surface of a slab, but also at depths when combined with ultrasound, suggesting that PUT may be effective in enhancing cavitation in a large range of soft tissues. Our results also demonstrated that the cavitation enhancement was based on the optical absorption of the targeted tissue, allowing for self-targeting treatments when optical contrast is present. Additionally, we demonstrated that for the greatest cavitation enhancement in deeper layers a focused laser beam geometry would be most effective.

Advances in Sonothrombolysis Techniques Using Piezoelectric Transducers

One of the great advancements in the applications of piezoelectric materials is the application for therapeutic medical ultrasound for sonothrombolysis. Sonothrombolysis is a promising ultrasound based technique to treat blood clots compared to conventional thrombolytic treatments or mechanical thrombectomy. Recent clinical trials using transcranial Doppler ultrasound, microbubble mediated sonothrombolysis, and catheter directed sonothrombolysis have shown promise. However, these conventional sonothrombolysis techniques still pose clinical safety limitations, preventing their application for standard of care. Recent advances in sonothrombolysis techniques including targeted and drug loaded microbubbles, phase change nanodroplets, high intensity focused ultrasound, histotripsy, and improved intravascular transducers, address some of the limitations of conventional sonothrombolysis treatments. Here, we review the strengths and limitations of these latest pre-clincial advancements for sonothrombolysis and their potential to improve clinical blood clot treatments.

An Introduction to High Intensity Focused Ultrasound: Systematic Review on Principles, Devices, and Clinical Applications

Ultrasound can penetrate deep into tissues and interact with human tissue via thermal and mechanical mechanisms. The ability to focus an ultrasound beam and its energy onto millimeter-size targets was a significant milestone in the development of therapeutic applications of focused ultrasound. Focused ultrasound can be used as a non-invasive thermal ablation technique for tumor treatment and is being developed as an option to standard oncologic therapies. High-intensity focused ultrasound has now been used for clinical treatment of a variety of solid malignant tumors, including those in the pancreas, liver, kidney, bone, prostate, and breast, as well as uterine fibroids and soft-tissue sarcomas. Magnetic resonance imaging and Ultrasound imaging can be combined with high intensity focused ultrasound to provide real-time imaging during ablation. Magnetic resonance guided focused ultrasound represents a novel non-invasive method of treatment that may play an important role as an alternative to open neurosurgical procedures for treatment of a number of brain disorders. This paper briefly reviews the underlying principles of HIFU and presents current applications, outcomes, and complications after treatment. Recent applications of Focused ultrasound for tumor treatment, drug delivery, vessel occlusion, histotripsy, movement disorders, and vascular, oncologic, and psychiatric applications are reviewed, along with clinical challenges and potential future clinical applications of HIFU.

Longitudinal Functional Assessment of Brain Injury Induced by High-Intensity Ultrasound Pulse Sequences

Exposure of the brain to high-intensity stress waves creates the potential for long-term functional deficits not related to thermal or cavitational damage. Possible sources of such exposure include overpressure from blast explosions or high-intensity focused ultrasound (HIFU). While current ultrasound clinical protocols do not normally produce long-term neurological deficits, the rapid expansion of potential therapeutic applications and ultrasound pulse-train protocols highlights the importance of establishing a safety envelope beyond which therapeutic ultrasound can cause neurological deficits not detectable by standard histological assessment for thermal and cavitational damage. In this study, we assessed the neuroinflammatory response, behavioral effects, and brain micro-electrocorticographic (µECoG) signals in mice following exposure to a train of transcranial pulses above normal clinical parameters. We found that the HIFU exposure induced a mild regional neuroinflammation not localized to the primary focal site, and impaired locomotor and exploratory behavior for up to 1 month post-exposure. In addition, low frequency (δ) and high frequency (β, γ) oscillations recorded by ECoG were altered at acute and chronic time points following HIFU application. ECoG signal changes on the hemisphere ipsilateral to HIFU exposure are of greater magnitude than the contralateral hemisphere, and persist for up to three months. These results are useful for describing the upper limit of transcranial ultrasound protocols, and the neurological sequelae of injury induced by high-intensity stress waves.

Magnetic resonance-guided, high-intensity focused ultrasound sonolysis: potential applications for stroke

Stroke is one of the leading causes of death worldwide and a significant source of long-term morbidity. Unfortunately, a substantial number of stroke patients either are ineligible or do not significantly benefit from contemporary medical and interventional therapies. To address this void, investigators recently made technological advances to render transcranial MR-guided, high-intensity focused ultrasound (MRg-HIFU) sonolysis a potential therapeutic option for both acute ischemic stroke (AIS)-as an alternative for patients with emergent large-vessel occlusion (ELVO) who are ineligible for endovascular mechanical thrombectomy (EMT) or as salvage therapy for patients in whom EMT fails-and intracerebral hemorrhage (ICH)-as a neoadjuvant means of clot lysis prior to surgical evacuation. Herein, the authors review the technological principles behind MRg-HIFU sonolysis, its results in in vitro and in vivo stroke models, and its potential clinical applications. As a noninvasive transcranial technique that affords rapid clot lysis, MRg-HIFU thrombolysis may develop into a therapeutic option for patients with AIS or ICH. However, additional studies of transcranial MRg-HIFU are necessary to ascertain the merit of this treatment approach for thrombolysis in both AIS and ICH, as well as its technical limitations and risks.

Phospholipid-Coated Hydrophobic Mesoporous Silica Nanoparticles Enhance Thrombectomy by High-Intensity Focused Ultrasound with Low Production of Embolism-Inducing Clot Debris

Here we report the efficacy of a nanoparticle-assisted high-intensity focused ultrasound (HIFU) treatment that selectively destroys blood clots while minimizing generation of microparticles, or microemboli, that can cause further complications postsurgery. Treatment of malignant blood clots (thrombi) and the resulting emboli are critical problems for numerous patients, and treatments addressing these conditions would benefit from advancements in noninvasive procedures such as HIFU. While recanalization of occlusive blood clots is currently addressed with surgical intervention that seeks to minimize formation of large emboli, there is a danger of microemboli (micrometer-size particles) that have been theorized to be responsible for the poor correlation between apparent surgical success and patient outcome. Here, the addition of phospholipid-coated hydrophobically modified silica nanoparticles (P@hMSNs) improved the efficacy of HIFU treatment by serving as cavitation nuclei for mechanical disruption of thrombi. This treatment was evaluated for the ability to clear the HIFU focal area of a thick and dense thrombus within 10 min. Moreover, it was found that the use of P@hMSN+HIFU treatment generated a significantly smaller microembolic load as compared to comparison techniques, including a HIFU + microbubble contrast agent, HIFU alone, and direct mechanical disruption. This reduction in the microembolic load can occur either with primary removal of the clot by P@hMSN+HIFU or by insonation of the clot fragments after mechanical thrombectomy. Lastly, this method was evaluated in a flow model, where nonocclusive model thrombi and model emboli were mechanically ablated within the focal area within 15 s. Together, these results represent a combination therapy capable of resolving thrombi and microembolisms resulting from thrombectomy through localized destruction of clotted material.

Delay multiply and sum beamforming method applied to enhance linear-array passive acoustic mapping of ultrasound cavitation

PURPOSE

Passive acoustic mapping (PAM) has been proposed as a means of monitoring ultrasound therapy, particularly nonthermal cavitation-mediated applications. In PAM, the most common beamforming algorithm is a delay, sum, and integrate (DSAI) approach. However, using DSAI leads to low-quality images for the case where a narrow-aperture receiving array such as a standard B-mode linear array is used. This study aims to propose an enhanced linear-array PAM algorithm based on delay, multiply, sum, and integrate (DMSAI).

METHODS

In the proposed algorithm, before summation, the delayed signals are combinatorially coupled and multiplied, which means that the beamformed output of the proposed algorithm is the spatial coherence of received acoustic emissions. We tested the performance of the proposed DMSAI using both simulated and experimental data and compared it with DSAI. The reconstructed cavitation images were evaluated quantitatively by using source location errors between the two algorithms, full width at half maximum (FWHM), size of point spread function (A₅₀ area), signal-to-noise ratio (SNR), and computational time.

RESULTS

The results of simulations and experiments for single cavitation source show that, by introducing DMSAI, the FWHM and the A₅₀ area are reduced and the SNR is improved compared with those obtained by DSAI. The simulation results for two symmetric or nonsymmetric cavitation sources and multiple cavitation sources show that DMSAI can significantly reduce the A₅₀ area and improve the SNR, therefore improving the detectability of multiple cavitation sources.

CONCLUSIONS

The results indicate that the proposed DMSAI algorithm outperforms the conventionally used DSAI algorithm. This work may have the potential of providing an appropriate method for ultrasound therapy monitoring.

Reduced clot debris size in sonothrombolysis assisted with phase-change nanodroplets

Thrombosis-related diseases such as stroke, deep vein thrombosis, and others represent leading causes of mortality and morbidity around the globe. Current clinical thrombolytic treatments are limited by either slow reperfusion (drugs) or invasiveness (catheters) and carry significant risks of bleeding. High intensity focused ultrasound (HIFU) has been demonstrated to be a non-pharmacological, non-invasive but yet efficient thrombolytic approach. However, clinical concerns still remain related to the clot debris produced via fragmentation of the original clot potentially being too large and hence occluding downstream vessels, causing hazardous emboli. In this study, we introduced phase-change nanodroplets into pulse HIFU-mediated thrombolysis. The size distribution of the clot debris generated in sonothrombolysis with and without nanodroplets was compared. The effects of nanodroplet concentration, acoustic power and pulse repetition frequency on the clot debris size were further evaluated. It was found that the volume percentage of the large clot debris particles (above 10 μm in diameter) was smaller and the average diameter of the clot debris reduced significantly in nanodroplets-assisted sonothrombolysis. The stable cavitation dose was higher in sonothrombolysis without nanodroplets but the inertial cavitation dose showed no significant differences under two conditions. Besides, the average diameter decreased with increasing nanodroplet concentration and acoustic power when calculated by number percentage, but was found to be similar when calculated by volume percentage. In addition, the number percentage of the clot debris above 30 μm was demonstrated to be larger upon applying a higher pulse repetition frequency. Taken in concert, this study demonstrated that the introduction of phase-change nanodroplets could provide a safer sonothrombolysis method by reducing the overall clot debris size.

Colloids, nanoparticles, and materials for imaging, delivery, ablation, and theranostics by focused ultrasound (FUS)

This review focuses on different materials and contrast agents that sensitize imaging and therapy with Focused Ultrasound (FUS). At high intensities, FUS is capable of selectively ablating tissue with focus on the millimeter scale, presenting an alternative to surgical intervention or management of malignant growth. At low intensities, FUS can be also used for other medical applications such as local delivery of drugs and blood brain barrier opening (BBBO). Contrast agents offer an opportunity to increase selective acoustic absorption or facilitate destructive cavitation processes by converting incident acoustic energy into thermal and mechanical energy. First, we review the history of FUS and its effects on living tissue. Next, we present different colloidal or nanoparticulate approaches to sensitizing FUS, for example using microbubbles, phase-shift emulsions, hollow-shelled nanoparticles, or hydrophobic silica surfaces. Exploring the science behind these interactions, we also discuss ways to make stimulus-responsive, or "turn-on" contrast agents for improved selectivity. Finally, we discuss acoustically-active hydrogels and membranes. This review will be of interest to those working in materials who wish to explore new applications in acoustics and those in acoustics who are seeking new agents to improve the efficacy of their approaches.

Applications of Focused Ultrasound in Cerebrovascular Diseases and Brain Tumors

Oncology and cerebrovascular disease constitute two of the most common diseases afflicting the central nervous system. Standard of treatment of these pathologies is based on multidisciplinary approaches encompassing combination of interventional procedures such as open and endovascular surgeries, drugs (chemotherapies, anti-coagulants, anti-platelet therapies, thrombolytics), and radiation therapies. In this context, therapeutic ultrasound could represent a novel diagnostic/therapeutic in the armamentarium of the surgeon to treat these diseases. Ultrasound relies on mechanical energy to induce numerous physical and biological effects. The application of this technology in neurology has been limited due to the challenges with penetrating the skull, thus limiting a prompt translation as has been seen in treating pathologies in other organs, such as breast and abdomen. Thanks to pivotal adjuncts such as multiconvergent transducers, magnetic resonance imaging (MRI) guidance, MRI thermometry, implantable transducers, and acoustic windows, focused ultrasound (FUS) is ready for prime-time applications in oncology and cerebrovascular neurology. In this review, we analyze the evolution of FUS from the beginning in 1950s to current state-of-the-art. We provide an overall picture of actual and future applications of FUS in oncology and cerebrovascular neurology reporting for each application the principal existing evidences.

Integrated Histotripsy and Bubble Coalescence Transducer for Thrombolysis

After the collapse of a cavitation bubble cloud, residual microbubbles can persist for up to seconds and function as weak cavitation nuclei for subsequent pulses in a phenomenon known as cavitation memory effect. In histotripsy, the cavitation memory effect can cause bubble clouds to repeatedly form at the same discrete set of sites. This effect limits the efficacy of histotripsy-based tissue fractionation. Our previous studies have indicated that low-amplitude bubble-coalescing (BC) ultrasound sequences interleaved with high-amplitude histotripsy pulses can coalesce the residual bubbles into one large bubble quickly. This reduces the cavitation memory effect and may increase treatment efficacy. Histotripsy has been investigated for thrombolysis by breaking up clots into debris smaller than red blood cells. However, this treatment has low efficacy for aged or retracted clots. In this study, we investigate the use of histotripsy with BC to improve the efficacy of treatment of retracted clots. An integrated histotripsy and bubble-coalescing (HBC) transducer system with specialized electronic driving system was built in-house. One high-amplitude (32 MPa), one-cycle histotripsy pulse followed by 36 low-amplitude (2.4 MPa), one-cycle BC pulses formed one HBC sequence. Results indicate that HBC sequences successfully generated a flow channel through the retracted clots at scan speeds of 0.2-0.5 mm/s. The channel size created using the HBC sequence was 128% to 480% larger than that created using histotripsy alone. The clot debris particles generated during HBC treatments were within the tolerable range. These results illustrate the concept that BC improves the treatment efficacy of histotripsy thrombolysis for retracted clots.

Receiver array design for sonothrombolysis treatment monitoring in deep vein thrombosis

High intensity focused ultrasound (HIFU) can disintegrate blood clots through the generation and stimulation of bubble clouds within thrombi. This work examined the design of a device to image bubble clouds for monitoring cavitation-based HIFU treatments of deep vein thrombosis (DVT). Acoustic propagation simulations were carried out on multi-layered models of the human thigh using two patient data sets from the Visible Human Project. The design considerations included the number of receivers (32, 64, 128, 256, and 512), their spatial positioning, and the effective angular array aperture (100° and 180° about geometric focus). Imaging array performance was evaluated for source frequencies of 250, 750, and 1500 kHz. Receiver sizes were fixed relative to the wavelength (pistons, diameter  =  λ/2) and noise was added at levels that scaled with receiver area. With a 100° angular aperture the long axis size of the  -3 dB main lobe was ~1.2λ-i.e. on the order of the vessel diameter at 250 kHz (~7 mm). Increasing the array aperture to span 180° about the geometric focus reduced the long axis by a factor of ~2. The smaller main lobe sizes achieved by imaging at higher frequencies came at the cost of increased levels of sensitivity to phase aberrations induced during acoustic propagation through the intervening soft tissue layers. With noise added to receiver signals, images could be reconstructed with peak sidelobe ratios  <  -3 dB using single-cycle integration times for source frequencies of 250 and 750 kHz (NRx  ⩾  128). At 1500 kHz, longer integration times and/or higher element counts were required to achieve similar peak sidelobe ratios. Our results suggest that a modest number of receivers(i.e. NRx  =  128) arranged on a semi-cylindrical shell may be sufficient to enable passive acoustic imaging with single-cycle integration times (i.e. volumetric rates up to 0.75 MHz) for monitoring cavitation-based HIFU treatments of DVT.

Magnetic Resonance-Guided Focused Ultrasound in Neurosurgery: Taking Lessons from the Past to Inform the Future

Magnetic resonance-guided focused ultrasound (MRgFUS) is a new emerging neurosurgical procedure applied in a wide range of clinical fields. It can generate high-intensity energy at the focal zone in deep body areas without requiring incision of soft tissues. Although the effectiveness of the focused ultrasound technique had not been recognized because of the skull being a main barrier in the transmission of acoustic energy, the development of hemispheric distribution of ultrasound transducer phased arrays has solved this issue and enabled the performance of true transcranial procedures. Advanced imaging technologies such as magnetic resonance thermometry could enhance the safety of MRgFUS. The current clinical applications of MRgFUS in neurosurgery involve stereotactic ablative treatments for patients with essential tremor, Parkinson's disease, obsessive-compulsive disorder, major depressive disorder, or neuropathic pain. Other potential treatment candidates being examined in ongoing clinical trials include brain tumors, Alzheimer's disease, and epilepsy, based on MRgFUS abilities of thermal ablation and opening the blood-brain barrier. With the development of ultrasound technology to overcome the limitations, MRgFUS is gradually expanding the therapeutic field for intractable neurological disorders and serving as a trail for a promising future in noninvasive and safe neurosurgical care.

MRI-Guided High-Intensity Focused Ultrasound as an Emerging Therapy for Stroke: A Review

Stroke, either ischemic or hemorrhagic, accounts for significantly high morbidity and mortality rates around the globe effecting millions of lives annually. For the past few decades, ultrasound has been extensively investigated to promote clot lysis for the treatment of stroke, myocardial infarction, and acute peripheral arterial occlusions, with or without the use of tPA or contrast agents. In the age of modern minimal invasive techniques, magnetic resonance imaging-guided high-intensity focused ultrasound is a new emerging modality that seems to promise therapeutic utilities for both ischemic and hemorrhagic stroke. High-intensity focused ultrasound causes thermal heating as the tissue absorbs the mechanical energy transmitted by the ultrasonic waves leading to tissue denaturation and coagulation. Several in-vitro and in-vivo studies have demonstrated the viability of this technology for sonothrombolysis in both types of stroke and have warranted clinical trials. Apart from safety and efficacy, initiation of trials would further enable answers regarding its practical application in a clinical setup. Though this technology has been under study for treatment of various brain diseases for some decades now, relatively very few neurologists and even neurosurgeons seem to be acquainted with it. The aim of this review is to provide basic understanding of this powerful technology and discuss its clinical application and potential role as an emerging viable therapeutic option for the future management of stroke.

An MR-based quantitative intraventricular hemorrhage porcine model for MR-guided focused ultrasound thrombolysis

PURPOSE

Intraventricular hemorrhage (IVH) affects approximately 50% of premature births where 50% further develop post-hemorrhagic ventricular dilation (PHVD). Patients face significant impact to long-term development if PHVD is not managed. Unfortunately, there is no accepted treatment to remove the thrombus caused by IVH. This paper describes an acute and chronic IVH model for use with magnetic resonance-guided focused ultrasound (MRgFUS) thrombolysis.

METHODS

A total of 12 pigs (~ 1 month in age) were used in the model (eight acute and four chronic). A pre-operative brain MRI was obtained for ventricular targeting. 1.25 cm³/kg of autologous blood was injected through a burr hole lateral to the midline and anterior of the coronal suture at a rate of 0.6 cm³/min. A craniotomy was performed to simulate a "fontanelle". Post-operative MRI was used to calculate the clot volume. Chronic piglets were recovered, monitored daily with a neurological scoring system (NSS), and MRI scanned for 21 days.

RESULTS

The clot injection was well tolerated. The average clot size was 3987 mm³ (median = 4330 mm, standard deviation = 739 mm³). Postmortem examination validated the presence of the clot. In the chronic animals, there was an increase in ventricular volume of 30%. Transient neurological impairment immediately followed clot injection and with onset of hydrocephalus in the chronic animals.

CONCLUSIONS

This model establishes a measurable and targetable IVH clot in an MRI-based neonatal porcine model. The progressive post-hemorrhagic ventricular dilation in the chronic model is a potential alterable outcome from MRgFUS thrombolysis.

Numerical investigation of the inertial cavitation threshold under multi-frequency ultrasound

Through the introduction of multi-frequency sonication in High Intensity Focused Ultrasound (HIFU), enhancement of efficiency has been noted in several applications including thrombolysis, tissue ablation, sonochemistry, and sonoluminescence. One key experimental observation is that multi-frequency ultrasound can help lower the inertial cavitation threshold, thereby improving the power efficiency. However, this has not been well corroborated by the theory. In this paper, a numerical investigation on the inertial cavitation threshold of microbubbles (MBs) under multi-frequency ultrasound irradiation is conducted. The relationships between the cavitation threshold and MB size at various frequencies and in different media are investigated. The results of single-, dual and triple frequency sonication show reduced inertial cavitation thresholds by introducing additional frequencies which is consistent with previous experimental work. In addition, no significant difference is observed between dual frequency sonication with various frequency differences. This study, not only reaffirms the benefit of using multi-frequency ultrasound for various applications, but also provides a possible route for optimizing ultrasound excitations for initiating inertial cavitation.

Microbubbles combined with ultrasound therapy in ischemic stroke: A systematic review of in-vivo preclinical studies

BACKGROUND

Microbubbles (MBs) combined with ultrasound sonothrombolysis (STL) appears to be an alternative therapeutic strategy for acute ischemic stroke (IS), but clinical results remain controversial.

OBJECTIVE

The aim of this systematic review is to identify the parameters tested; to assess evidence on the safety and efficacy on preclinical data on STL; and to assess the validity and publication bias.

METHODS

Pubmed® and Web of ScienceTM databases were systematically searched from January 1995 to April 2017 in French and English. We included studies evaluating STL on animal stroke model. This systematic review was conducted in accordance with the PRISMA guidelines. Data were extracted following a pre-defined schedule by two of the authors. The CAMARADES criteria were used for quality assessment. A narrative synthesis was conducted.

RESULTS

Sixteen studies met the inclusion criteria. The result showed that ultrasound parameters and types of MBs were heterogeneous among studies. Numerous positive outcomes on efficacy were found, but only four studies demonstrated superiority of STL versus recombinant tissue-type plasminogen activator on clinical criteria. Data available on safety are limited.

LIMITATIONS

Quality assessment of the studies reviewed revealed a number of biases.

CONCLUSION

Further in vivo studies are needed to demonstrate a better efficacy and safety of STL compared to currently approved therapeutic options.

SYSTEMATIC REVIEW REGISTRATION

http://syrf.org.uk/protocols/.

High-intensity focused ultrasound: past, present, and future in neurosurgery

Since Lynn and colleagues first described the use of focused ultrasound (FUS) waves for intracranial ablation in 1942, many strides have been made toward the treatment of several brain pathologies using this novel technology. In the modern era of minimal invasiveness, high-intensity focused ultrasound (HIFU) promises therapeutic utility for multiple neurosurgical applications, including treatment of tumors, stroke, epilepsy, and functional disorders. Although the use of HIFU as a potential therapeutic modality in the brain has been under study for several decades, relatively few neuroscientists, neurologists, or even neurosurgeons are familiar with it. In this extensive review, the authors intend to shed light on the current use of HIFU in different neurosurgical avenues and its mechanism of action, as well as provide an update on the outcome of various trials and advances expected from various preclinical studies in the near future. Although the initial technical challenges have been overcome and the technology has been improved, only very few clinical trials have thus far been carried out. The number of clinical trials related to neurological disorders is expected to increase in the coming years, as this novel therapeutic device appears to have a substantial expansive potential. There is great opportunity to expand the use of HIFU across various medical and surgical disciplines for the treatment of different pathologies. As this technology gains recognition, it will open the door for further research opportunities and innovation.

High-intensity focused ultrasound ablation around the tubing

High-intensity focused ultrasound (HIFU) has been emerging as an effective and noninvasive modality in cancer treatment with very promising clinical results. However, a small vessel in the focal region could be ruptured, which is an important concern for the safety of HIFU ablation. In this study, lesion formation in the polyacrylamide gel phantom embedded with different tubing (inner diameters of 0.76 mm and 3 mm) at varied flow speeds (17–339 cm/s) by HIFU ablation was photographically recorded. Produced lesions have decreased length (~30%) but slightly increased width (~6%) in comparison to that without the embedded tubing. Meanwhile, bubble activities during the exposures were measured by passive cavitation detection (PCD) at the varied pulse repetition frequency (PRF, 10–30 Hz) and duty cycle (DC, 10%-20%) of the HIFU bursts. High DC and low flow speed were found to produce stronger bubble cavitation whereas no significant influence of the PRF. In addition, high-speed photography illustrated that the rupture of tubing was produced consistently after the first HIFU burst within 20 ms and then multiple bubbles would penetrate into the intraluminal space of tubing through the rupture site by the acoustic radiation force. Alignment of HIFU focus to the anterior surface, middle, and posterior surface of tubing led to different characteristics of vessel rupture and bubble introduction. In summary, HIFU-induced vessel rupture is possible as shown in this phantom study; produced lesion sizes and shapes are dependent on the focus alignment to the tubing, flow speed, and tubing properties; and bubble cavitation and the formation liquid jet may be one of the major mechanisms of tubing rupture as shown in the high-speed photography.

Catheter Hydrophone Aberration Correction for Transcranial Histotripsy Treatment of Intracerebral Hemorrhage: Proof-of-Concept

Histotripsy is a minimally invasive ultrasound therapy that has shown rapid liquefaction of blood clots through human skullcaps in an in vitro intracerebral hemorrhage model. However, the efficiency of these treatments can be compromised if the skull-induced aberrations are uncorrected. We have developed a catheter hydrophone which can perform aberration correction (AC) and drain the liquefied clot following histotripsy treatment. Histotripsy pulses were delivered through an excised human skullcap using a 256-element, 500-kHz hemisphere array transducer with a 15-cm focal distance. A custom hydrophone was fabricated using a mm PZT-5h crystal interfaced to a coaxial cable and integrated into a drainage catheter. An AC algorithm was developed to correct the aberrations introduced between histotripsy pulses from each array element. An increase in focal pressure of up to 60% was achieved at the geometric focus and 27%-62% across a range of electronic steering locations. The sagittal and axial -6-dB beam widths decreased from 4.6 to 2.2 mm in the sagittal direction and 8 to 4.4 mm in the axial direction, compared to 1.5 and 3 mm in the absence of aberration. After performing AC, lesions with diameters ranging from 0.24 to 1.35 mm were generated using electronic steering over a mm grid in a tissue-mimicking phantom. An average volume of 4.07 ± 0.91 mL was liquefied and drained after using electronic steering to treat a 4.2-mL spherical volume in in vitro bovine clots through the skullcap.

Effect of Frequency and Focal Spacing on Transcranial Histotripsy Clot Liquefaction, Using Electronic Focal Steering

This in vitro study investigated the effects of ultrasound frequency and focal spacing on blood clot liquefaction via transcranial histotripsy. Histotripsy pulses were delivered using two 256-element hemispherical transducers of different frequency (250 and 500 kHz) with 30-cm aperture diameters. A 4-cm diameter spherical volume of in vitro blood clot was treated through 3 excised human skullcaps by electronically steering the focus with frequency proportional focal spacing: λ/2, 2 λ/3 and λ with 50 pulses per location. The pulse repetition frequency across the volume was 200 Hz, corresponding to a duty cycle of 0.08% (250 kHz) and 0.04% (500 kHz) for each focal location. Skull heating during treatment was monitored. Liquefied clot was drained via catheter and syringe in the range of 6-59 mL in 0.9-42.4 min. The fastest rate was 16.6 mL/min. The best parameter combination was λ spacing at 500 kHz, which produced large liquefaction through 3 skullcaps (23.1 ± 4.0, 37.1 ± 16.9 and 25.4 ± 16.9 mL) with the fast rates (3.2 ± 0.6, 5.1 ± 2.3 and 3.5 ± 0.4 mL/min). The temperature rise through the 3 skullcaps remained below 4°C.

Megahertz rate, volumetric imaging of bubble clouds in sonothrombolysis using a sparse hemispherical receiver array

It is well established that high intensity focused ultrasound can be used to disintegrate clots. This approach has the potential to rapidly and noninvasively resolve clot causing occlusions in cardiovascular diseases such as deep vein thrombosis (DVT). However, lack of an appropriate treatment monitoring tool is currently a limiting factor in its widespread adoption. Here we conduct cavitation imaging with a large aperture, sparse hemispherical receiver array during sonothrombolysis with multi-cycle burst exposures (0.1 or 1 ms burst lengths) at 1.51 MHz. It was found that bubble cloud generation on imaging correlated with the locations of clot degradation, as identified with high frequency (30 MHz) ultrasound following exposures. 3D images could be formed at integration times as short as 1 µs, revealing the initiation and rapid development of cavitation clouds. Equating to megahertz frame rates, this is an order of magnitude faster than any other imaging technique available for in vivo application. Collectively, these results suggest that the development of a device to perform DVT therapy procedures would benefit greatly from the integration of receivers tailored to bubble activity imaging.

Design of a HIFU array for the treatment of deep venous thrombosis: a simulation study

Deep venous thrombosis of the iliofemoral veins is a common and morbid disease, with the recommended interventional treatment carrying a high risk of hemorrhaging and complications. High intensity focused ultrasound delivered with a single element transducer has been shown to successfully precipitate thrombolysis non-invasively in vitro and in vivo. However, in all previous studies damage to the veins or surrounding tissue has been observed. Using a simulation model of the human thigh, this study investigated whether a phased array device could overcome the large focal region limitations faced by single transducer treatment devices. Effects of the size, shape and frequency of the array on its focal region were considered. It was found that a [Formula: see text] spaced array of 7680 elements operating at 500 kHz could consistently focus to a region fully contained within the femoral vein. Furthermore, it is possible to reduce the number of elements required by building arrays operating at lower frequencies. The results suggest that phased transducer arrays hold potential for developing a safe, non-invasive treatment of thrombolysis.

Non-Invasive Thrombolysis Using Microtripsy in a Porcine Deep Vein Thrombosis Model

Histotripsy is a non-invasive therapeutic technique that uses ultrasound generated from outside the body to create controlled cavitation in targeted tissue, and fractionates it into acellular debris. We have developed a new histotripsy approach, termed microtripsy, to improve targeting accuracy and to avoid collateral tissue damage. This in vivo study evaluates the safety and efficacy of microtripsy for non-invasive thrombolysis in a porcine deep vein thrombosis model. Acute thrombi were formed in left femoral veins of pigs (∼35 kg) by occluding the vessel using two balloon catheters and infusing with thrombin. Guided by real-time ultrasound imaging, microtripsy thrombolysis treatment was conducted in 14 pigs; 10 pigs were euthanized on the same day (acute) and 4 at 2 wk (subacute). To evaluate vessel damage, 30-min free-flow treatment in the right femoral vein (no thrombus) was also conducted in 8 acute pigs. Blood flow was successfully restored or significantly increased after treatment in 13 of the 14 pigs. The flow channels re-opened by microtripsy had a diameter up to 64% of the vessel diameter (∼6 mm). The average treatment time was 16 min per centimeter-long thrombus. Only mild intravascular hemolysis was induced during microtripsy thrombolysis. No damage was observed on vessel walls after 2 wk of recovery, venous valves were preserved, and there was no sign of pulmonary embolism. The results of this study indicate that microtripsy has the potential to be a safe and effective treatment for deep vein thrombosis in a porcine model.

Intravascular forward-looking ultrasound transducers for microbubble-mediated sonothrombolysis

Effective removal or dissolution of large blood clots remains a challenge in clinical treatment of acute thrombo-occlusive diseases. Here we report the development of an intravascular microbubble-mediated sonothrombolysis device for improving thrombolytic rate and thus minimizing the required dose of thrombolytic drugs. We hypothesize that a sub-megahertz, forward-looking ultrasound transducer with an integrated microbubble injection tube is more advantageous for efficient thrombolysis by enhancing cavitation-induced microstreaming than the conventional high-frequency, side-looking, catheter-mounted transducers. We developed custom miniaturized transducers and demonstrated that these transducers are able to generate sufficient pressure to induce cavitation of lipid-shelled microbubble contrast agents. Our technology demonstrates a thrombolysis rate of 0.7 ± 0.15 percent mass loss/min in vitro without any use of thrombolytic drugs.