Skip to content

Advertisement

  • Meeting abstracts
  • Open Access

5th International Symposium on Focused Ultrasound

North Bethesda, MD, USA. 28 August- 1 September 2016
  • 1,
  • 1,
  • 1,
  • 1,
  • 1,
  • 1,
  • 2,
  • 2,
  • 2,
  • 3,
  • 2,
  • 4,
  • 4,
  • 4,
  • 4,
  • 4,
  • 4,
  • 4,
  • 5,
  • 6,
  • 6,
  • 6,
  • 5,
  • 5,
  • 6,
  • 5,
  • 7,
  • 7,
  • 7,
  • 7,
  • 7,
  • 7,
  • 7,
  • 7,
  • 8,
  • 9,
  • 10,
  • 11,
  • 10,
  • 12,
  • 11,
  • 11,
  • 11,
  • 11,
  • 11,
  • 11,
  • 10,
  • 13,
  • 14,
  • 15,
  • 15,
  • 15,
  • 7,
  • 7,
  • 7,
  • 7,
  • 7,
  • 7,
  • 16, 17,
  • 18,
  • 17,
  • 16, 17,
  • 1, 17,
  • 18,
  • 19,
  • 19,
  • 19,
  • 20,
  • 20,
  • 20,
  • 21,
  • 16, 17,
  • 22,
  • 16,
  • 16, 17,
  • 21,
  • 2,
  • 2,
  • 2,
  • 23,
  • 23,
  • 24,
  • 16, 17,
  • 25,
  • 21,
  • 21,
  • 21,
  • 21,
  • 21,
  • 26,
  • 27,
  • 26,
  • 27,
  • 26,
  • 26,
  • 2,
  • 2,
  • 28,
  • 2,
  • 2,
  • 22, 29,
  • 5,
  • 22,
  • 22,
  • 22,
  • 22,
  • 5,
  • 5,
  • 5,
  • 22,
  • 22,
  • 22,
  • 30,
  • 31,
  • 30,
  • 31,
  • 32,
  • 30,
  • 30,
  • 33,
  • 30,
  • 31,
  • 34,
  • 16,
  • 35,
  • 35,
  • 35,
  • 16,
  • 16,
  • 36,
  • 35,
  • 35,
  • 35,
  • 36,
  • 16,
  • 23,
  • 23,
  • 23,
  • 23,
  • 23,
  • 7,
  • 7,
  • 37,
  • 37,
  • 37,
  • 38,
  • 38,
  • 16,
  • 16, 17,
  • 17,
  • 16, 17,
  • 18,
  • 16,
  • 17,
  • 16, 17,
  • 8,
  • 39,
  • 40,
  • 40,
  • 9,
  • 8,
  • 8,
  • 9,
  • 9,
  • 8,
  • 41,
  • 41,
  • 42,
  • 16, 17,
  • 16, 17,
  • 17,
  • 16, 17,
  • 16, 17,
  • 16, 17,
  • 43,
  • 16, 17,
  • 44,
  • 17,
  • 16, 17,
  • 45,
  • 46,
  • 47,
  • 45,
  • 45,
  • 5, 48,
  • 48,
  • 49,
  • 45,
  • 45,
  • 5,
  • 22,
  • 5,
  • 50,
  • 22,
  • 22,
  • 22,
  • 5,
  • 22,
  • 51,
  • 51,
  • 5,
  • 51,
  • 22,
  • 51,
  • 51,
  • 51,
  • 29,
  • 52,
  • 52,
  • 52,
  • 22,
  • 51,
  • 51,
  • 7,
  • 7,
  • 7,
  • 7,
  • 7,
  • 7,
  • 53,
  • 53,
  • 54,
  • 5, 22,
  • 5,
  • 5,
  • 5,
  • 5,
  • 5,
  • 5,
  • 5,
  • 5,
  • 55,
  • 56,
  • ,
  • 57,
  • 57,
  • 57,
  • 57,
  • 58,
  • 58,
  • 58,
  • 58,
  • 58,
  • 58,
  • 58,
  • 58,
  • 59,
  • 59,
  • 59,
  • 58,
  • 58,
  • 58,
  • 58,
  • 60,
  • 51,
  • 51,
  • 51,
  • 51,
  • 51,
  • 51,
  • 61, 62,
  • 61,
  • 63,
  • 64,
  • 65,
  • 66,
  • 67,
  • 68,
  • 69,
  • 70,
  • 61,
  • 71,
  • 72,
  • 72,
  • 72,
  • 72,
  • 72,
  • 61,
  • 64,
  • 61,
  • 73,
  • 69,
  • 74,
  • 61, 62,
  • 61,
  • 61,
  • 7,
  • 7,
  • 7,
  • 37,
  • 7,
  • 7,
  • 7,
  • 75,
  • 76,
  • 76,
  • 2,
  • 77,
  • 78,
  • 79,
  • 79,
  • 79,
  • 80,
  • 81,
  • 80,
  • 81,
  • 81,
  • 81,
  • 82,
  • 82,
  • 82,
  • 82,
  • 82,
  • 83,
  • 83,
  • 82,
  • 84,
  • 85,
  • 85,
  • 85,
  • 85,
  • 85,
  • 85,
  • 86,
  • 86,
  • 58,
  • 86,
  • 87,
  • 87,
  • 88,
  • 89,
  • 90,
  • 91,
  • 91,
  • 92,
  • 93,
  • ,
  • 94,
  • 95,
  • 96,
  • 97,
  • 98,
  • 98,
  • 98,
  • 98,
  • 99,
  • 98,
  • 98,
  • 98,
  • 2,
  • 2,
  • 2,
  • 100,
  • 22,
  • 85,
  • 101,
  • 2,
  • 60,
  • 102,
  • 102,
  • 102,
  • 103,
  • 103,
  • 103,
  • 103,
  • 103,
  • 103,
  • 103,
  • 103,
  • 104,
  • 105,
  • 104,
  • 105,
  • 106,
  • 107,
  • 108,
  • 109,
  • 110,
  • 111,
  • 111,
  • 111,
  • 112,
  • 112,
  • 111,
  • 111,
  • 111,
  • 111,
  • 111,
  • 111,
  • 113,
  • 111,
  • 112,
  • 112,
  • 111,
  • 114,
  • 114,
  • 115,
  • 115,
  • 116,
  • 115,
  • 117,
  • 117,
  • 117,
  • 118,
  • 118,
  • 119, 120,
  • 120,
  • 121,
  • 121,
  • 121,
  • 122,
  • 122,
  • 123,
  • 124,
  • 125,
  • 124,
  • 125,
  • 126,
  • 127,
  • 128,
  • 129,
  • 129,
  • 129,
  • 129,
  • 129,
  • 129,
  • 129,
  • 129,
  • 129,
  • 130,
  • 130,
  • 130,
  • 130,
  • 130,
  • 131,
  • 132,
  • 132,
  • 131,
  • 132,
  • 133,
  • 134,
  • 135,
  • 135,
  • 134,
  • 133,
  • 131,
  • 132,
  • 136,
  • 137,
  • 137,
  • 137,
  • 137,
  • 137,
  • 137,
  • 137,
  • 137,
  • 137,
  • 137,
  • 138,
  • 139,
  • 139,
  • 139,
  • 139,
  • 140,
  • 140,
  • 141,
  • 141,
  • 141,
  • 141,
  • 141,
  • 141,
  • 141,
  • 141,
  • 141,
  • 141,
  • 141,
  • 141,
  • 142,
  • 143,
  • 144,
  • 144,
  • 144,
  • 144,
  • 144,
  • 145,
  • 146,
  • 146,
  • 147,
  • 146,
  • 148,
  • 149,
  • 150,
  • 150,
  • 148,
  • 149,
  • 151,
  • 151,
  • 151,
  • 151,
  • 151,
  • 151,
  • 151,
  • 151,
  • 152,
  • 152,
  • 152,
  • 152,
  • 152,
  • 153,
  • 154,
  • 154,
  • 154,
  • 153,
  • 153,
  • 153,
  • 155,
  • 156,
  • 156,
  • 156,
  • 156,
  • 157,
  • 157,
  • 157,
  • 157,
  • 157,
  • 157,
  • 157,
  • 158,
  • 158,
  • 159,
  • 158,
  • 158,
  • 160,
  • 160,
  • 160,
  • 160,
  • 160,
  • 160,
  • 160,
  • 161,
  • 161,
  • 162,
  • 162,
  • 163,
  • 161,
  • 164,
  • 161,
  • 161,
  • 162,
  • 165,
  • 165,
  • 165,
  • 165,
  • 165,
  • 165,
  • 166,
  • 167, 168,
  • 169,
  • 168,
  • 169,
  • 167, 168,
  • 170,
  • 170,
  • 170,
  • 171,
  • 170,
  • 170,
  • 170,
  • 170,
  • 172,
  • 172,
  • 172,
  • 173,
  • 173,
  • 173,
  • 174,
  • 174,
  • 174,
  • 174,
  • 174,
  • 175,
  • 175,
  • 176,
  • 176,
  • 176,
  • 177,
  • 177,
  • 177,
  • 177,
  • 178,
  • 178,
  • 179,
  • 180,
  • 180,
  • 181,
  • 180,
  • 181,
  • 181,
  • 181,
  • 181,
  • 180,
  • 182,
  • 182,
  • 182,
  • 182,
  • 182,
  • 183,
  • 182,
  • 182,
  • 184,
  • 184,
  • 185,
  • 184,
  • 184,
  • 184,
  • 186,
  • 186,
  • 184,
  • 187,
  • 187,
  • 187,
  • 187,
  • 187,
  • 187,
  • 188,
  • 188,
  • 188,
  • 188,
  • 188,
  • 189,
  • 190,
  • 191,
  • 191,
  • 192,
  • 192,
  • 193,
  • 192,
  • 194,
  • 194,
  • 194,
  • 195,
  • 195,
  • 196,
  • 197,
  • 198,
  • 199,
  • 200,
  • 200,
  • 200,
  • 201,
  • 202,
  • 201,
  • 203,
  • 204,
  • 205,
  • 205,
  • 205,
  • 205,
  • 205,
  • 206,
  • 205,
  • 207,
  • 207,
  • 207,
  • 207,
  • 207,
  • 207,
  • 208,
  • 209,
  • 208,
  • 208,
  • 208,
  • 210,
  • 210,
  • 211,
  • 211,
  • 211,
  • 212,
  • 213,
  • 212,
  • 214,
  • 214,
  • 214,
  • 214,
  • 214,
  • 215,
  • 215,
  • 215,
  • 215,
  • 215,
  • 215,
  • 216,
  • 217,
  • 218,
  • 219,
  • 219,
  • 219,
  • 219,
  • 220,
  • 220,
  • 220, 221, 222,
  • 220,
  • 223,
  • 224,
  • 223,
  • 225,
  • 226,
  • 226,
  • 226,
  • 225,
  • 225,
  • 226,
  • 226,
  • 226,
  • 227,
  • 227,
  • 227,
  • 227,
  • 227,
  • 228,
  • 229,
  • 230,
  • 229,
  • 230,
  • 229,
  • 231,
  • 232,
  • 233,
  • 234,
  • 232,
  • 233,
  • 235,
  • 234,
  • 236,
  • 237,
  • 238,
  • 239,
  • 239,
  • 239,
  • 237,
  • 236,
  • 240,
  • 240,
  • 240,
  • 240,
  • 240,
  • 241,
  • 241,
  • 241,
  • 241,
  • 241,
  • 242,
  • 242,
  • 242,
  • 242,
  • 242,
  • 242,
  • 242,
  • 242,
  • 242,
  • 242,
  • 243,
  • 244,
  • 242,
  • 242,
  • 245,
  • 245,
  • 246,
  • 245,
  • 247,
  • 248,
  • 248,
  • 245,
  • 249,
  • 249,
  • 249,
  • 249,
  • 249,
  • 249,
  • 250,
  • 250,
  • 250,
  • 250,
  • 250,
  • 250,
  • 251,
  • 251,
  • 251,
  • 251,
  • 251,
  • 251,
  • 252,
  • 252,
  • 252,
  • 252,
  • 253,
  • 253,
  • 254,
  • 253, 255,
  • 256,
  • 256,
  • 256,
  • 256,
  • 256,
  • 256,
  • 256,
  • 257,
  • 257,
  • 257,
  • 257,
  • 257,
  • 257,
  • 257,
  • 257,
  • 258,
  • 258,
  • 258,
  • 258,
  • 259,
  • 259,
  • 259,
  • 260,
  • 260,
  • 261,
  • 262,
  • 263,
  • 263,
  • 263,
  • 263,
  • 264,
  • 263, 265,
  • 262,
  • 266,
  • 267,
  • 268,
  • 269,
  • 267,
  • 267,
  • 270,
  • 271,
  • 267, 272,
  • 268,
  • 273,
  • 273,
  • 273,
  • 273,
  • 273,
  • 274,
  • 274,
  • 274,
  • 274,
  • 275,
  • 275,
  • 275,
  • 275,
  • 276,
  • 277,
  • 278,
  • 278,
  • 278,
  • 279,
  • 278,
  • 278, 280,
  • 281,
  • 281,
  • 281,
  • 281,
  • 281,
  • 281, 282,
  • 283,
  • 283,
  • 284,
  • 283,
  • 284,
  • 283, 285,
  • 287,
  • 287,
  • 287,
  • 287,
  • 287,
  • 288,
  • 289,
  • 290,
  • 288,
  • 291, 293,
  • 292,
  • 293,
  • 294,
  • 292,
  • 293,
  • 293,
  • 293,
  • 295,
  • 295,
  • 296,
  • 295,
  • 295,
  • 295,
  • 295,
  • 295,
  • 295,
  • 297,
  • 297,
  • 298,
  • 298,
  • 298,
  • 298,
  • 298,
  • 298,
  • 298,
  • 299,
  • 300,
  • 300,
  • 301,
  • 302,
  • 302,
  • 302,
  • 303,
  • 304,
  • 303,
  • 303,
  • 305,
  • 303,
  • 303,
  • 306,
  • 307,
  • 307,
  • 308,
  • 306,
  • 306,
  • 309,
  • 310,
  • 306,
  • 306,
  • 311,
  • 311,
  • 311,
  • 311,
  • 311,
  • 312,
  • 311,
  • 311,
  • 311,
  • 313,
  • 311,
  • 311,
  • 311,
  • 314,
  • ,
  • 314,
  • 314,
  • 315,
  • 315,
  • 315,
  • 316,
  • 315,
  • 317,
  • 317,
  • 317,
  • 317,
  • 317,
  • 5, 22,
  • 318,
  • 5, 22,
  • 26,
  • 319,
  • 320,
  • 321,
  • 319,
  • 322,
  • 320,
  • 319,
  • 323,
  • 324,
  • 325,
  • 323,
  • 325,
  • 323,
  • 325,
  • 324,
  • 323,
  • 326,
  • 327,
  • 328,
  • 328,
  • 328,
  • 328,
  • 327,
  • 329,
  • 329,
  • 330,
  • 331,
  • 331,
  • 331,
  • 332,
  • 331,
  • 333,
  • 332,
  • 332,
  • 332, 334,
  • 335,
  • 336,
  • 336,
  • 336,
  • 337,
  • 337,
  • 338,
  • 337,
  • 337,
  • 339,
  • 339,
  • 339,
  • 340,
  • 340,
  • 340,
  • 341,
  • 340,
  • 342,
  • 342 and
  • 342
Journal of Therapeutic Ultrasound20164 (Suppl 1) :31

https://doi.org/10.1186/s40349-016-0076-5

  • Published:

A1 Treatment of essential tremor and Parkinson’s disease tremor by MRI guided Focused Ultrasound: a report of 38 consecutive cases in a single center

Menashe Zaaroor, Alon Sinai, Dorit Goldsher, Ayelet Eran, Maria Nassar, Ilana Schlesinger

Rambam Health Care Campus, Haifa, Israel

Objectives

Thalamotomy of the ventral intermediate nucleus (VIM) is effective in alleviating medication resistant tremor in patients with essential tremor (ET) and Parkinson’s disease (PD). MRI guided Focused Ultrasound (MRgFUS) is an innovative technology that enables non-invasive thalamotomy via thermal ablation.

Methods

Thirty eight ET and PD patients with severe medication resistant tremor underwent MRgFUS underwent unilateral VIM thalamotomy using MRgFUS. Effect was evaluated using clinical Rating Scale of Tremor (CRST) in ET patients and Unified PD Rating Scale motor part (UPDRS) in PD patients. Quality of life was assessed by Quality of life in ET Questionnaire (QUEST) and PD Questionaire (PDQ-39).

Results

Tremor stopped in the treated hand in 37 patients immediately following the treatment. In one patients tremor was modified but not abolished. At one month post-treatment, the ET patients’ CRST score decreased from 38.6 ± 12.0 to 9.3 ± 7.7 (p < 0.001) and QUEST scores decreased from 44.8 ± 17.8 to 13.1 ± 15.9 (p < 0.001). In PD patients UPDRS-motor part decreased from 26.2 ± 8.7 to 16.3 ± 11.0 (p = 0.0087) and PDQ39 decreased from 40.8 ± 18.2 to 26.5 ± 15.1 (p = 0.027). During follow up of 1-24 months (mean 10.9 ± 8.1 months) tremor reappeared in seven of the patients, but in all but three, to a lesser degree than before the procedure.

Adverse events that transiently occurred during sonication included: Headache (n = 11), short lasting vertigo (n = 17) and dizziness (n = 4), nausea (n = 4), burning scalp sensation (n = 3), vomiting (n = 3) and lip paresthesia (n = 2). Adverse events that lasted after the procedure included gait ataxia (n = 5), unsteady feeling when walking (n = 4,) unilateral taste disturbances (n = 3) and hand ataxia (n = 3). All adverse events were transient and none lasted beyond 3 months.

Conclusions

MRgFUS VIM thalamotomy to relieve medication resistant tremor was safe and effective in ET, and PD. Current results emphasize its low adverse events profile and high efficacy in treating tremor. Large randomized studies are needed to assess prolonged efficacy and safety.

A2 Focused Ultrasound likely dominates deep brain stimulation and stereotactic radiosurgery for medically-refractory essential tremor: an initial decision and cost-effectiveness analysis

Jonathon Parker1, Vinod Ravikumar1, Pejman Ghanouni1, Sherman Stein2, Casey Halpern1

1Stanford University, Stanford, California, USA; 2University of Pennsylvania, Philadelphia, Pennsylvania, USA

Objectives

Essential Tremor (ET) is one of the most common neurologic conditions, and conservative measures are frequently suboptimal. Recent data from a multi-institution, randomized controlled clinical trial demonstrated that Magnetic Resonance-guided Focused Ultrasound (MRgFUS) thalamotomy improves upper limb tremor in medically refractory ET. This study assesses the cost-effectiveness of this novel therapy in comparison to existing procedural options.

Methods

PubMed and Cochrane Library searches were performed for studies of MRgFUS, Deep Brain Stimulation (DBS), and Stereotactic Radiosurgery (SRS) for ET. Pre- and post-operative tremor-related disability scores were collected from 32 studies involving 83 MRgFUS, 615 DBS, and 260 SRS cases. Utility (defined as percent change in functional disability) was calculated, and Medicare reimbursements were collected as a proxy for societal cost – costs of MRgFUS for ET were derived from a combination of available costs of approved indications and SRS costs where appropriate. A decision and cost-effectiveness analysis was then constructed, implementing meta-analytic techniques.

Results

MRgFUS thalamotomy resulted in significantly higher utility scores compared with DBS and SRS based on estimates of Medicare reimbursement (p < 0.001). MRgFUS was also the most inexpensive procedure out of the three (p < 0.001).

Conclusions

Preliminary experience with MRgFUS for ET suggests that this novel therapeutic may be more effective than available alternatives and potentially less costly for society. It thus will likely “dominate” DBS and SRS as a more cost-effective option for medically refractory ET. Our findings support further investigation of MRgFUS for ET and broad adoption.

A3 Tractography-based VIM identification for Focused Ultrasound thalamotomy: initial results

Vibhor Krishna, Amelia Hargrove, Punit Agrawal, Barbara Changizi, Eric Bourekas, Michael Knopp, Ali Rezai

The Ohio State University, Columbus, Ohio, USA

Objectives

The ventral intermediate nucleus (VIM) is not visible on conventional Magnetic Resonance Imaging (MRI). A novel method for tractography-based VIM identification has recently been described. We report the short-term clinical results of prospective VIM targeting with tractography in a cohort of patients undergoing Focused Ultrasound thalamotomy.

Methods

All patients underwent structural and diffusion weighted imaging (60 diffusion directions, 2 mm isovoxel) with 3 Tesla MRI scanner (Philips Ingenia CX). The images were processed using streamline tractography (Stealth Viz, Medtronic Inc.). The lateral and posterior borders of VIM were defined by tracking the pyramidal tract and medial lemniscus respectively. A VIM region of interest (ROI) was placed 3 mm away from these borders (Figs. 1, 2 and 3). The structural connectivity of this VIM ROI was confirmed to the motor cortex (M1) and cerebellum. The coordinates of tractography-based VIM in relation to posterior commissure were noted for surgical targeting. The parameters analyzed include a clinical tremor scale (pre-, intraoperative, and post operative), operative time, and number of sonications.

Results

Tractography-based VIM targeting was successful in 7 out of 8 patients. The coordinates of tractography-based VIM were significantly different from the standard coordinates (3-D distance 3.9 ± 2.4 mm). Therapeutic sonication (>55 °C temperature, 10 seconds) at the tractography target resulted in >50 % tremor improvement with intraoperative objective tremor assessment without any motor or sensory side-effects. The mean operative time was 78 ± 3.3 minutes with 12.8 ± 3.9 average sonications. Overall the tremor scores significantly improved one month after surgery (preop CRST total 62.1 ± 15.5 versus 30.3 ± 14.1, two tailed t-test p = 0.006). None of the patients experienced sensory deficits or motor weakness during follow-up.

Conclusions

We report that prospective tractography-based VIM targeting is safe and feasible. The short-term clinical results are satisfactory. Long-term tremor efficacy outcomes are desirable to further assess the usefulness of this technique.
Fig. 1 (abstract A3).
Fig. 1 (abstract A3).

Axial T1 projection showing the relation of VIM target 3 mm medial and anterior to pyramidal tract and medial lemniscus respectively

Fig. 2 (abstract A3).
Fig. 2 (abstract A3).

Postoperative sagittal T1 projection demonstrating the relationship between pyramidal tract and medial lemniscus in relation to thalamotomy lesion

Fig. 3 (abstract A3).
Fig. 3 (abstract A3).

Postoperative axial T1 projection demonstrating the relationship between pyramidal tract and medial lemniscus in relation to thalamotomy lesion

A4 Targeted delivery of brain-penetrating non-viral GDNF gene vectors to the striatum with MRI-guided Focused Ultrasound reverses neurodegeneration in a Parkinson’s disease model

Brian Mead1, Namho Kim2, Panagiotis Mastorakos2, Jung Soo Suk2, Wilson Miller1, Alexander Klibanov1, Justin Hanes2, Richard Price1

1University of Virginia, Charlottesville, Virginia, USA; 2Center for Nanomedicine/Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA

Objectives

Parkinson’s disease (PD) is characterized by the degeneration of dopaminergic neurons in the motor control pathways of the brain. Gene therapy using glial cell derived neurotrophic factor (GDNF) has shown some limited promise for treating PD; however, we hypothesize that outcomes could be further improved by enhancing gene vector distribution. We previously developed a gene therapy approach that entails delivering systemically administered non-viral gene-bearing nanoparticles (BPN) across the Blood-Brain Barrier with MRI-guided Focused Ultrasound (FUS). BPN rapidly penetrate brain tissue due to a dense coat of polyethylene glycol, and this approach mediates efficient and localized transgene expression in the brain of healthy rats. Here, we tested whether the FUS-mediated delivery of GDNF plasmid-bearing BPN (GDNF-BPN) reverses neurodegeneration in the rat 6-OHDA PD model.

Methods

6-OHDA rats were ultrasonically coupled to a 1.15 MHz MRI-compatible FUS transducer. T2 and T2* pre-treatment scans were obtained to allow FUS targeting of striatum. Microbubbles (2x105/g) and 100 μg of ~50 nm non-viral GDNF plasmid-bearing BPN (polyethylene glycol/polyethylenimine) were co-injected i.v. and FUS was applied at 0.6 MPa, with a 0.5 % duty cycle, for 2 min. Contrast T1 and T2* images allowed semi-real time confirmation of BBB disruption and safety, respectively. Efficacy was assessed using an ELISA for GDNF, tyrosine hydroxylase (TH) and VMAT2 immunolabeling for neural degeneration, HPLC for dopamine, and behavioral analysis (i.e. apomorphine-induced rotational asymmetry and forepaw use bias in 6-OHDA rats).

Results

Striatum-targeted delivery of GDNF plasmid-bearing BPN with FUS led to an ~80 % reduction in apomorphine-induced rotational asymmetry, eliminated forepaw use bias (Fig. 4a,b), and fully restored TH+ dopaminergic neuron density in both the substantia nigra pars compacta (SNpc) and striatum compared to untreated 6-OHDA rats (Fig. 4c,d). T2* MRI confirmed safety of the BBB opening approach.

Conclusions

FUS-mediated delivery of systemically circulating non-viral GDNF-BPN to the striatum of 6-OHDA rats confers a significant behavioral benefit as well as a restoration of TH+ cell number in the nigrostriatal pathway, indicating cessation and/or reversal of neurodegeneration. Our studies indicate that delivery of GDNF-BPN with FUS may provide a powerful, non-invasive and highly tailorable gene therapy approach to slow or stop the neurodegenerative process in PD.
Fig. 4 (abstract A4).
Fig. 4 (abstract A4).

Graphs of rotational bias (a) or forepaw use bias (b) following 6-OHDA injection. (c) Representative images of TH-immunlolabeled sections through the SNpc. Graphs represent TH+ cell number in SNpc (d) and staining intensity in the striatum (e). * p < 0.05

A5 Focused ultrasound facilitated gene delivery for neuro-restoration in Parkinson’s disease mice

Shutao Wang, Oluyemi Olumolade, Tara Kugelman, Vernice Jackson-Lewis, Maria Eleni (Marilena) Karakatsani, Yang Han, Serge Przedborski, Elisa Konofagou

Columbia University, New York, New York, USA

Objectives

Not released for publication

Methods

Not released for publication

Results

Not released for publication

Conclusions

Not released for publication

A6 MRI-g-FUS for the treatment of Alzheimer’s disease

Kullervo Hynynen1, Isabelle Aubert2

1Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; 2Sunnybrook Research Institute, Toronto, Ontario, Canada

Objectives

Over the past ten years consistent effort has been put forward at the University of Toronto to develop Focused Ultrasound methods for the treatment of AD. This talk will review the progress made so far.

Methods

The first studies demonstrated safe antibody delivery in AD mouse model with significant reduction in the plaque load. A follow up studies with two-photon microscopy showed that blood vessels with plague deposits showed a different type of opening than vessels in normal brain but large molecule delivery into the brain was still possible in these animals. Another study demonstrated that plaque reduction can be achieved by just opening the BBB with microbubbles.

Results

The histology revealed stimulation of neurogenesis. Multiple treatments of old mice resulted in memory rescue without any observable side-effects. A follow up study demonstrated that this neurogenesis was not induced with exposures that did not cause observable BBB opening even with the presence of the microbubbles. An ongoing study in large animals has shown that half-brain BBB opening can be safely and repeatable performed indicating the feasibility of clinical translation.

A7 Scanning Focused Ultrasound disruption of the blood-brain barrier as an Alzheimer’s disease therapy

Gerhard Leinenga1, Rebecca Nisbet2, Robert Hatch1, Anneke Van der Jeugd3, Harrison Evans2, Jürgen Götz2

1Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, St Lucia, Queensland, Australia; 2The University of Queensland, Brisbane (St Lucia Campus), QLD, Australia; 3University of Leuven, Leuven, Belgium, Belgium

Objectives

Alzheimer’s disease is the most common form of dementia. Pathological abnormalities in the Alzheimer’s disease brain includes the presence of amyloid-beta plaques, hyperphosphorylation and intracellular aggregation of tau and synaptic degeneration. Focused ultrasound combined with intravenous injection of microbubbles has been shown to reversibly open the blood-brain-barrier (BBB). By moving the focus in scanning mode we are able to open the BBB throughout the brain of a mouse. Here we tested the effects of repeated scanning ultrasound (SUS) in APP23 amyloid plaque-bearing mice, pR5 tau mice and wild-type mice to determine the effects of SUS on amyloid, tau and dendritic spines.

Methods

The device used was the Therapy Imaging Probe System (TIPS, Philips Research), which has an eight-element annular array transducer with a focal length of 80 mm a radius of curvature of 80 mm, a 33 mm central opening, and a motorized 3D positioning system. The focus 6 dB size was 1.5 mm x 1.5 mm x 12 mm at 1 MHz. Settings that were applied were 1 MHz centre frequency, 0.7 MPa peak rarefactional pressure applied outside the skull, 10 Hz pulse repetition frequency, 10 ms pulse length and 10 % duty cycle immediately after retroorbital injection of in-house made microbubbles. APP23 mice that accumulate amyloid beta, pR5 mice that overexpress FTD-mutant tau, and wild-type C57Bl/6 mice were treated weekly by scanning ultrasound (SUS) for periods of 4 to 7 weeks.

Results

In APP23 mice we used repeated scanning ultrasound (SUS) treatments of the mouse brain to remove amyloid-beta. Spinning disk confocal microscopy revealed extensive internalization of Abeta into the lysosomes of activated microglia in mouse brains subjected to SUS. Plaque burden was reduced in SUS-treated AD mice compared to sham-treated animals. Treated AD mice also displayed improved performance on three memory tasks.

In PR5 mice we investigated the efficacy of a novel tau isoform-specific single chain antibody fragment, RNX, delivered by passive immunization in the P301L human tau transgenic pR5 mouse model. When administration of RNX was combined with scanning ultrasound (SUS), RNX delivery into the brain and uptake by neurons were markedly increased, as were reductions in tau phosphorylation and anxiety-like behavior.

In wild-type mice we investigated the effects of SUS on neuronal excitability and morphology. We performed patch-clamp recordings from hippocampal CA1 pyramidal neurons in wild-type mice 2 and 24 hours after a single SUS treatment, and one-week and three months after six weekly SUS treatments. No change in CA1 neuronal excitability was observed compared to sham-treated neurons at any time-point. Multiple SUS treatments had the effect of preventing the loss of CA1 synapses that occurred in sham-treated neurons.

Conclusions

We show that scanning Focused Ultrasound disruption of the BBB has multiple biological effects in the brain which make it an attractive candidate for an Alzheimer disease therapy. SUS reduced plaque burden and amyloid-beta levels in APP23 amyloid mice, through activation of microglia, and improved performance on tests of memory function. In pR5 tau mice SUS alone reduced hyperphosphorylation of tau, and enhanced the delivery of anti-tau antibodies resulting in improved reductions in pathology and behavioral abnormalities. In wild-type mice SUS was shown to have no effect on the firing of hippocampal neurons or their morphology, but prevented spine loss at 3 months after six weekly SUS treatments. If these effects on Abeta and tau pathology, and dendritic morphology are recapitulated in human patients SUS may emerge as a promising AD therapy.

A8 Scanning ultrasound as a treatment tool of proteinopathies including Alzheimer’s disease

Jürgen Götz1, Rebecca Nisbet1, Ann Van der Jeugd1, Harrison Evans1, Gerhard Leinenga2

1The University of Queensland, Brisbane (St Lucia Campus), QLD, Australia; 2Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, St Lucia, Queensland, Australia

Objectives

Neurological disorders constitute a substantial social and economic burden, as they cause considerable ill health but few direct deaths. Treatment strategies for neurodegenerative diseases are hampered by the fact that the Blood-Brain Barrier (BBB) establishes an efficient barrier for therapeutic agents (Leinenga et al., Nature Reviews Neurology 2016). We have recently shown that scanning ultrasound (SUS) allows microglial-mediated clearance of extracellularly deposited amyloid-beta in APP mutant APP23 mice and restores memory functions in three cognitive tests to wild-type levels, in the absence of overt damage to the brain (Leinenga and Götz, Science Translational Medicine 2015) However, it had not been determined whether SUS treatment reduces the intracellular tau pathology that together with amyloid deposition characterizes Alzheimer’s disease.

Methods

We investigated the efficacy of a novel tau-specific single chain antibody fragment, delivered by passive immunization in the human tau transgenic pR5 mouse model, a model of the tau pathology of Alzheimer’s disease (Götz et al., Science 2001). To further assess the efficacy and drug-delivering ability of SUS, we established four experimental groups, using the novel anti-tau antibody that was injected weekly over four weeks, either on its own, or together with SUS. A third group used SUS only, and a fourth was the anaesthesia control group. The mice were analysed on the elevated plus maze, histologically and biochemically. Furthermore, uptake of the antibody by the brain was determine using fluorescently labelled single-chain antibody fragments.

Results

A histological and biochemical analysis of the pR5 tau transgenic mice revealed that SUS as well as the employed antibody ameliorated the tau pathology that characterizes the pR5 mice. In addition, the anxiety-like behaviour that characterizes pR5 mice was significantly reduced. We furthermore found enhanced delivery of the antibody using SUS yielding a synergistic therapeutic effect as determined by histology and using the elevated plus maze.

Conclusions

Our study suggests that SUS is a method that benefits diseases with protein aggregates more generally, whether they are intra- or extracellular. The therapeutic delivery combined with SUS could offer significant clinical benefits for the treatment of patients with Alzheimer’s disease and related tauopathies. Considering that the yearly costs of passive immunotherapy for AD is expected to exceed $25,000 per patient, combining SUS with antibody delivery could drastically reduce these costs.

A9 Enhancement of FUS mediated delivery of stem cells to the brain

Paul Fishman1, Paul Yarowsky2, Victor Frenkel3, Shen Wei-Bin3, Ben Nguyen3

1University of Maryland School of Medicine/Baltimore VAMC, Baltimore, Maryland, USA; 2Research & Development Service, VA Maryland Healthcare System and University of Maryland School of Medicine, Baltimore, Maryland, USA; 3University of Maryland School of Medicine, Baltimore, Maryland, USA

Objectives

FUS mediated Blood-Brain Barrier disruption (BBBD) can enable even large therapeutics such as stem cells to enter brain from the bloodstream and could be a major advance in cell delivery over current invasive methods of brain injection. The efficiency of cellular entry after FUS mediated BBBD alone however is low. We hypothesized that this process could be enhanced by combining it with a complementary strategy termed magnetic targeting. Stem cells can be safely loaded with super-paramagnetic iron oxide nanoparticles (SPION) in culture, allowing cells to be attracted by an external magnet. Our previous study showed SPION loaded stem cells to have enhanced brain retention near a magnet on the skull in a rat model of traumatic brain injury, where BBBD also occurs. The goal of our current project was to determine if magnetic attraction of SPION loaded stem cells would also enhance their delivery to brain after FUS mediated BBBD.

Methods

With a small animal MRI guided FUS device (Image Guided Therapy, IGT and 7 T Bruker MRI), we sonicated young adult rats (~120 g) with both radiologic (enhancement of the target region with gadolinium on post-sonication TI MRI), and histologic (staining with Evans’ blue dye) evidence of BBBD, without tissue damage or hemorrhage. Confirmation of the cells within brain as those injected was performed by staining with Perl’s reagent for iron and by immuno-histochemistry with a human specific antigen. The procedure was then combined with the application of a powerful magnet to the head directly after IV injection of hNPCs.

Results

With BBBD alone human neuro-progenitor cells (hNPCs) loaded with SPION were observed in rat brain after intravenous (IV) injection directly after sonication only within the treated regions. To demonstrate the effect of magnetic attraction, we injected equal numbers of SPION and non-SPION labeled cells, where each cell type was labeled with a different fluorophore. In animals that had FUS mediated BBBD followed by a magnet applied to the head, significantly greater numbers of SPION labeled cells were observed compared to the non-labeled cells. This result was most pronounced in regions of the brain close to the skull (cerebral cortex) and magnet surface. More powerful magnets including magnetic arrays resulted in more effective retention of SPION labeled cells in even deeper brain regions such as the striatum. There, 90 % of hNPCs observed contained SPIONs compared to 60-70 % with a less powerful magnet.

Conclusions

These results demonstrate that the use of magnetic attraction can substantially enhance delivery of stem cells after BBBD. In prior published work, stem cells were delivered to brain after FUS mediated BBBD using cells injected directly into the carotid artery. In an effort to accomplish this goal in a safer and less invasive manner, our study utilized IV cell injection (tail vein), supporting the view that the combination of FUS mediated BBBD and magnetic attraction can allow stem cells to enter brain with a minimally invasive strategy.

A10 Fluorescent lipid microbubbles for targeted brain drug delivery through the Focused Ultrasound-induced blood-brain barrier opening in vivo

Carlos Sierra Sanchez, Camilo Acosta, Cherry Chen, Shih-Ying Wu, Maria Eleni (Marilena) Karakatsani, Elisa Konofagou

Columbia University, New York, New York, USA

Objectives

Focused ultrasound (FUS) in the presence of lipid microbubbles can induce non-invasive, transient and reversible Blood-Brain Barrier (BBB) opening. This study entailed assessment of the feasibility of fluorescently loaded microbubbles, labeled with the fluorophore 5-dodecanoylaminfluorescein (C-12), as a vector for targeted brain drug delivery. Compared to prior studies by our group, where fluorescently-labeled dextrans were co-administered with microbubbles, this new methodology improves the safety and allows a more targeted drug delivery with potentially lower toxicity, avoiding systemic exposure. The main objective was thus to determine feasibility and safety of using the loaded microbubbles as carriers towards targeted brain drug delivery with simultaneous cavitation monitoring.

Methods

A spherical, single-element, FUS transducer (center frequency 1.5 MHz) was used. A pulse-echo transducer (center frequency 10 MHz), confocally mounted at the center of the FUS transducer, was utilized for passive cavitation detection (PCD). FUS (pulse length 10,000 cycles; pulse repetition frequency 5 Hz; duration 5 minutes; acoustic pressure 450-750 kPa) targeted mouse brains in vivo, in combination with fluorescent microbubbles for C-12 delivery, which was evaluated by in vivo transcranial PCD, through the quantification of inertial (ICD) and stable harmonic (SCDh) and ultraharmonic (SCDu) cavitation doses at 30, 60 and 300 s; together with ex vivo fluorescence imaging. The BBB opening was verified using in vivo T1-w Magnetic Resonance Imaging (MRI). The safety of this technique was assessed through ex vivo hematoxylin & eosin staining for microhemorrhage detection and immunohistochemistry (Iba-1 for microglial activation) together with in vivo T2-w MRI for edema assessment.

Results

Successful targeted C-12 delivery was achieved at 600 and 750 kPa in six out of 14 cases (Fig. 5). Comparison of ICD, SCDh and SCDu between successful and unsuccessful cases yielded a statistically significant linear relationship between the successful targeted drug delivery and CD and specific thresholds for efficient delivery were identified.

No edema was detected in mice sacrificed on Day 0 but edema appeared on Day 1 on mice sacrificed on Day 7. In all cases cases (except one) it was repaired within a week. Microhemorrhages were observed after sonication in some cases but were also cleared within the first week. However, a higher number of cell nuclei was observed in the sonicated region compared to the unsonicated side in some mice survived up to one week after opening. Iba-1 immunohistochemistry also showed microglial activation.

Conclusions

FUS was applied in conjunction with fluorescent microbubbles and, for the first time, the existence of CD thresholds for assessing successful drug delivery was defined. For CD above these thresholds, significant fluorescent enhancement was observed, demonstrating C-12 targeted delivery. One week after sonication, edema was cleared out but microglial activation was observed in certain cases. Therefore, this study indicates the feasibility and safety of a new methodology of FUS-induced BBB opening for targeted albeit potentially riskier brain drug delivery and provides a platform for predicting successful delivery via PCD.
Fig. 5 (abstract A10).
Fig. 5 (abstract A10).

BBB opening and fluorescence delivery: T1-w MRI showing BBB opening at pressures (a) 450, (b) 600 and (c) 750 kPa. Fluorescence delivery (green) and DAPI (blue) in two horizontal sections of mouse brains sonicated at (d) 600 and (e) 750 kPa

A11 Ultrasound-mediated delivery of gadolinium and fluorescent–labelled liposomes through the Blood-Brain Barrier

Muna Aryal1,2, Iason T Papademetriou3, Yong-Zhi Zhang2, Chanikarn Power1,2, Nathan McDannold1,2, Tyrone Porter3

1Brigham and Women’s Hospital, Boston, Massachusetts, USA; 2Harvard Medical School, Boston, Massachusetts, USA; 3Boston University, Boston, Massachusetts, USA

Objectives

The main objectives of this study were: 1) to examine whether gadolinium and fluorescent labelled liposomes can extravasate into the brain parenchyma after ultrasound mediated Blood-Brain Barrier disruptions; and 2) to test whether extravasated liposomes were size dependent or not. The liposomes were labelled with gadolinium (Gd) and fluorophore, thus enabling detection of extravasated liposomes via MRI in vivo and fluorescence methods in tissue, respectively.

Methods

Liposomes labelled with gadolinium and fluorophore were prepared using lipid film hydration and extrusion to two different sizes; ~70-85 nm and ~ 130-150 nm. Animals were divided into two different groups based on the use of particle sizes; group A (~70-85 nm) and group B (~130-150 nm). Focused ultrasound mediated Blood-Brain Barrier disruption (BBBD) was produced in one hemisphere in 15 mice. Particles were injected before sonication. Sonications (0.69 MHz at 0.42 MPa) were performed in two locations combine with Definity (10 μl/kg). Acoustic emissions were recorded during FUS. T1-weighted contrast enhanced and T2*-weighted MRI were used to confirm Gd leakage and damage detection respectively. Mice were euthanized 5-24 hours after FUS and post-process for fluorescence measurement.

Results

In T1-weighted contrast enhanced MRI, gadolinium-leakage was able to detect on sonicated area at 5-24 after FUS but not on non-sonicated area (control). Detection of fluorescence signal from brain tissue homogenates confirm the liposomal particles extravasation on sonicated locations. On group A, gadolinium and fluorescence signal intensities on sonicated locations were increased by 26 % and 62 % respectively as compared with control and signal enhancement were statistically significant compared with control ( p = 0.017 and p = 0.02 respectively, two-tailed, paired ttest). On group B, gadolinium and fluorescence signal intensities on sonicated locations were increased by 24 % and 40 % respectively as compared with control. Comparison of fluorescence signal intensities between two groups on sonicated location was statically significant whereas it was not significant on controls (p < 0.05 and p = 0.07 respectively, one-tailed unpaired ttest).

Conclusions

Overall, this work demonstrates that ultrasound can deliver upto ~ 150 nm liposomes that labelled with gadolinium and fluorophore through the Blood-Brain Barrier. The results indicate that the extravasation of liposomes were size dependent.

A12 Sterile inflammatory response (SIR) in the brain following exposure to low intensity pulsed Focused Ultrasound and microbubble infusion

Zsofia Kovacs1, Saejeong Kim1, Neekita Jikaria1, Farhan Qureshi2, Michele Bresler2, Joseph Frank2

1National Institutes of Health, Bethesda, Maryland, USA; 2National Institutes of Health Clinical Center, Bethesda, Maryland, USA

Objectives

Magnetic Resonance Imaging (MRI)-guided pulsed Focused Ultrasound (pFUS) in combination with systemic injection of microbubbles (MB) is being advocated to increase drug or gene delivery by causing localized Blood-Brain Barrier (BBB) disruption (D). The objective of this study is to investigate the molecular and cellular responses following pFUS + MB associated with BBBD in the rat brain.

Methods

Female Sprague Dawley rats (<200 g) were sonicated at 0.3 MPa acoustic pressures with 10 ms burst length and 1 % duty cycle (9 focal points, 120 sec/9 focal points) using a single-element spherical FUS transducer (589.636 kHz; FUS Instruments). 100 μl Optison™ MB (GE Healthcare) was administered intravenously. Gadofosveset-enhanced T1w images were obtained with a 3.0 T MRI (Phillips). Proteomic and mRNA expression in the brain following pFUS + MB were analyzed with ELISA, Western blot, quantitative real-time PCR or immunofluorescent staining (Fig. 6a). Proteomics were normalized to sham and statistical analysis was performed by one-way ANOVA corrected for multiple comparisons. Rats were also injected with 8 mg/kg Rhodamine encapsulated magnetic polymers (MicroTRACK™; BioPal) 3 days prior to sonication to label splenic macrophages (CD68) to monitor tropism to the brain.

Results

Post contrast T1w MRI and histology showed open BBB without evidence of microhemorrhage. Within 5 minutes following sonication, increased expression of pro-inflammatory and anti-inflammatory cytokines, chemokines and trophic factors (CCTF) was detected in the parenchyma lasting up to 24 hours (Fig. 6b). Increases in heat shock protein 70 (HSP70), tumor necrosis alpha (TNFa), and interleukin (IL) 1a, 1b and 18 consistent with damage associated molecular patterns (DMAP)1 and activation of nuclear factor kappa-light-chain-enhancer of activated B cells (NFkB) inflammatory pathways were observed with SIR to injury2 (Fig. 6b). NFkB pathway-related gene activation along with anti-apoptotic genes, immune cell chemoattractants, selectins, and cell adhesion molecules showed significant (>2fold) increases in mRNA expression (Fig. 6c). Histological analysis showed significant increases (p < 0.05) in the following: number of TUNEL positive cells within 6 hrs, GFAP and Iba1 staining for activated astrocytes and microglia (1-24 hrs) and increase of ICAM up to 24 hrs post sonication. We also detected a >4 fold greater (p < 0.05) CD68 positive cells on day 6 post sonication containing intracellular fluorescent beads within the pFUS + MB treated hemisphere compared to contralateral hemisphere.

Conclusions

The temporal molecular response to pFUS + MB is indicative of SIR2 originating from the parenchyma. The pattern of cytokines immediately after pFUS + MB is initiated by cellular release of DAMPs and TNFa observed with mild cerebral trauma or ischemia [1,2]. Increases in monocyte chemoattractant protein (MCP-1), vascular endothelial growth factors (VEGF), stromal derived factor 1 (SDF-1), erythropoietin (EPO) and brain derived neurotropic factor (BDNF) are associated with BBBD stimulating angiogenesis, neurogenesis and stem cell migration observed with ischemia and trauma. These results indicate that pFUS + MB rapidly affects the cerebral vasculature as evident by BBBD in addition to the shockwave from MB collapse that induces mild stress within various cellular elements in the parenchyma inducing a SIR.

References

1. Chen, G. Y., et al. 2010 Nat Rev Immunol 10(12):826-37.

2. Gadani, S. P., et al. 2015 Neuron 87(1):47-62.
Fig. 6 (abstract A12).
Fig. 6 (abstract A12).

pFUS + MB elicits a transient microenvironmental response in the brain that reflects a sterile inflammation

A13 Volumetric MR thermometry in a clinical transcranial MR guided Focused Ultrasound system

Henrik Odéen1, George Chiou2,3, John Snell4, Nick Todd2, Bruno Madore2,3, Dennis Parker1

1University of Utah, Salt Lake City, Utah, USA; 2Brigham and Women’s Hospital, Boston, Massachusetts, USA; 3Harvard Medical School, Boston, Massachusetts, USA; 4Focused Ultrasound Foundation, Charlottesville, Virginia, USA

Objectives

Transcranial MR-guided Focused Ultrasound (tcMRgFUS) applied within a small central brain volume has achieved excellent outcomes in treatment of movement disorders (Elias NEJM 2013). Although transducers used in tcMRgFUS have been designed with large apertures to spread the beam energy over as much skull as possible to reduce skull and cortex heating, currently used MR temperature imaging (MRTI) methods cannot monitor the temperature increase over the entire insonified brain volume. Instead, temperatures are typically measured in one 2D slice, leaving the majority of the insonified brain volume unmonitored. We have previously developed and published methods to achieve fully 3D MRTI covering the entire insonified brain with good spatial and temporal resolution (Todd MRM 2009/2010) but the techniques have not been evaluated on clinical tcMRgFUS systems. In this work-in-progress study we demonstrate the value of volumetric MRTI with two different pulse sequences applied during heating on a clinical tcMRgFUS system.

Methods

PRF MRTI was performed with a product 3D gradient recalled echo (GRE) pulse sequence and a custom-implemented 3D GRE segmented echo planar imaging (EPI) pulse sequence on a 3 T MRI (Discovery 750 T, GEMS). tcFUS heatings were performed in an ex vivo human skull filled with tissue-mimicking gel (ATS Laboratories) in a clinical tcMRgFUS system (ExAblate Neuro, Insightec).

Pulse sequences parameters are listed in Table 1. All data were zero filled interpolated (ZFI) to 1-mm isotropic spacing (GRE data additionally ZFI to 0.5-mm spacing). The skull was physically positioned in the FUS system, and the focus electronically steered, to target deep brain-structures located outside the normal treatment envelope. FUS sonications were applied at 940 W for 30/60 s while imaging with the GRE/EPI sequences, respectively. The EPI sequence used an echotrain length of 16 with bi-polar readout gradient, sampling 192 phase encodings in each direction, so that full “positive only” and “negative only” images could be reconstructed.

k-space data were retrospectively down sampled by a factor of R = 4 and 8 (split into multiple time-frames without throwing any data away) for the GRE and EPI experiments, respectively, giving acquisitions times of 3.6 and 7.8 s, and reconstructed with a temporally constrained reconstruction algorithm (Todd MRM 2009).

Results

Figure 7 shows three orthogonal views of temperature maps overlaid on magnitude images in the GRE experiment. Attempting to focus this far outside the normal treatment envelope results in severe near- and far-field heating. Heating on both the cortex and in the far-field along the petrous bone is visible. In Fig. 8 the temperature evolution at the focal spot is compared to that near the petrous bone. The gel near the bone shows a delayed and greater maximum temperature compared to the focus.

Three orthogonal views of the larger FOV in the segmented EPI experiment are shown in Fig. 9. Heating along large parts of the cortex can be seen. In the underlying magnitude images it can be seen that the EPI sequence experiences more artifacts than the GRE sequence.

The focal spot position (evaluated as the temperature center-of-mass) was tracked as a function of time during the heating in the GRE data ZFI to 0.5 mm (data not shown). The focal spot did not experience any shift to within the finer ZFI spacing.

Conclusions

This study shows that volumetric thermometry over a FOV covering the focal spot and the skull base can be achieved with readily available pulse sequences. With custom implemented pulse sequences the fully insonified FOV (from skull cap to skull base) can be covered. Even though the reconstruction is done retrospectively, the described methods are valuable as research tools in e.g. treatment envelope evaluations. By utilizing 3D imaging ZFI can be performed in all directions to minimize partial volume effects, and very accurate dynamic focal spot localization can be performed.

Future studies will compare the accuracy and precision of the described methods to standard 2D MR thermometry. Experiments comparing 3D MRTI with fiber optic probe measurements at potential target positions outside the currently available treatment envelope will also be performed (Monteith JNS 2016).
Table 1 (abstract A13).

MR scan parameters. TR – Repetition time, TE – Echo time, FA – Flip angle, BW – Bandwidth (readout), FOV – Field of view, Res – Resolution, Tacq – Acquisition time (before subsampling)

 

TR (ms)

TE (ms)

FA (deg)

BW (kHz)

FOV (mm)

Matrix

Res. (mm)

Tacq (s)

GRE

9.2

4

12

15.63

240x240x48

192x96x16

1.25x2.50x3.00

14.3

EPI

52

14.4

30

250

220x220x145

192x192x50

1.15x1.15x2.90

62

Fig. 7 (abstract A13).
Fig. 7 (abstract A13).

Three orthogonal views of GRE temperature maps overlaid on magnitude image

Fig. 8 (abstract A13).
Fig. 8 (abstract A13).

Temporal evolution of heating comparing focal spot to far-field next to petrous bone

Fig. 9 (abstract A13).
Fig. 9 (abstract A13).

Three orthogonal views of EPI temperature maps overlaid on magnitude image

A14 Multi-echo MR thermometry compared to single echo MR thermometry in the treatment of essential tremor

Kim Butts Pauly, Mike Marx, Pejman Ghanouni

Stanford University, Stanford, California, USA

Objectives

The choice of receive bandwidth in MR thermometry acquisitions needs to balance two competing choices. Low bandwidths improve SNR, while high bandwidths reduce spatial shift of the hotspot due to the temperature off-resonance. The low bandwidth MR thermometry sequence in use in essential tremor MRgFUS treatments required repeated swapping of phase and frequency directions since the location of the hotspot could only be trusted in the phase encode direction.

A solution is to use multiple high bandwidth acquisitions, which when averaged, regain much of the SNR of the lower bandwidth image. Such a multiecho sequence has recently become available for clinical use. The purpose of this work was to compare the performance of the multi-echo (ME) MR thermometry to the single echo (SE) MR thermometry in clinical treatments of essential tremor.

Methods

Fifteen patients were treated for essential tremor, 12 with only single echo thermometry (TE and BW/pix = 12.8 and 44), 2 with only multi-echo thermometry (TE and BW/pix = 3, 8, 13, 18, 22 and 278), and 1 with both sequences. All other image parameters remained the same, including TR = 100. All thermometry images were processed offline in Matlab with a single baseline subtraction (α = -0.00909), followed by referenceless processing for constant and linear terms. The multi-echo thermometry was further processed with a phase unwrapping algorithm in the TE dimension. The multiple echoes were then combined with a weighting by the square of the temperature SNR of each image.

Results

The decrease in sampling time for the ME thermometry dictates a theoretical decrease in temperature SNR of only 11 % due to the decrease in sampling time alone. In the one patient that had both sequences in the same scan planes for two sonications, there was a 9 % decrease in SNR in the ME thermometry as measured in the frame used for the referenceless processing, comparing well with theory.

A review of all sonications with ME thermometry when phase encoding was S/I revealed much reduced artifacts over SE thermometry with phase encoding in the S/I direction. Example images are provided in Fig. 10. The region of interest measurement indicated a 30 % improvement in temperature SNR for the ME over the single echo, due to this artifact reduction.

The spatial shifts should theoretically be reduced by a factor of 6.3 in the ME thermometry, as compared to the SE thermometry, due to the increase in receive BW. For example, a 23 °C temperature rise would result in a 0.6 mm shift with the single echo, and only a 0.1 mm shift with the multi-echo.

Conclusions

When phase encoding is S/I, multi-echo thermometry is superior to single echo thermometry due to a reduction in ghosting artifacts and spatial shifts. Alignment of the focal spot should not require swapping phase and frequency directions. Future work will include a prospective study to verify this. In the other directions, ME thermometry is comparable to SE thermometry with the reduction of spatial shifts coming with a loss of temperature SNR of about 10 %.
Fig. 10 (abstract A14).
Fig. 10 (abstract A14).

Comparison of MR thermometry images when phase encoding is S/I. The single echo thermometry (a,b) demonstrates numerous ghosting artifacts (yellow arrows) that are not seen in ME thermometry (c,d). (a,b,d) are from the same patient

A15 High-resolution whole-brain MR thermometry with a 3D EPI stack-of-stars pulse sequence

Sumeeth Jonathan, William Grissom

Vanderbilt University, Nashville, Tennessee, USA

Objectives

Real-time whole-brain MR thermometry is needed for transcranial MR-guided Focused Ultrasound to accurately track rapid heating at the focus and to monitor for unsafe heating in the near- and far-field. Previous efforts to meet this need have been based on 3D segmented echo planar imaging (EPI) and spiral MR readouts (Fielden et al., 2014). Here, we propose a 3D EPI stack-of-stars temperature mapping pulse sequence that enables greater volume coverage than has been reported with previous approaches. The sequence allows flexible adjustment of the scan acceleration factor and does not require a high density of receive coils for high frame rate thermometry.

Methods

Readout Trajectory: Fig. 11 shows the proposed readout trajectory. Each TR comprises a 2D EPI plane that is frequency-encoded in the axial (x-y) and phase-encoded in the slice (z) dimensions. The plane is rotated between TRs by 111.25 degrees to sample a golden angle stack-of-stars k-space. The sequence was implemented on a Philips Achieva 3 Tesla scanner with parameters: field-of-view = 28.0 x 28.0 x 11.9 cm, 43 slices, in-plane resolution = 1.50 x 1.50 x 2.75 mm, 17 ms TE/45 ms TR, 14.5° flip angle, spectrally-selective fat suppression.

In vivo Experiment: To confirm the achievable brain volume coverage and image quality, with local IRB approval, brain images in a healthy volunteer were acquired without heating using the pulse sequence with one, two, and three interleaved shots and with an 8-channel receive coil array. Fully-sampled images were reconstructed using the density-compensated conjugate gradient method.

Phantom Heating Experiment: A tissue-mimicking gel phantom was sonicated using a clinical MR-HIFU system (Philips Sonalleve) operated at 1.2 MHz and 80 W for 12 s, while scanning with the proposed sequence with one shot and with 5 abdominal receive coils. Temperature maps were reconstructed in one second increments using the k-space hybrid method at three scan acceleration factors.

Results

In vivo Results: Distortions and signal dropouts caused by off resonance are visible in the sagittal and lower axial single-shot brain images in Fig. 12 (white arrows). The distortions can be reduced by increasing the number of EPI shots per angle, which increases the pixel bandwidth in z. An axial slice positioned for monitoring Focused Ultrasound thalamotomy (red arrow) is also shown, which contains no visible distortions at any multishot factor.

Phantom Heating Results: Fig. 13a shows reconstructed sagittal and axial temperature maps through the middle of the phantom at peak heat. Significant temperature aliasing does not appear until the scan is accelerated by a factor of 14.1 or a 1 second window width. The hotspot temperature curve plots in Fig. 13b show that the reconstructed temperatures all coincide, though the 14.1x curve appears noisier. Importantly, at all acceleration factors, there is agreement with a hotspot measurement obtained by a 2D multislice Cartesian EPI temperature mapping pulse sequence (7 slices, same in-plane resolution) which was used as a reference standard.

A video of the entire sonication monitored using this pulse sequence can be viewed at https://www.youtube.com/watch?v=z3cVXjkgyLg.

Conclusions

A 3D EPI stack-of-stars temperature mapping pulse sequence was proposed and validated against a 2D multislice Cartesian EPI temperature mapping pulse sequence. The sequence enables fine spatiotemporal resolution with large volume coverage, without requiring temporally-regularized reconstruction or a large number of receive coils.
Fig. 11 (abstract A15).
Fig. 11 (abstract A15).

Illustration of the 3D k-space trajectory. A 2D EPI plane is scanned each TR and rotated by 111.25 degrees between TRs to sample a 3D volume. Scan acceleration is achieved by using a small number of consecutive rotated planes/TRs for reconstruction

Fig. 12 (abstract A15).
Fig. 12 (abstract A15).

Brain images acquired with the proposed sequence. The sagittal and lower axial slice images contain distortions and dropout in regions with large frequency offsets (white arrows), which are diminished when multiple shots are used to shorten each readout

Fig. 13 (abstract A15).
Fig. 13 (abstract A15).

Phantom temperature map reconstructions (a) and hot spot temperature curves (b) at three acceleration factors. Significant aliasing does not appear until the scan is accelerated by 14.1x. There is good reference standard agreement at all accelerations

A16 Ultrafast and sensitive volumetric passive acoustic mapping

Costas Arvanitis1, Nathan McDannold2,3, Gregory Clement4

1Georgia Institute of Technology, Atlanta, Georgia, USA; 2Brigham and Women’s Hospital, Boston, Massachusetts, USA; 3Harvard Medical School, Boston, Massachusetts, USA; 4Cleveland Clinic, Cleveland, Ohio, USA

Objectives

Not released for publication

Methods

Not released for publication

Results

Not released for publication

Conclusions

Not released for publication

A17 Tissue stiffness imaging with interleaved multiple-point MR-ARFI

Dennis Parker, Joshua de Bever, Henrik Odéen, Allison Payne, Douglas Christensen

University of Utah, Salt Lake City, Utah, USA

Objectives

Although Focused Ultrasound (FUS) has the potential to treat a number of pathologies the methods used to guide treatment are still limited in the ability to identify effective treatment endpoints. Changes in MRI parameters such as proton density and T1 and T2 relaxation times may result from reversible edema instead of tissue death. While dynamic contrast enhanced and late Gd-enhanced MRI are more specific, Gd contrast cannot be administered multiple times during a procedure to monitor treatment progression. MRI acoustic radiation force impulse imaging (MR-ARFI) can monitor tissue stiffness, but the acquisition is relatively slow, and must be repeated to measure tissue displacement at more than a single point [1]. The purpose of this work was to develop an efficient method to use MR-ARFI to measure tissue displacement volumetrically with an array of points as a first step towards monitoring tissue stiffness changes during MRgFUS procedures.

Methods

A 3D segmented gradient echo (GRE) echo-planar pulse sequence, designed to simultaneously measure tissue displacement with MR-ARFI and the corresponding tissue heating [2–5], was further modified to allow interleaved acquisition of multiple point MR-ARFI (mpMR-ARFI) volumes. Phase change due to displacement was separated from that due to temperature by complex subtraction of an interleaved volume acquired with no FUS applied. Temperature was obtained using the proton resonance frequency method with a referenceless background phase subtraction [6].

Experiments were performed in a gelatin phantom and excised pig brain on 3 T MRI scanners (Siemens Tim Trio and PrismaFit). Pulse sequence parameters were: TR/TE = 73/43 ms, FA = 30°, readout bandwidth = 752 Hz/pixel, echotrain length = 7, FOV = 160x114x55mm, matrix = 128x91x22 giving voxel dimensions of 1.25x1.25x2.5 mm before zero filled-interpolation. Bipolar motion-encoding gradients (MEG) of 15 ms duration (each bipolar lobe) were applied prior to signal readout. Ultrasound pulses of 50 acoustic watts were applied during the second 15 ms bipolar MEG lobe. Navigator echoes were used to measure and compensate for B0 field drift due to gradient heating caused by high MEG strength and duty cycle. The same navigators echoes can be used for respiratory correction in vivo [7].

Results

Results from a13-point mpMR-ARFI acquisition in a gelatin phantom using the Siemens Tim Trio and MEG = 20mT/m are given in Fig. 14. An example cropped single slice from 10 of the 13 acquired displacement volumes is shown in Fig. 14a with a cropped slice of the mpMR-ARFI composite of all 13 displacement volumes shown in Fig. 14b. The corresponding temperature increase measured during the mpMR-ARFI acquisition is shown in Fig. 14c and was relatively low (<3 °C). (For all mpMR-ARFI images, point separation is 5 mm).

Figure 15 shows the improved image quality achieved by the phase-navigator correction in mpMR-ARFI measurements obtained using a PrismaFit 3 T MRI scanner with MEG = 40 mT/m. The ghosting artifact in Fig. 15a due to B0 field drift caused by high amplitude (40mT/m) and duty cycle (40 %) MEG gradients during mpMR-ARFI acquisition. After correction (Fig. 15b) mpMR-ARFI displacement images have negligible artifact.

Results of the displacement measured in excised pig brain using the Siemens PrismaFit 3 T MRI scanner and MEG = 40 are shown in Fig. 16 before (Fig. 16a) and after (Fig. 16c) FUS ablation. An estimate of the cumulative thermal dose is shown in Fig. 16b. Note the decreased displacement at central point.

Conclusions

Measuring tissue stiffness (displacement as a function of ultrasound intensity) and changes in displacement before, during, and after the procedure provides the unique potential to remotely palpate the ablated volume to monitor the formation of lesions created with MRgFUS. It will also provide a crucially needed assessment of tissue change in regions of fat where conventional MR thermometry fails.

References

1. Gerstenmayer M, Magnin R, Fellah B, Le Bihan D, Larrat B. MAGNETIC RESONANCE ACOUSTIC RADIATION FORCE IMAGING FOR IN VIVO ESTIMATION OF ULTRASONIC TRANSMISSION FACTOR THROUGH RAT SKULLS. ISTU; 2016; Tel Aviv, Isreal. P 95.

2. de Bever J, Farrer A, Odeen H, Parker DL. A 3D multi-contrast pulse sequence for acquisition of MR acoustic radiation force imaging concurrently with proton resonance shift thermometry. ISTU; 2014; Las Vegas, Nevada.

3. de Bever J, Farrer A, Odeen H, Parker DL. Simultaneous Acquisition of MR Acoustic Radiation Force Imaging and Proton Resonance Shift Thermometry with 3D Multi-Contrast Pulse Sequence. ISMRM; 2014; Milan, Italy.

4. de Bever J, Odeen H, Parker DL. Measurement of dynamic tissue response to focused ultrasound using 3D MR-ARFI. ISTU; 2014 April 17, 2015; Utrecht, The Netherlands. p Abstract: 2174218

5. de Bever J, Odeen H, Parker DL. Simultaneous Acquisition of Acoustic Radiation Force Imaging and Proton Resonance Frequency Shift Thermometry Using Interleaved Acquisition with Temporally Constrained Reconstruction for Increased Temporal Resolution. ISMRM; 2016; Singapore.

6. Rieke V, Vigen KK, Sommer G, Daniel BL, Pauly JM, Butts K. Referenceless PRF shift thermometry. Magn Reson Med 2004;51(6):1223-1231.

7. Svedin BT, Payne A, Parker DL. Respiration artifact correction in three-dimensional proton resonance frequency MR thermometry using phase navigators. Magn Reson Med 2015; Early View; PMCID: PMC4752934
Fig. 14 (abstract A17).
Fig. 14 (abstract A17).

a Individual images, b Composite displacement, c simultaneous heating

Fig. 15 (abstract A17).
Fig. 15 (abstract A17).

Ghosting (a) is corrected by navigator echoes (b) allowing clean mpMR-ARFI displacement measurement (c,d)

Fig. 16 (abstract A17).
Fig. 16 (abstract A17).

mpMR-ARFI displacement measurements in an excised pig brain before (a) and after (c) MRgFUS ablation with estimated cumulative dose in CEM (b)

A18 Binary localization of cavitation activity based on harmonic content for transcranial brain therapy

Guillaume Maimbourg1, Mathieu David Santin2, Alexandre Houdouin1, Stéphane Lehericy2, Mickael Tanter1, Jean Francois Aubry1

1Institut Langevin Ondes et Images, ESPCI ParisTech, CNRS UMR 7587, INSERM U979, Paris, France; 2CENIR, ICM, CNRS U7225, INSERM U975, Paris, France

Objectives

Cavitation activity may occur during BBB disruption (due to UCA injections) and also during HIFU treatment due to nucleation under high negative pressure. The corresponding microbubble activity has to be monitored to assess the safety and efficiency of brain treatments by ultrasound. The purpose of this study is to binary discriminate the position of microbubbles, inside or outside the skull, in order to know whether cavitation occurs in the brain of the patient or not.

Binary localization is achieved here by taking advantage of the attenuation properties of the skull. The skull acts indeed as a low pass filter for acoustic signals. Thus we hypothesize that the harmonic content of signals from cavitation events could be used as a binary indicator of their localization: inside or outside the brain case.

Methods

A wideband Passive Cavitation Detector (PCD) recorded the acoustic signals from microbubbles activity.

An in vitro setup (Fig. 17) mimics a BBB opening configuration (contrast agent flow with 0.6 MPa sonication during 10 ms at focus) or a thermal ablation (calf brain sample at focus with 3-4 MPa sonication during 0.3 s at focus). Experiments were performed either with no skull in place, or with human (6 samples) or monkey (1 sample) skull in front of the PCD.

In vivo BBB opening were conducted on macaque (900 kHz, 0.6 MPa at focus) with the same PCD mounted on the monkey head.

The spectra are computed from data recorded by the PCD and reveal harmonics, subharmonic and ultraharmonics of the excitation frequency (900 kHz in all cases).

The ratio of a high frequency harmonics over a lower frequency harmonic was then calculated. This ratio is expected to decrease when the acoustic signal from cavitation activity crosses through the skull. In order to achieve binary localization, two types of ratio have been computed: ultraharmonic ratios (e.g. 5/2 over 1/2) and harmonic ratios (e.g. 4 over 2).

Results

The ultraharmonics ratio obtained during in vitro thermal-like ablation is plotted in Fig. 18. This ratio significantly decreases when acoustic signal crosses through the skull. Thus a threshold can be introduced to binary localize cavitation inside/outside the skull.

Table 2 summarises the results for harmonic ratio 4 over 2 and ultraharmonic ratio 5/2 over 1/2 obtained in vitro and in vivo during BBB opening and thermal necrosis. For BBB opening, neither the sub- nor the ultraharmonics appears in vivo, probably due to the confinment of the largest microbubbles by the vasculature. Thankfully in vitro experiments point out that the harmonic ratio remains relevant to binary localize microbubbles in the human case. Indeed the harmonic ratio 4 over 2 exhibits a -30 ± 3 dB decrease when crossing through human skull.

In order to ensure the repeatability of this method, each configuration was statistically investigated by plotting receiver operating characteristics (ROC) curves. These plots (Fig. 19) illustrate the performance of this approach. Except for in vivo BBB opening on monkey, ROC curves demonstrate that a sensitivity and a specificity which are simultaneously nearly 100 % can be obtained for the binary localization of cavitation activity.

Conclusions

This preliminary study, mainly done in vitro, shows that a low-cost and easy-to-use PCD can binary localize cavitation activity inside/outside the skull using the filtrating effect of the skull on the harmonic content of the spectra. The statistical study shows that the method is able to localize microbubble activity inside or outside the skull with high sensibility and high sensitivity. We look forward to testing extensively this technique in vivo for both BBB opening and thermal necrosis.
Fig. 17 (abstract A18).
Fig. 17 (abstract A18).

In vitro experimental setup for mimicking BBB opening

Fig. 18 (abstract A18).
Fig. 18 (abstract A18).

Ultraharmonics ratio (3/2 to 15/2 over 1/2) recorded during in vitro thermal ablation

Table 2 (abstract A18).

ultraharmonic (5/2 over 1/2) and harmonic (4 over 2) ratio during thermal necrosis and BBB opening in dB scale

   

Harmonic 4 Harmonic 2

Ultraharmonic 5/2 Subharmonic 1/2

BBB opening (UCA + US)

in vitro

Reference: no skull

-5

1

Monkey skull

-8

-21

Human skull

-35

-26

in vivo

Macaque

-13

no signal

Thermal necrosis (US only in calf brain)

in vitro

Reference: no skull

-10

-14

Monkey skull

-29

-38

Human skull

-28

-30

Fig. 19 (abstract A18).
Fig. 19 (abstract A18).

Receiver operating characteristics for ultraharmonic (5/2 over 1/2) ratio and harmonic ratio (4 over 2) during thermal ablation and BBB opening

A19 Inflection of temperature vs. power curve in tcMRgFUS: correlation with lesion location

Kim Butts Pauly1; Christian Federau1; Beat Werner2; Casey Halpern1; Pejman Ghanouni1

1Stanford University, Stanford, California, USA; 2University Children’s Hospital Zurich, Zurich, Switzerland

Objectives

During tcMRgFUS, power levels are progressively increased to align, verify treatment location, and create a durable ablation. It is predicted that the measured temperature at the focus for a consistent timepoint will increase monotonically with power. However, the temperature rise is often observed to actually decrease with increasing power, creating an inflection in the peak temperature vs. power graph (Fig. 20). The purpose of this work was to show this behavior in the temperature rise is correlated with a lack of alignment between the thermal lesion and the monitored scan plane.

Methods

Fifteen ET datasets were included in this study. Post-treatment 3D T2-weighted FSE images (FOV 24 cm, matrix 320x320, slice thickness 1 mm) were thresholded at the signal intensity of zone 1 (Fig. 20). Measurements from the targeted ACPC plane to the top and bottom edges of zone 2 were made in the sagittal plane.

MR thermometry (TE/TR = 12.8/100 (n = 13); TE/TR = 3,8,13,18,22/100, (n = 2)) was processed with a single baseline subtraction (α = -0.00909), followed by referenceless processing for constant and linear terms. The maximum temperature of the third time point (k-space center 8.8 s after sonication initiation) in the axial scan plane was plotted vs. power. This time point was chosen because all sonications were at least 10s in duration. The number of sonications after any inflection was noted.

In 12 cases, temperature-power curves from early sonications in the axial scan plane were extrapolated to higher power levels. The amount that the measured temperature was below the estimated temperature was measured.

Results

The results are shown in Fig. 21. While the distance from the treatment plane to the inferior aspect of the lesion remains essentially constant, the distance from the treatment plane to the superior aspect of the lesion increases with number of sonications after inflection. While it is expected that multiple sonications at the same location may increase lesion size, this data demonstrates that lesion size increases preferentially in the direction of the transducer as we increase sonications after inflection.

The movement of the lesion superiorly from the AC-PC plane is correlated with the difference between the actual and estimated temperature (✰). Although this was quantitated only in the axial scan plane, the inflection was seen in all three scan planes. Prior work demonstrated that the lesion is double oblique (the superior aspect of the lesion is posterior and medial); therefore, movement of the focal spot towards the effective transducer aperture moves it also out of the monitored sagittal and coronal scan planes.

Conclusions

One interpretation of this data is that an increase in the acoustic absorption effectively shields the focal spot, with subsequent hotspots located closer to the transducer. A second explanation is that the acoustic properties of the skull may be changing during treatment.

An additional implication of this work is for comparison of simulation with thermometry. To simplify this comparison without the complication of the alignment of the thermometry plane, a sonication early in the treatment should be used for comparison.
Fig. 20 (abstract A19).
Fig. 20 (abstract A19).

a Temperature in the third temperature image (*) b does not always rise monotonically with power. c The distance from ACPC plane to the top and bottom edges of zone 2 were measured on images thresholded at the zone 1 signal intensity

Fig. 21 (abstract A19).
Fig. 21 (abstract A19).

a The lesion top edge is moving superior to the ACPC plane with increasing sonication number. b As the lesion is moving out of the measured scan plane, the temperature is increasingly underestimated, giving rise to a temperature inflection

A20 MR-guided Focused Ultrasound pig brain tissue and its histology as a function of thermal dose

Dong-Guk Paeng1,3, Zhiyuan Xu2, John Snell3, Anders Quigg3, Matt Eames3, Changzhu Jin3, Ashli Everstine2, Jason Sheehan2, M. Beatriz Lopes2, Neal Kassell3

1Jeju National University, Jeju, Republic of Korea; 2University of Virginia, Charlottesville, Virginia, USA; 3Focused Ultrasound Foundation, Charlottesville, Virginia, USA

Objectives

This study is to investigate the effects of Magnetic Resonance-guided Focused Ultrasound (MRgFUS) on in vivo pig brain tissue by comparison of the tissue damage in histology with the changes in MR images as a function of thermal dose (TD) up to 200 cumulative equivalent minutes (CEM) at 43 °C.

Methods

We have implemented a PI (proportional-Integral) control system in a laptop with an Arduino-based controller to modulate pulse duration of a FUS system (ExAblate 4000 Neuro 650 kHz system, InSightec) based on the temperature difference between target temperature and focal temperature as measured by an MRI system (Discovery MR75-3.0 T, GE Medical systems) with proton resonant frequency (PRF) thermometry. Accumulated thermal dose in CEM was calculated every 3.7 seconds and used to stop the sonication when a prescribed thermal dose of interest was reached and delivered to the target brain tissue. After tuning of a closed loop control system in a phantom, one acute and seven chronic pig experiments with three-day survival were conducted to investigate the correlation of lesions between the MR images of pig brain tissue with the corresponding histology. Craniectomy was performed to create an acoustic window, and sonication was applied on 4 spots in the thalamus of each pig. Absolute temperature in pig brain tissue was computed based on the MR thermometry using the rectal temperature as a baseline. TD varied from 7 to 195 CEM with target temperature between 46 and 52 °C at appropriate acoustic powers. This pig study was approved by the University of

Results

From the acute pig experiment, we observed one large and 2 small lesions on MR images 1 hour after a sonication and subsequent histology showed 4 lesions of target. For the chronic pig experiments, 22 sonication spots in 6 pigs were analyzed through MR images and histology. One pig was excluded due to air bubbles introduced between the dura and scalp during the surgery procedure, and 2 sonication spots were failed to generate due to technical problems. Results show that large brain tissue damage was observed in MR images in all 7 spots with doses larger than 100 CEM and the corresponding histology results confirmed infarction with necrotic center for all except one with a dose of 101 CEM. The diameter of those lesions on T2-weighted axial MR images was measured to 2.9 ± 0. 4 mm (mean ± SD,) with a mean volume of 30.7 ± 12.9 mm3. All with TD lower than 17 CEM produced no visible lesions in either MR images or histology. There was a discrepancy in generating lesions with TD between 18 and 100 CEM, so that six smaller lesions (3 in volume) were shown except one large change in MR images at

Conclusions

In conclusion, large tissue damages were observed on MR images and histology for all TD above104 CEM, but no change was shown for all TD below 17 CEM. There is a variability in tissue changes between these TD levels. These results may contribute toward prescription of thermal dose rather than peak temperature or acoustic power for brain treatments, and expand the treatment envelope beyond the current limitations in selecting targets and patients.

A21 Visualization tools for transcranial Focused Ultrasound procedure planning, simulation and analysis

John Snell, Anders Quigg

Focused Ultrasound Foundation, Charlottesville, Virginia, USA

Objectives

The interactions between particular transcranial transducer and skull geometries are challenging to understand without interactive visual computing tools. Such a tool has been created to allow the visual exploration of the estimated treatment envelope of a transcranial transducer given a patient specific imaging dataset. The impetus for developing such a system is to aid in understanding treatment envelope constraints and to serve as a tool for specifying the input to various acoustic simulation systems.

Methods

A visualization application was created which makes heavy use of a modern GPU to interactively display a transcranial Focused Ultrasound transducer, patient specific brain and skull anatomy, and the interaction of each transducer element beam path with the skull. The incident angle of each transducer element beam axis with the outer table of the skull is calculated and displayed in an interactive fashion as the natural focus of the transducer is moved within the intracranial volume. Skull geometry is derived from a treatment compatible CT dataset. An MR dataset is registered with the CT for targeting. Due to the interactive nature of the tool, presumptive targets can be rapidly and intuitively explored and understood in terms of geometric constraints and estimated treatment efficiency.

Results

The visualization system functions will be demonstrated including targeting, transducer positioning and assessment of transducer efficiency in terms of effective transducer element count.

Conclusions

An interactive visualization system has proven valuable for facilitating understanding of the complex interaction of transducer and skull geometries. Future applications of this system may include patient screening, post-treatment analysis, indication feasibility screening and acoustic simulation initialization.

A22 HIFU for Pediatric Operations (HOPE) – a pediatric neurosurgical treatment system

James Drake1, Karl Price2, Lior Lustgarten1, Vivian Sin2, Charles Mougenot3, Elizabeth Donner1, Emily Tam1, Mojgan Hodaie4, Adam Waspe1, Thomas Looi2, Samuel Pichardo5

1Hospital for Sick Children, Toronto, Ontario, Canada; 2Centre for Image Guided Innovation and Therapeutic Intervention, Toronto, Ontario, Canada; 3Philips Healthcare Canada, Toronto, Ontario, Canada; 4Toronto Western Hospital, Toronto, Ontario, Canada; 5Thunder Bay Regional Research Institute, Thunder Bay, Ontario, Canada

Objectives

Pediatric patients have distinctive neuroanatomic features and specific disorders that make them unique candidates for transcranial MR-guided Focused Ultrasound treatment. Children have thinner skulls, and neonates in particular, possess a natural acoustic window through their fontanelle. This results in lower phase aberration and decreases the need for the larger hemispherical dome transducers used for current adult transcranial procedures. These systems also require fixation of the head in a stereotactic frame, which is dangerous for their fragile skull. In addition, neonates often require MR-compatible incubators and dedicated neuro-interventional coils for imaging. Focal brain ablation/disconnection for medical refractory epilepsy and lysis of intra-ventricular hemorrhage are some of the proposed noninvasive treatment options for this population. To provide such treatment, we have developed HOPE – HIFU for Pediatric Operations – an integrated neonatal HIFU treatment system.

Methods

HOPE is composed of multiple elements: a 5 degree of freedom MR-compatible robot positioning device, a 256 element phased-array transducer, an 8 channel neuro-interventional coil, and a real-time Python-based treatment planning and delivery software system. The specifications for HOPE were determined by a team of clinicians and researchers as follows: compatible with clinical neonatal incubators and MRI techniques, imaging coil integrated into the incubator, positioning system to couple and deliver the HIFU treatment and real-time control/monitoring of the treatment (Fig. 22). The hardware elements are designed and tested with a Philips Achieva 3.0TX MRI with an Imasonic 256 element transducer. For coupling, a custom designed water bag system was created to interface with the patients’ head. The software platform includes robot kinematics, robot visualization, registration, transducer control and MRI communication. A calibration procedure was developed using a series of Vitamin E markers visible in a 3D gradient echo sequence without fat suppression; the markers were attached to an extension of the robot that recreates the acoustic cone of the HIFU beam. A user-interface module was developed to calculate the center of mass of each marker and to co-register the coordinate systems of the MRI and the robot.

Results

The hardware system of HOPE has been designed and tested to show it can perform T1, T2 and DTI imaging that is comparable to clinical coils while delivering HIFU treatment in a phantom model. The neuro-interventional coils provide high resolution images for treatment planning (Fig. 23). The MR-conditional robotic system positions the transducer to an accuracy of 0.59 +/- 0.25 mm and delivers thermal ablation treatment to targets in a Philips HIFU quality assurance phantom. The custom water coupler bag provided a transmission path for the HIFU with minimal energy loss. The HOPE software platform controls each of the robotic positioning axes with hardware safety switches in a real-time Python interface (Fig. 24). The software registration of the patient, MRI and robot frame allows the user to select specific brain targets. During treatment, real-time thermometry is displayed.

Conclusions

HOPE is an MR-guided Focused Ultrasound system aimed at delivering HIFU therapy (both thermal ablation and cavitation-based treatment) for neonatal and pediatric patients. The system has been designed to operate within an incubator and clinical MRI system which minimizes the impact to the patient. Future work involves characterizing the treatment accuracy and performing in vivo animal studies to test the overall system feasibility and usability for treatment of epilepsy and IVH clots. Other treatments that will be investigated are thermal ablation of brain tumors, hyperthermia and targeted drug delivery.
Fig. 22 (abstract A22).
Fig. 22 (abstract A22).

HOPE Concept (1 – incubator, 2 – coil, 3 – neonatal patient, 4 – transducer, 5 – robot and 6 – MR bore)

Fig. 23 (abstract A22).
Fig. 23 (abstract A22).

Coil comparison in a T1-TFE image of a porcine brain in vivo (Left: Prototype 8 channel neuro-interventional coil, Right: Philips clinical 32 channel head coil)

Fig. 24 (abstract A22).
Fig. 24 (abstract A22).

HOPE software interface with robot, treatment planning and real-time monitoring of HIFU exposure in phantom material

A23 Simultaneous stimulation of the human primary and secondary somatosensory cortices using transcranial Focused Ultrasound

Wonhye Lee1, Yong An Chung2, Yujin Jung2, In-Uk Song2, Seung-Schik Yoo1

1Brigham and Women’s Hospital, Boston, Massachusetts, USA; 2Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, Republic of Korea

Objectives

Low-intensity transcranial Focused Ultrasound (FUS) is making progress as a new mode of non-invasive brain stimulation, having potential for superior spatial selectivity and depth penetration compared to transcranial direct current stimulation (tDCS) or transcranial magnetic stimulation (TMS). With accumulating evidences of the FUS-mediated neuromodulatory effects in small and large animal models, the sonication given to the primary somatosensory cortex (SI) has recently shown to be capable of eliciting tactile sensations in humans. Here, we further investigated the creation of tactile sensations induced by simultaneous FUS stimulation of the secondary somatosensory cortex (SII) and SI of the hand.

Methods

Ten healthy volunteers (two females, ages = 23–34, average of 27.8 ± 4.1 yrs) participated, and all procedures were conducted under the approval of the local Institutional Review Board of the Catholic University of Korea. For targeting of FUS focus to the individual functional neuroanatomy, each participant’s brain image was acquired using a 3-T MR scanner with anatomical (T1-weighted) and functional MRI (fMRI, T2*-weighted) protocols. The SI and SII areas were mapped while using four types of external tactile stimuli to the palm of the right hand—vibrotactile, pressure, warmth, and coolness. CT scan of the head was also acquired for the planning of transcranial sonication path. As guided by these individual-specific neuroimage data, FUS sonication (210 kHz, single-element FUS transducer with focal length of 38 mm) was administered to the SI and SII simultaneously (or separately), with an incident acoustic intensity of 35 W/cm2 Isppa, tone-burst-duration of 1 ms, pulse-repetition frequency of 500 Hz (yielding a 50 % duty cycle), and a sonication duration of 500 ms. The SII was targeted as divided into four sub-regions that are specifically activated by the external tactile stimuli.

Results

Across the differential selective stimulations (i.e., SI only, SII only, or SI and SII simultaneously), participants felt various types of elicited tactile sensations (while ‘tingling’ was dominant) from the hand areas contralateral to the sonication, such as the palmar/dorsal side of the hand or as single/multiple adjacent fingers. These results were similar to our previous study on FUS stimulation of the SI, while the elicitations of ‘vibrotactile’ and ‘warmth’ sensations were newly reported in the present study. The types of tactile sensations did not match to the sensations that are associated with the specific sub-regions in the SII. However, two individuals reported matching types of sensations (‘vibrotactile’, ‘pressure’, and ‘warmth’) during stimulation of the SI/SII simultaneously or the SII only. The stimulatory effects of the FUS were transient and reversible, and the sonication procedures did not induce any discomforts or adverse changes in the subjects’ physical/mental status.

Conclusions

Simultaneous stimulation of the SI/SII in the same hemisphere was achieved by using multiple FUS transducers, which elicited various types of tactile sensations. Stimulation of the SII only also induced the creation of tactile sensations. The ability to stimulate multiple region-specific brain areas may shed light on examining the causal relationships between regional brain activities and subsequent behavioral/cognitive outcomes.

A24 Transcranial Focused Ultrasound stimulation of the primary visual cortex in humans

Wonhye Lee1, Hyun-Chul Kim2, Yujin Jung3, Yong An Chung3, In-Uk Song3, Jong-Hwan Lee2, Seung-Schik Yoo1

1Brigham and Women’s Hospital, Boston, Massachusetts, USA; 2Department of Brain and Cognitive Engineering, Korea University, Seoul, Republic of Korea; 3Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, Republic of Korea

Objectives

Transcranial Focused Ultrasound (FUS) has been suggested as a new non-invasive modality of regional brain stimulation, with potential to be more spatially-selective and to reach deep cortical/subcortical areas compared to the conventional methods of transcranial magnetic stimulations (TMS) or transcranial direct current stimulation (tDCS). In humans, low-intensity FUS sonication has been demonstrated to temporarily change the neural activities in the primary somatosensory cortex (SI), based on the observations of subjective sensory manifestations and electrophysiological responses. However, functional neuroimaging evidence of increased neural activity in the stimulated region, as well as the associated network-wide brain responses, has not yet been shown in humans. Here, we administered stimulatory FUS to the primary visual cortex (V1) as guided by the individual-specific neuroanatomy. Concurrent functional MRI was acquired to assess the brain regions that were activated due to the stimulation.

Methods

19 healthy volunteers (five females, ages 20–45, average 26.1 ± 5.4 yrs) participated, and all procedures were conducted under the approval of the Institutional Review Boards of both the Catholic University of Korea and Korea University. Functional MRI (fMRI; for mapping of the visual areas) and cranial CT were obtained from each participant to provide the individual-specific V1 location for sonication planning/targeting. Then, in a separate session, an MR-compatible sonication setup (270 kHz, single-element FUS transducer with radius-of-curvature of 30 mm) was used to deliver FUS to the V1 under a clinical 3-T MR scanner for the image-guidance and the simultaneous acquisition of fMRI data. Separate from the FUS-fMRI session, electroencephalographic (EEG) potentials elicited by the FUS stimulation were also measured. We used a pulsing scheme having a sonication duration of 300 ms with a tone-burst-duration of 1 ms repeated at a pulse repetition frequency of 500 Hz (yielding a 50 % duty cycle). The incident acoustic intensity at the FUS focus was 16.6 W/cm2 Isppa. Retrospective numerical simulation of the transcranial acoustic wave propagation was performed proximal to the sonicated area to estimate the in situ acoustic intensity and spatial accuracy of sonication.

Results

Simultaneous acquisition of fMRI during FUS sonication to the V1 revealed the elicited activation not only from the sonicated brain area, but also from the network of regions involved in visual and higher-order cognitive processes. Accompanying phosphene perception was also reported. The EEG responses showed distinct peaks associated with the sonication, having similarities with the classical visual evoked potentials (VEP) generated by photic stimulation. The procedures did not induce any discomforts or adverse effects from the participants, based on the subjective reporting and neuroradiological/neurological examinations. Retrospective numerical simulation of the transcranial FUS suggested the variability in individual responsiveness to the stimulation.

Conclusions

Simultaneous fMRI acquisition during FUS application to the V1 revealed the functional neuroimaging-based evidence in humans that the FUS stimulation activates the sonicated brain area and concurrently elicits the associated phosphene perception. Successful stimulation of the V1 was also supported by the presence of the evoked EEG potentials associated with FUS. The individual variability in responsiveness to the stimulation suggested needs for an elaborate image-guidance.

A25 Focused Ultrasound modulation of visual search performance and associated EEG in monkeys

Charles Caskey, Wolf Zinke, Josh Cosman, Jillian Shuman, Jeffrey Schall

Vanderbilt University, Nashville, Tennessee, USA

Objectives

Focused ultrasound (FUS) is a promising tool for neuromodulation because of its noninvasivness and better spatial precision compared to other noninvasive methods, such as transcranial magnetic stimulation (TMS) or transcranial direct current stimulation (tDCS). FUS neuromodulation has been demonstrated in multiple animal models, including a prior study where ultrasound was applied transcranially over macaque frontal eye field (FEF) to influence saccade response time in an anti-saccade task. In this work, we applied FUS through a craniotomy over the macaque FEF while measuring saccade response times and EEG signals associated with selective attention.

Methods

A single element focused transducer was positioned through a craniotomy over FEF, a cortical area that plays a key role in the eye movement and attention systems. FUS stimulation was applied during a complex visual search task where the monkey was required to shift its gaze to a target among distractors. We alternated blocks of trials with or without FUS stimulation (300 ms of pulsed FUS with a 50 % duty cycle starting 150 ms before search display onset, center frequency 500 kHz, repetition frequency 2 kHz, pulse duration 0.25 ms, peak negative pressures of 250 kPa or 425 kPa, warming of brain tissue < 1.5 °C). Saccade response time and intracranial EEG recordings were acquired in two monkeys performing 9 sessions each.

Results

In both monkeys, event-related potentials (ERPs) associated with selective attention (N2pc) were significantly reduced during stimulation with both intensities. FUS stimulation attenuated the N2pc over the entire session block, rather than on a trial-by-trial basis. In one monkey with a craniotomy positioned directly over FEF, the mean saccade response times were reduced by 5 ms by FUS stimulation at 425 kPa (p < 0.001) when the target appeared in the upper hemifield contralateral to the FUS stimulation, while another animal with a craniotomy more ventrally did not show such a systematic behavioral modulation.

Conclusions

We are continuing to explore potential spatial relationships between stimulation location and behavioral modulations in ongoing work. Overall, our findings demonstrate prolonged FUS modulation of attention ERPs and suggest potential spatial selectivity based on the location of stimulation.

A26 Ultrasound-mediated modulation of motor and ocular responses in anesthetized mice in vivo

Christian Aurup1, Shutao Wang1, Hong Chen2, Camilo Acosta1, Elisa Konofagou1, Hermes Kamimura3, Antonio Carneiro3

1Columbia University, New York, New York, USA; 2Washington University in St. Louis, St. Louis, Missouri, USA; 3Universidade de Sao Paolo, Sao Paulo, Brazil

Objectives

Focused ultrasound has been identified as a non-invasive technique for modulating brain activity. Most studies involving sedate rodents utilize frequencies in the kilohertz-range, which allow for optimal transmission of acoustic power through the skull. The tradeoff with using lower frequencies involves producing larger acoustic foci and resultant poor target-specificity. Megahertz-range frequencies can therefore be used to improve target-specificity. This study demonstrates that Focused Ultrasound in the megahertz range can be used to evoke motor and ocular responses in mice under deep anesthesia by targeting cortical and subcortical structures, respectively. Contralateral-paired hind limb movements were observed when stimulating cortical regions, demonstrating the ability of megahertz-range FUS to stimulate activity in highly-targeted regions. Additionally, pupil dilation was observed when deep-seated anxiety-related structures were targeted, demonstrating the ability of FUS to modulate activity in a small subcortical structures.

Methods

For this study, wild-type adult male mice were anesthetized with intraperitoneal injections of sodium pentobarbital (65 mg/kg) and fixed in a stereotaxic frame. A single-element FUS transducer with fundamental frequency of 1.94 MHz was fixed to a 3D positioning system for accurate navigation through the brain. A 6x6 mm grid centered +2 mm anterior of the lambda skull suture was sonicated in a random order using a center frequency of 1.9 MHz, pulse repetition frequency of 1 kHz, 50 % duty cycle, 1 second pulse duration, 1 second inter-pulse interval for a total of 10 pulse repetitions. The acoustic pressure applied was varied in order to evaluate thresholds for eliciting physiological responses like motor movement, eye movement, or pupil dilation. Motor movements were validated using video recordings and intramuscular electromyography recordings from the biceps femoris in both hind limbs. Pupil movement and dilation from subcortical modulation were evaluated using a high-resolution camera aimed at the right eye and frame-by-frame processing technique.

Results

The minimum peak rarefactional pressure required to elicit hind limb movements was 1.45 MPa when targeting cortical regions, calibrated using an excised mouse skull. Higher pressures increased the success rate from 20 % (at the 1.45 MPa threshold) to 70 % (1.79 MPa) (Fig. 25). Targeting eye-motor and anxiety-related regions of the brain elicited eye movements and pupil dilations up to 20 %. Sonicating the superior colliculus resulted in both eye movement and pupil dilation at a lower threshold pressure (1.20 MPa) than the hippocampus and locus coeruleus, which required pressures greater than 1.80 MPa. A histological evaluation performed in five mice at 1.93 MPa and 3 MPa peak rarefactional pressure resulted in no red blood cell extravasation (Fig. 26).

Conclusions

This study successfully demonstrated that megahertz-range Focused Ultrasound can be used to elicit motor and ocular responses with high specificity in mice in vivo. It was also shown that the success rate of stimulation increased with acoustic pressure for motor movements associated with cortical modulation but depends greatly on the region of the brain targeted. These findings emphasize the complex and yet to be determined mechanism of action involved in ultrasonic neuromodulation.
Fig. 25 (abstract A26).
Fig. 25 (abstract A26).

Evaluation of the pressure threshold when applying FUS to location within the somatosensory cortex. This location resulted in contralateral hind-limb movement relative to the sonication site

Fig. 26 (abstract A26).
Fig. 26 (abstract A26).

Histological evaluation of brain at 1.93 MPa (left) and 3 MPa (right) revealed now red blood cell extravasation

A27 Non-invasive neuromodulation via targeted delivery of neurotransmitter chemicals

Nick Todd1, Tao Sun1,2, Yong-Zhi Zhang2, Chanikarn Power1,2, Navid Nazai3, Sam Patz1, Margaret Livingstone2, Nathan McDannold1,2

1Brigham and Women’s Hospital, Boston, Massachusetts, USA; 2Harvard Medical School, Boston, Massachusetts, USA; 3Boston University, Boston, Massachusetts, USA

Objectives

Focused ultrasound (FUS)-microbubble treatment has been used to open the Blood-Brain Barrier (BBB) for targeted delivery of a wide variety of therapeutics. Here we propose to deliver neurotransmitter chemicals such as GABA or glutamate for the purpose of non-invasive neuromodulation. These chemicals function to transmit or suppress signals across the chemical synapses that connect neurons in the brain. This novel approach affects signaling between neurons, as opposed to existing neuromodulation techniques that affect the transmission of electrical signals along neurons. Such an approach could be an important new complimentary tool for basic neuroscience or lead to new therapies for neurological disorders.

Previously, we used electrophysiology measurements to demonstrate functional blockade via BBB disruption and GABA administration. Here we present initial results demonstrating the proof of concept in a rodent model using delivered GABA to modulate neuronal activity and functional MRI to measure the effects.

Methods

Sprague-Dawley rats underwent bilateral hindpaw electrical stimulation (1-5 mA, 0.3 ms duration, 2 Hz) to elicit a functional response of the somatosensory network. Varying levels of GABA were systemically injected under conditions No BBB opening and BBB opening. Functional activity in the thalamus and S1 was measured using fMRI to quantify any effects of neuromodulation.

BBB opening: Microbubbles injected (Optison, 200 μl/kg), 274 kHz dual aperture transcranial FUS with 32 ms bursts applied at 4 Hz for 60 seconds.

GABA delivery: Systemic tail vein bolus injection in doses from 10 mg/kg to 50 mg/kg.

fMRI: Images acquired on a Bruker 7 T scanner with a single shot EPI sequence (TR = 1.5 s, TE = 18 ms, 18 slices, 300 images). Stimulation performed in a 40 s OFF, 20 s ON block design over 7.5 total minutes. T-scores obtained using general linear model analysis in SPM 12.

Results

BBB Closed: Fig. 27 shows activation results in S1 for the case of No BBB opening. Compared to the baseline case of No GABA injected, a GABA injection of 10 mg/kg showed significant decrease in activity (p < 0.05) but GABA injections of 25 mg/kg and 50 mg/kg did not.

BBB Open: Fig. 28 shows activation results in the thalamus for the case of BBB opening. BBB opening was targeted, and confirmed through gadolinium imaging, in the right hemisphere. Bilateral activation was seen in the thalamus for the baseline case of No GABA injected. For GABA injection of 25 mg/kg, a significant decrease in activation was seen in the right (opened) ROI (p < 0.001), but not the left (unopened) ROI. For GABA injection of 50 mg/kg, a significant decrease in activation was seen in both ROIs (p < 0.001).

Conclusions

More experiments on a number of rats are necessary to confirm and expand these findings. However, these very preliminary results are a promising indicator that a neurotransmitter such as GABA can be delivered through the opened BBB for targeted manipulation of neuronal activity.
Fig. 27 (abstract A27).
Fig. 27 (abstract A27).

fMRI results without BBB opening. Top: T-score values overlaid on a T1w image. Bottom: Paxinos/Watson rat brain atlas with hindleg S1 area colored red and bar plots for t-score metrics comparing the activity for the various GABA doses. * = p < 0.05

Fig. 28 (abstract A27).
Fig. 28 (abstract A27).

fMRI results with BBB opening in right thalamus. Top: T-score values overlaid on a T1w image. Left: Extent of BBB opening. Bar plots show t-score metrics from right ROI (yellow/opened) and left ROI (green/closed). ** = p < 0.001

A28 Initial experience in a pilot study of Blood-Brain Barrier opening for chemo-drug delivery to brain tumors by MR-guided Focused Ultrasound

Todd Mainprize1, Yuexi Huang2, Ryan Alkins3, Martin Chapman3, James Perry4, Nir Lipsman1, Allison Bethune1, Arjun Sahgal4, Maureen Trudeau4, Kullervo Hynynen1

1Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; 2Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada; 3University of Toronto, Toronto, Ontario, Canada; 4Sunnybrook Research Institute, Toronto, Ontario, Canada

Objectives

Magnetic Resonance-guided Focused Ultrasound (MRgFUS) has been shown to reversibly open the Blood-Brain Barrier (BBB) for targeted drug delivery [1]. Research on animal models, including non-human primates [2], has been conducted to investigate the effectiveness and characteristics of BBB openings. Here we describe our initial experience in a pilot clinical study to establish the feasibility, safety and preliminary efficacy of Focused Ultrasound to temporarily open the BBB to deliver chemotherapy to brain tumors.

Methods

This phase-one clinical trial of BBB opening by Focused Ultrasound was approved by Health Canada. A modified clinical MRgFUS brain system (ExAblate 4000, 230 kHz, Insightec, Tirat Carmel, Israel) was used with a 3 T MR scanner (Signa MR750, GE Healthcare, Milwaukee, WI, USA). Two hours before the procedure, liposomal doxorubicin Caelyx (Janssen, Toronto, Ontario, Canada) was intravenously infused over 1 hour at a dose of 30 mg/m2. The patient’s head was then shaved and positioned in the FUS array with a stereotactic frame. Two targets close to the posterior margin of the glial tumor were chosen based on T2 images (Fig. 29). Each target consisted of a 3x3 grid of 9 spots at 3 mm spacing. For each spot, 2.6 ms on, 30.4 ms off FUS pulses were repeated for 300 ms before steering to the next spot. The pattern was repeated periodically resulting in an overall pulse repetition frequency (PRF) for each spot of 0.9 %. A bolus injection of 4 ul/kg of Definity microbubbles (Lantheus Medical Imaging, N. Billerica, MA, USA) was applied simultaneously with each sonication (1/5th of the clinical dose for ultrasound imaging). With the first injection of microbubbles, 10s short sonications at 5 W, 7 W and 9 W acoustic power were applied to find the appropriate power level based on feedback of cavitation signals. Cavitation signals were detected by two receivers and sampled at a rate of 2 MHz. Spectrum integration from 75 kHz to 155 kHz was calculated and two threshold levels of the spectrum integration were defined as a safety mechanism based on pre-clinical studies on a trans-human skull pig model [3]. 9 W was found to be adequate for these targets. 50 s sonications at 9 W were then applied at each target, with a separate bolus injection of microbubbles for each. Post sonication, Gd (Gadovist, Bayer)-enhanced 3D FSPGR images were acquired to verify the BBB openings, and T2*-weighted GRE images (TE = 15 ms) were collected to detect potential hemorrhage. After the treatment, the patient was released from the head frame and MR scans were repeated with an 8-channel head coil for better quality images. The patient underwent routine tumor resection the next day and tissue samples at the two BBB opening targets were collected for quantification of chemotherapy drug concentration.
Fig. 29 (abstract A28).
Fig. 29 (abstract A28).

Intraoperative T2w MR image showing the tumor and the first BBB target

Results

The opening of the BBB was successful at both locaitons with clear Gd enhancement in the 3x3 grid pattern. (Figs. 30 and 31). Despite using the same power level, the actual acoustic pressure at the 2nd target was lower than the first due to steering of the FUS beam. Low-level extravasation of red blood cells were seen as small dark signals within individual sonicated sponts in the T2* image (Fig. 32). The quantification of drug concentration is pending further analysis.

Conclusions

The 3 mm spacing of the 9 spots was intentionally designed to form a grid pattern of Gd enhancement for easier confirmation in heterogeneous tumors for the initial cases. We do not expect an impact on other parameters if the spacing needs to be reduced for a more uniform drug distribution within the BBB opening volume. There was a small level of RBC extravasation but this was not a concern in the tumor enviromment. Our animal experiments have shown that the cavitation signal can be used during the sonications to control the power level for eliminating the RBC exravasations [4]. The current system did not use this method during sonications.

The tumor in this patient was in the right temporal lobe adjacent to the skull. The two targets were ~4 cm lateral from the midline of the brain, and the 2nd target was also ~2.5 cm posterior. Thermal ablations by FUS at these off-centre locations are technically challenging due to excessive skull heating. However, successful BBB openings at these locations were demonstrated at low powers at 230 kHz. If these results can be repeated in other patients without complications, then the method may provide a new way to deliver therapeutic agents into brain for the treatment of tumors and other brain diseases.

References

1. Hynynen K et al. Radiology 2001;220:640-6.

2. McDannold N et al. Cancer Research 2012;72:3652-63.

3. Huang Y et al. ISMRM 2015, abstract 37.

4. O’Reilly MA et al. Radiology 2012;263:96-106.
Fig. 30 (abstract A28).
Fig. 30 (abstract A28).

a Axial Gd-enhanced T1w MR images showing the first (top arrow) and second (bottom) BBB openings

Fig. 31 (abstract A28).
Fig. 31 (abstract A28).

b Coronal view across the second target

Fig. 32 (abstract A28).
Fig. 32 (abstract A28).

T2*w image shows low level of RBC extravasation (small dark spots) within the two target volumes

A29 Enhanced bevacizumab delivery to the CNS by Focused Ultrasound induced blood-brain barrier opening for malignant glioma treatment

Hao-Li Liu1, Po-Hung Hsu1, Kuo-Chen Wei2

1Chang Gung University, Taoyuan, Taiwan; 2Chang Gung Memorial Hospital, Taoyuan, Taiwan

Objectives

Malignant glioma is the most severe form of primary brain tumors with an extremely high recurrence rate and the poorest prognosis. Current anti-angiogenic monoclonal antibody (mAb) treatment failed to show therapeutic efficacy due to transient “vascular normalization” stage that restores BBB integrity in tumor regions and restricts anti-angiogenic mAb penetration, preventing angiogenic suppression of tumor cells in the CNS and diminishing the improvement in overall survival in clinical treatment observation. The purpose of this study is to demonstrate that transcranial Focused Ultrasound (FUS) enhances Blood-Brain Barrier (BBB) permeability of the antiangiogenic monoclonal antibody, bevacizumab, for glioblastoma multiforme (GBM) treatment.

Methods

Transcranial FUS in the presence of microbubbles was used to transiently open BBB, and enhance CNS penetration of bevacizumab in normal and glioma-bearing mice. Bevacizumab was quantitated by high-performance liquid chromatography (HPLC), and Western blotting confirmed bevacizumab in the CNS. Bevacizumab permeability was estimated in vivo via contrast-enhanced Magnetic Resonance Imaging (CE-MRI), and glioma progression was longitudinally followed via T2-MRI. Morphological changes and vascular inhibition were confirmed histologically with H&E and CD-31 immunohistochemistry (Fig. 33).

Results

HPLC confirmed that FUS significantly enhanced CNS delivery of bevacizumab from 5.7- to 56.7-fold. The high correlations between CE-MRI imaging indices and bevacizumab concentration (r2 = 0.56-0.7378) suggested feasible non-invasive in vivo imaging of large-molecule BBB penetration. FUS-enhanced bevacizumab delivery significantly inhibited glioma progression, and improved median survival (ISTmedian = 135 %, compared to 48 % in bevacizumab-administration alone, Fig. 34).

Conclusions

In conclusion, anti-angiogenic glioma therapy is enhanced via our proof-of-concept study that FUS enhances large molecule bevacizumab BBB permeability, and combining Focused Ultrasound to open the Blood-Brain Barrier with bevaczumab delivery can overcome bevaczumab vascular normalization and potentiate bevacizumab’s anti–angiogenic tumor therapy effect.
Fig. 33 (abstract A29).
Fig. 33 (abstract A29).

a Representative imaging indexes obtained from DCE -MRI analysis (T1-WI, R1-AUC, Ktrans, and Ve). b CD-31 IHC fluorescent microcopies. Bar = 100 μm

Fig. 34 (abstract A29).
Fig. 34 (abstract A29).

Kaplan–Meier plot to demonstrate animal survival among each experimental groups. BEV = Bevacizumab

A30 Closed-loop control of targeted drug delivery across the blood-brain barrier in rat glioma models

Tao Sun1,2, Chanikarn Power1,2, Yong-Zhi Zhang2, Jonathan Sutton1,2, Phillip Alexander1,2, Muna Aryal1,2, Eric Miller3, Nathan McDannold1,2

1Brigham and Women’s Hospital, Boston, Massachusetts, USA; 2Harvard Medical School, Boston, Massachusetts, USA; 3Tufts University, Medford, Massachusetts, USA

Objectives

Microbubble-mediated Focused Ultrasound (FUS) can induce targeted drug delivery through Blood-Brain Barrier disruption (BBBD). Real-time feedback control of cavitation is critical to realize desired treatment outcome while avoiding tissue damage. Here, we propose an acoustic emissions-based controlling paradigm that can sustain stable cavitation (harmonic emission, HE) while suppressing inertial cavitation (broadband emission, BE). Our objective is to deliver desired drug dose by controlling HE strength during BBBD, while keeping the brain damage-free.

Methods

A dual-aperture FUS setup (f  =  274.3 kHz) produced a sub-centimeter focal depth in rats’ brain (n = 50) in vivo, and a passive detector (fcentral = 650 kHz) monitored cavitation activity. HE and BE were analyzed during 32-ms bursts in real time and fed back for control of the next pulse. The impact of multiple FUS parameters and microbubble (Optison) injection protocol on the controller performance was studied. To avoid inertial cavitation, the pressure was reduced if BE was detected and terminated if it crossed a set threshold. Both wild type and F98 glioma (ATCC # CRL-2397) models have been used in this study. Delivery of a model drug (Trypan Blue; 960 Da) and chemotherapeutic drug (Doxorubicin) was assessed using fluorescent imaging of formalin-fixed tissue blocks 1-h post sonication.

Results

Pilot study demonstrated the HE-pressure linearity (R2 = 0.93) and found that the BE threshold decreased as bubble dose (up to 400 μl/kg) was augmented. To optimize controller performance in sustaining HE while suppressing BE, a Phase-1 study demonstrated that: 1) 4-Hz PRF (compared to 1-Hz, P < 0.001) significantly suppressed the HE signal variance; 2) Infusing microbubbles after an initial bolus prevented the decline of HE and a corresponding increase in pressure, and further improved HE stability (P < 0.05 for all comparisons, Fig. 35a) while reducing the likelihood of BE (33.7 % vs. 16.7 %).

Using optimal settings, a Phase-2 study investigated HE control and Trypan Blue delivery (Fig. 35b). Integrated HE was exponentially correlated with epi-fluorescence intensity (R2 = 0.82; red symbols in Fig. 35c). Based on this calibration, a Phase-3 study tested if we could deliver a desired amount of drug by sonicating until the HE reached a preset goal. The resulting fluorescent intensity matched well with the reference curve for three different goals (n > 5 per group, green symbols in Fig. 35c).

Conclusions

Our proposed controlling system and method has been demonstrated to effectively sustain the stable cavitation behavior while suppressing the inertial cavitation at a minimum level. Moreover, this real-time closed-loop controller can enable the reliable delivery of a pre-determined amount of drug to the brain.
Fig. 35 (abstract A30).
Fig. 35 (abstract A30).

a Signal stability assessment (*: P < 0.05, ***: P < 0.001, ****: P < 0.0001); b Cavitation control profile (HE in black and BE in red) and Trypan blue delivery; c Calibrated BBBD correlation (in red) and controlled delivery results (in green)

A31 MR-guided Focused Ultrasound for antibody delivery in a brain metastasis model

Thiele Kobus1, Yong-Zhi Zhang2, Nathan McDannold2,3

1Radboud University Medical Center, Nijmegen, Netherlands; 2Harvard Medical School, Boston, Massachusetts, USA; 3Brigham and Women’s Hospital, Boston, Massachusetts, USA

Objectives

Treatment options for breast cancer patients with metastases in the brain are limited. The blood-brain barrier (BBB) prevents most drugs from entering the brain and tumor. Although survival in patients with extracranial metastases of HER2-positive breast cancer can be prolonged by the use of antibody therapies like trastuzumab and pertuzumab, the response of brain metastases to these drugs is poor [1]. We aim to improve antibody delivery by temporary disruption of the BBB using magnetic resonance (MR)-guided focused ultrasound (MRgFUS) in combination with microbubbles. The treatment benefit was evaluated using MR imaging.

Methods

The treatment effect of the antibodies trastuzumab and pertuzumab in combination with MRgFUS to disrupt the BBB was evaluated. MDA-MB-361 cells (HER2-positive human cancer cells) were injected in the brain. Six weekly treatments started 5 weeks later. Three groups of 10 nude rats were included: a control-group that received no treatment; a group that only received both antibodies; and a FUS + antibody-group that received the antibodies in combination with BBB disruption using MRgFUS. The ultrasound treatments took place in a 7 T MR-system using a spherically-focused 690 kHz-transducer. Before and after the sonications, T2-weighted (T2w) and T1w images were obtained for targeting and confirmation of BBB disruption. At the start of each sonication (duration 60s, 10-ms bursts, burst repetition frequency 1 Hz), the ultrasound contrast agent Optison (100 μl/kg) was injected. The complete tumor was treated in 4 to 14 sonications using peak negative pressures between 0.46 and 0.62 MPa.

After the sonications gadolinium (Magnevist) was injected and T1w was repeated to confirm BBB disruption. The difference in signal intensity change in pre- and post-contrast T1w images was determined between the tumor and contralateral brain region (=ΔSI%). In two animals tumor leakiness was studied before the tumors were sonicated and quantified similarly.

Every other week, high-resolution T2w imaging was performed to determine tumor volume. The volumes were fitted with: volume(t) = a*exp(r*t), in which r is the growth rate and t is the time in days. r was determined for the treatment period (week 5 to 11) and the follow-up period (week 11 till sacrifice). An animal was classified as ‘responder’ if the growth rate r was lower than the mean r of the control animals minus two standard deviations.

The animal was euthanized if its condition was poor or the tumor diameter exceeded 13 mm. Brains were stained for hematoxylin and eosin (H&E) and HER2.

Results

BBB disruption was successful in all sessions with an average ΔSI% of 21.2 % (range 4.5–77.6 %). The mean ΔSI% of two tumors before BBB disruption during the six treatment weeks were 0.4 % and 0.6 %, indicating that the tumors were not leaky before disruption.

In the FUS + antibody-group, 4/10 animals were classified as responders during the treatment period with an average growth rate of 0.010 ± 0.007, compared to 0.043 ± 0.013 for the non-responders. There was no difference in the average ΔSI% of the responding rats (21.8 % ± 16.7) and the non-responding rats (20.7 % ± 9.7). None of the control or antibody-only animals were classified as responder. For the follow-up period, none of the animals was classified as responder.

High-resolution T2w imaging showed that the tumor was homogenous in most animals till week 13-15, when cystic and necrotic areas started to develop. The tumors showed also a heterogeneous appearance on H&E-stained sections and the complete tumor was HER2-expressing in the examined brains (Fig. 37).

Conclusions

In this study, we demonstrate that BBB disruption using MRgFUS in combination with antibody therapy can slow down the growth of breast cancer brain metastasis. As the tumors were not leaky before BBB disruption and there were no responders in the antibody-only group, the disruption of the BBB is necessary for drug delivery to these brain metastasis. Part of the rats responded to the treatment, while the other animals had the same growth rate as the control-group. This is in line with a previous study [2], where antibody therapy was combined with FUS in a different breast cancer brain metastasis model and only in part of the animals a response was observed. The difference in response could not be explained by the tumor volume at the start of the treatment, nor was there a difference in contrast-enhancement after BBB disruption or in HER2-expression. Better understanding of why certain animals respond is needed and will help in translating this technique to the clinic.

References

1. Pieńkowski and Zielinski. 2009. Ann Oncol: 917–24.

2. Park et al. 2012. J. Control. Release: 277–284
Fig. 36 (abstract A31).
Fig. 36 (abstract A31).

a T1weighted images before contrast administration. The red arrow indicates the tumor. b No difference in enhancement of the tumor is observed after contrast administration (ΔSI = 0.4 %). c After focused ultrasound-mediated Blood-Brain Barrier disruption, the tumor enhances after contrast administration (ΔSI = 30.1 %)

Fig. 37 (abstract A31).
Fig. 37 (abstract A31).

a T2w image of an animal that not responded to the therapy and was euthanized after imaging (at week 21 after implantation). The tumor shows a heterogeneous appearance with cysts b The H&E-stained section shows a similar appearance. c HER2-stained section shows that the complete tumor is HER2-expressing

A32 Phase I/IIa clinical trial of blood-brain barrier disruption by pulsed ultrasound

Alexandre Carpentier1, Michael Canney2, Alexandre Vignot3, Kevin Beccaria1, Delphine Leclercq1, Cyril Lafon4,5, Jean Yves Chapelon5, Khe Hoang-Xuan6, Jean-Yves Delattre1, Ahmed Idbaih1

1Hopital de la Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France; 2CarThera, Denver, Colorado, USA; 3CarThera, Lyon, France; 4University of Virginia, Charlottesville, Virginia, USA; 5INSERM Unit 1032, Lyon, France; 6Institut du Cerveau et de la Moelle épinière, ICM, Paris, France

Objectives

The Blood-Brain Barrier (BBB) limits the delivery and efficacy of systemically administered drugs to the brain. Pre-clinical studies have demonstrated that ultrasound-induced disruption of the BBB can significantly increase the intracerebral concentration of chemotherapy. To harness this approach, our group has developed an implantable ultrasound device, SonoCloud®, that allows for simple and repeated disruption of the BBB. The goal of this work was to determine the safety of repeated disruption of the BBB using the SonoCloud® device in patients with recurrent glioblastoma prior to receiving carboplatin chemotherapy.

Methods

A Phase 1/2a clinical trial was initiated at the Hospital Pitie Salpetriere in Paris, France in July 2014. Patients with recurrent glioblastoma were implanted with an 11.5-mm diameter biocompatible 1 MHz ultrasound transducer. The device was fixed to the skull bone in a standard burr hole, after which the skin was closed. Once a month, the device was connected to an external generator system using a transdermal needle connection and patients received a 150 second ultrasound sonication (25,000 cycles/burst, 1 Hz) in combination with systemic administration of an ultrasound contrast agent. BBB disruption was monitored immediately after sonication using gadolinium-enhanced Magnetic Resonance Imaging (MRI). Systemic intravenous injection of carboplatin chemotherapy (AUC 4-6) was administered immediately following acquisition of each patient’s post-sonication MRI (<1 hr after BBB disruption). Patients followed a progression of ultrasound dose in which the acoustic pressure was increased from 0.5 to 1.1 MPa throughout the course of the study.

Results

Fifteen patients were included in this on-going study from July 2014-January 2016. A total of 41 BBB disruption sessions were performed. Contrast-enhanced MRI indicated that the BBB was disrupted at acoustic pressure levels up to 1.1 MPa without detectable adverse effects on MRI or clinical examination.

Conclusions

Our preliminary results from this Phase I/IIa study indicate that repeated disruption of the BBB using the SonoCloud® device is safe and well tolerated in patients with recurrent GBM and may improve chemotherapy delivery in the brain.

A33 Preliminary report on sonodynamic therapy for C6 glioma rat model

Zhiyuan Xu1, David Moore2, Alexis Xu1, Paul Schmitt3, John Snell2, Jessica Foley2, Matt Eames2, Jason Sheehan1, Neal Kassell2

1University of Virginia, Charlottesville, Virginia, USA; 2Focused Ultrasound Foundation, Charlottesville, Virginia, USA; 3University of Virginia Health System, Charlottesville, Virginia, USA

Objectives

Not released for publication

Methods

Not released for publication

Results

Not released for publication

Conclusions

Not released for publication

A34 In vivo porcine histotripsy brain treatments

Jonathan Sukovich1, Charles Cain1, Zhiyuan Xu2, Aditya Pandey1, John Snell3, Neeraj Chaudhary1, Sandra Camelo-Piragua1, Steven Allen1, Dong-Guk Paeng4, Jon Cannata5, Dejan Teofilovic5, Jim Bertolina5, Neal Kassell3, Timothy Hall1, Zhen Xu1

1University of Michigan, Ann Arbor, Michigan, USA; 2University of Virginia, Charlottesville, Virginia, USA; 3Focused Ultrasound Foundation, Charlottesville, Virginia, USA; 4Jeju National University, Jeju, Jeju, Republic of Korea; 5HistoSonics, Inc., Ann Arbor, Michigan, USA

Objectives

Focused ultrasound thermal therapies have been explored for brain applications including treatment of essential tremors, Parkinson’s disease, and stroke. Histotripsy, a cavitation based ultrasound therapy, is being investigated for treatment of brain tumor and intracerebral hemorrhage, but there are concerns that excessive hemorrhage may be induced in the brain during histotripsy treatment by disrupting blood vessels. This study investigates the in vivo feasibility and safety of generating targeted lesions in the porcine brain using histotripsy. The goal is to demonstrate that lesion generation may be accomplished safely and without excess hemorrhage, edema, or other major complications associated with treatment. We also seek to investigate the histotripsy dose required to fully ablate target brain regions.

Methods

Histotripsy treatments were delivered to brains of 11 pigs using a 1.5 MHz focused transducer following a craniotomy. Lesions generated were targeted in the cortex at depths of 5 to 20 mm from the exposed surface of the brain. Using ultrasound imaging guidance, treatment regions were targeted to be contained within individual gyri to avoid perforations into the sulci. During dosage studies, single lesions were generated using between 1 and 200 histotripsy pulses delivered at ≤10Hz PRF with an estimated peak negative pressure of 45 MPa. Large lesions were generated by incrementally repositioning the histotripsy target site during treatment to ablate entire target volumes. 7 acute pigs were sacrificed within 6 hours of treatment and brains were removed for MRI and histology. 4 sub-acute pigs were survived for 3 days after treatment. To assess lesion damage, hemorrhage and edema surrounding the lesions, MR images of the brains were acquired at 1 hour and at 3 days after treatment for sub-acute pigs. After euthanization brains were dissected for histology.

Results

In 4 acute pigs, with ultrasound guidance, histotripsy was used to generate precise single lesions of 1.5x2.5 mm within the gyri. Dosage studies revealed that a single histotripsy pulse was sufficient to generate identifiable damage in the brain in MRI and complete cell fractionation in lesions was achieved by 50 pulses. In 3 acute pigs, 5 larger lesions measuring up to 7 mm diameter were generated in the brain. MRI and histology revealed that lesions confined to within the gyri show no hemorrhage or other major complication associated with treatment. In 4 sub-acute pigs, 6 single lesions were generated by 10 and 50 pulses, and two larger square lesions of 3.5 mm were created. MRI following treatment showed no hemorrhage or damage outside the target regions and at 3 days showed no additional hemorrhage and only minor edema near the lesion boundary. No midline shift or brain herniation was observed. Histology showed damage confined to within target volumes, with well demarcated boundaries between treated and untreated tissues and no evidence of hemorrhage, ischemic changes, encephalitis, or acute, sub-acute or chronic inflammatory infiltrate beyond the areas of the lesion.

Conclusions

The results of this study demonstrate that histotripsy may be used to generate targeted lesions in the brain without causing excess hemorrhage, edema, or other major complications associated with treatment. Lesions were observed to have well defined boundaries between treated and untreated tissues, with little damage beyond the confines of the lesion area. Tissues surrounding the lesions appear very viable with no acute, sub-acute or chronic inflammatory infiltrate, and tissues in adjacent gyri appear uninvolved and unremarkable. These results demonstrate that histotripsy may be applied in the brain without causing major complications and suggest the potential of histotripsy for use in brain therapy applications.

A35 Neuronavigation-guided Focused Ultrasound and real-time acoustic mapping: evaluation in non-human primates with blood-brain barrier opening

Shih-Ying Wu, Maria Eleni (Marilena) Karakatsani, Julien Grondin, Carlos Sierra Sanchez, Vincent Ferrera, Elisa Konofagou

Columbia University, New York, New York, USA

Objectives

Focused ultrasound (FUS) has shown great promise for noninvasive brain treatment, including surgical ablation, Blood-Brain Barrier (BBB) opening and drug delivery, and neuromodulation. Accurate and precise targeting with personalized planning is the key for treatment success. Furthermore, repetitive procedure is often required for BBB opening and drug delivery as well as neuromodulation, which entails the demand for a portable system apart from the current MR-guided FUS system requiring a dedicated and custom-built suite. In this study, a neuronavigation-guided FUS system was developed (Fig. 38), combined with in silico preplanning based on CT and MRI as well as real-time acoustic mapping in visualizing the location and intensity of the cavitation events associated with BBB opening. The system was evaluated in non-human primates with BBB opening, with the treatment preplanning and targeting accuracy validated both in silico and in vivo.

Methods

Three rhesus macaques were sonicated (N = 15) and the subcortical structure of the basal ganglia was targeted, which is associated with neurodegenerative diseases including Parkinson’s and Huntington’s disease. Both CT and MRI were acquired for personalized pre-planning and neuronavigation guidance (Brainsight). The 3D numerical simulation of the acoustic pressure field was performed for pre-planning and post comparison with the BBB opening. A single-element, 0.5-MHz FUS transducer (diameter: 64 mm) with in-house microbubbles were used for sonication, and a programmable data acquisition system (Verasonics) with an array of acoustic detectors for real-time passive cavitation mapping. Both the FUS and cavitation mapping were guided with the neuronavigation system in real time during the FUS procedure. After sonication, the contrast enhanced T1-weighted MRI was used to confirm the location and size of BBB opening. The accuracy of both the FUS targeting and cavitation mapping were assessed.

Results

The target shift was on average 2.0 mm laterally and 3.5 mm axially in the in vivo experiment, and the shift due to the skull was predicted to be 0-1 mm laterally and 1.0-5.5 mm axially in silico. Real-time cavitation mapping confirmed the sonicated area with and without BBB opening, and distance between the centroid of the cavitation map and that of the resulting BBB opening was under 2 mm. In order to achieve the desired BBB opening volume, the pressure and focal spot size in situ were estimated in silico and tailored for targeting in each subject. Simulation results showed a smaller focal spot size through the skull (2.6 mm laterally and 16.7 mm axially, compared with the original size of 4.0 mm laterally and 35.3 mm axially), which corresponded to the BBB opening volume under specific peak negative pressures (NHP 1 at 200 kPa, NHP 2 at 600 kPa). This pressure difference between individuals was due to the difference in skull attenuation, since the in silico pressure reduction was estimated to be 30.9 % ± 12.4 % and 53.9 % ± 14.3 % in NHP 1 and NHP 2, respectively.

Conclusions

In conclusion, the new portable neuronavigation-guided FUS with in silico preplanning and real-time cavitation mapping was shown feasible and could facilitate the BBB opening and neuromodulation applications while maintaining translational capability to a clinical setting.
Fig. 38 (abstract A35).
Fig. 38 (abstract A35).

Treatment preplanning, on-line targeting and monitoring, and post assessment

A36 Definition of basic properties of physical immunotherapy in pancreatic cancer using HIFU and immune checkpoint inhibition

Gail ter Haar1, Petros Mouratidis1, Elizabeth Repasky2

1The Institute of Cancer Research, Sutton, Surrey, United Kingdom; 2Roswell Park Cancer Institute, Buffalo, New York, USA

Objectives

The latest advances in cancer immunotherapy have improved our understanding of how to stimulate the patient’s immune system to fight their own disease. Notwithstanding the unparalleled success of treating melanoma tumours and non-small cell lung cancer with immune checkpoint inhibitors, patients are not all getting the same benefit. In this context, pancreatic cancer presents unique challenges. Its dense stroma characteristics result in limited immune cell infiltration in the tumour microenvironment. In addition the low number of mutations in pancreatic cancer cells result in few tumour antigens, thereby reducing their immunogenicity. HIFU may address some of these limitations by ablating segments of the tumour to induce a stronger inflammatory response and degrade the stroma to facilitate enhanced diffusion of tumour antigens out of the tumour, and increased penetration of lymphocytes to the tumour. We propose to co-treat pancreatic tumours with HIFU and immune checkpoint inhibitors to elicit an effective anti-tumour immune

Methods

In vitro characterization of the effects of heat on the presentation of cell surface receptors associated with the immune response has been undertaken in human colon cancer HCT116 cells and mouse pancreatic cancer Panc02 cells using FACS analysis. A KPC-derived pancreatic cancer cell line will be transplanted in C57BL/6 subjects to form syngeneic subcutaneous and orthotopic pancreatic tumours. These tumours will be treated with HIFU, and within vivo monoclonal anti-CLTA-4 and anti-PD-1 antibodies. The phenotype of markers of the adaptive immune response will be assessed to identify whether HIFU exposures can initiate intrinsic anti-tumoural cellular immunity at the site of treatment. Analysis by flow cytometry and immunohistochemistry of both effector cells (cytotoxic CD8+ T cells, dendritic cells), and immunosuppressive cells (Tregs, myeloid derived suppressor cells), as well as cytokines and chemokines at various time points post HIFU will be performed. Tumour growth will be determined using high resolution ultrasound imaging, and the results will be correlated with overall survival.

Results

Thermal exposure of cancer cells results in a time-dependent regulation of the transmembrane receptor CD47. CD47 decreases immediately after, and 1 day after treatment, and increases 3 and 4 days after treatment relative to the sham-exposed cancer cells. Further data on the effects of thermal exposures on the regulation of immune-associated pancreatic cancer cell surface receptors will be presented.

Conclusions

Detailed pre-clinical studies in various mouse models of pancreatic cancer can provide a mechanistic understanding of the combinatorial effects of HIFU and immune checkpoint inhibitors. Strong evidence that HIFU stimulates endogenous immunity against pancreatic tumor cells, and augments the immunotherapy treatment of poorly immunogenic pancreatic tumours could be used as proof-of-concept for the initiation of Phase 1 clinical trials of HIFU-enhanced immunotherapy in patients with pancreatic cancer.

A37 Melanoma growth control via ultrasound depends on the adaptive immune system and surpasses αPD-1

Kelsie Timbie1,2, Lena Badr2, Benjamin Campbell2, John McMichael2, Andrew Buckner2, Jessica Prince2, Aaron Stevens2, Timothy Bullock2, Richard Price2

1Focused Ultrasound Foundation, Charlottesville, Virginia, USA; 2University of Virginia, Charlottesville, Virginia, USA

Objectives

Melanoma incidence continues to rise, while Stage IV 5 year survival remains below 20 %. Targeted immunotherapy approaches, designed to enhance natural anti-tumor mechanisms or inhibit the immunosuppressive tumor microenvironment, have shown promise in early clinical use. The programmed death receptor and its ligand (PD-1 and PD-L1) have drawn considerable attention. PD-L1 is known to inhibit the activity of anti-tumorigenic cytotoxic T cells, promoting a pro-tumor immune profile, and ultrasound (US) can promote the infiltration of immune cells into the tumor. Here, we tested the hypothesis that a combination of pulsed US, microbubbles (MBs) and anti-PD-1 will improve tumor growth control in a mouse model of melanoma in a manner dependent on the adaptive immune system. Melanoma incidence continues to rise, while Stage IV 5 year survival remains below 20 %. Targeted immunotherapy approaches, designed to enhance natural anti-tumor mechanisms or inhibit the immunosuppressive tumor microenvironment, have shown promise in early clinical use.

Methods

Eight week old immunocompetent C57BL/6 male mice were inoculated unilaterally with B16-F10 melanoma cells and divided into four groups: Control (untreated), US + MBs, αPD-1, or US + MBs + αPD-1. Immunocompromised Rag1-/- mice were similarly inoculated and divided into two groups: Control (untreated) or US + MBs. On day 11 post-inoculation, animals receiving US were anesthetized and sonicated with a 0.75” unfocused 1 MHz transducer as previously described1 for 60 minutes. MBs (105/g b.w.) were injected i.v. throughout the sonication. The αPD-1 groups were given an IP injection of 250 μg of αPD-1 on Days 10, 13 and 16. Tumors were monitored until Day 18, when tumors were resected for flow cytometry. Helper T cells (CD4+), cytotoxic T cells (CD8+), T regulatory cells (Treg), macrophages and natural killer cells (NK) were counted in immunocompetent mice, and dendritic cells (DC), natural killer cells, M1 and non-M1 macrophages were counted in immunocompromised mice.

Results

In immunocompetent mice, treatment with US + MBs provided improved tumor growth control compared to all other groups (Fig. 39a) as well as a significant survival benefit (not shown). Additionally, US + MBs generated a significant increase in macrophages (not shown) and Tregs (Fig. 39b) compared to control. Interestingly, the αPD-l and US + MBs groups performed similarly in CD4+ and CD8+ cell counts (Fig. 39b), but the combined US + MBs + αPD-1 treatment generated fewer T cells than either treatment alone. In immunocompromised animals, treatment with US + MBs did not provide tumor growth control (Fig. 39c) or a survival benefit (not shown), but did generate a significant decrease in M1 macrophages within the tumor (Fig. 39d), although total myeloid cell counts remained the same (not shown).

Conclusions

US indiscriminately increases the numbers of immune cells within subcutaneous melanoma; therefore, we expected that US-enhanced delivery of αPD-1 would provide an additional benefit; namely, a shift towards an anti-tumorigenic immune profile. However, αPD-1 did not synergize with US + MB treatment. While the mechanism is not yet understood, low power noninvasive US + MBs provided excellent tumor growth control and may serve as a stand-alone clinical treatment. Furthermore, this anti-tumor effect is clearly dependent on the adaptive immune system, since US + MBs treatment in immunocompromised mice produced no benefit. A better understanding of this mechanism may identify adjunct treatments that would synergize with US and further enhance the anti-tumor effect demonstrated here.

Reference

1. Burke, C. W. et al. Ultrasound-activated agents comprised of 5FU-bearing nanoparticles bonded to microbubbles inhibit solid tumor growth and improve survival. Mol. Ther. 22, 321–8 (2014).
Fig. 39 (abstract A37).
Fig. 39 (abstract A37).

a Tumor growth in immunocompetant C57BL/6 hosts. *P < 0.05 vs. control. b Immune cell representation in tumors in C57BL/6 hosts. c Tumor growth in immunocompromised Rag1-/- hosts. d Immune cell representation in tumors in Rag1-/- hosts

A38 Stress response of cancer cells after low intensity Focused Ultrasound

Karin Skalina1, Chandan Guha2

1Albert Einstein College of Medicine, Bronx, New York, USA; 2Montefiore Medical Center, Bronx, New York, USA

Objectives

Low intensity Focused Ultrasound (LOFU) results in sublethal stress to tumor cells. We investigated the cell surface expression of immunomodulatory molecules in three murine cell lines (Lewis lung, breast and prostate adenocarcinoma). The immunomodulation was examined by flow cytometry of cell surface stress proteins: HSP70 & calreticulin, of immunomodulatory co-activating signals: CD40, CD80, CD86 and other receptors: MHC I, Fas). Surface expression of these molecules trigger activation of or phagocytosis by dendritic cells. Additionally, the activation of the unfolded protein response (indicated by phosphorylation of PERK or IRE1α or cleavage of ATF6α) can trigger apoptosis – a programmed cellular death pathway which can also activate the immune system. We hypothesize that by altering the total acoustic power of LOFU, we can modulate the stress signals both on the cell surface and within the cells.

Methods

LOFU treatment was performed on the Philips Therapy and Imaging Probe System (TIPS, Philips Research Briarcliff, USA) using 3 W or 5 W, 100 % duty cycle, 1.5 seconds, 1 mm spacing. LOFU treatment was performed on a cell pellet which were then replated and incubated at 37 °C, 5 % CO2 for the specified time. At the end of the incubation time, cells were lightly scraped for flow cytometry staining or lysis buffer was added to the adherent cells and then scraped for Western blot analysis.

Results

The analysis of murine lung and breast cancer indicates that there is a significant surface localization of both HSP70 and calreticulin as early as 4 hours after LOFU treatment and this localization diminishes by 24 hours post treatment. For murine prostate cancer cells, however, the surface localization of HSP70 increases at 4 hours after treatment and increases further at 24 hours. Additionally, there is a significant increase in surface localization of both HSP70 and calreticulin with a higher output power of 5 W compared to 3 W. For immunomodulatory co-activating signals, there is increased surface expression in Lewis lung carcinoma and prostate adenocarcinoma, but not breast carcinoma. Results of the activation of the unfolded protein response are still pending at the time of submission, but preliminary results indicate the both phosphorylation of PERK and IRE1α are increased following LOFU treatment.

Conclusions

Tumor stress response to LOFU treatment can be altered by the total acoustic power of LOFU treatment. The increased surface localization of HSP70, calreticulin, CD40, CD80 and CD86 have the capacity to augment the immune response to the tumor. Therefore, LOFU can be used in combination with ablative therapies in order to induce anti-tumor immunity and destroy the primary tumor.

A39 The “abscopal” effect after USgHIFU treatment of advanced pancreatic cancer

Franco Orsi, Guido Bonomo, Paolo Della Vigna, Giovanni Mauri, Gianluca Varano

Istituto Europeo di Oncologia, Milan, Italy

Objectives

Pancreatic cancer is considered one of the main big “killers” in Oncology, with still a very poor prognosis, both in patients amenable to resection and of course in more advanced stage disease. More than 50 % of patients are diagnosed with an advanced stage disease, where chemotherapy is usually the main therapy option. External radiotherapy is the most common palliative loco-regional treatment in pancreatic cancer, but in the last few years HIFU has been proposed as an alternative option for palliation in advanced stage.

From our specific experience of USgHIFU for pancreatic cancer, we report few cases of ABSCOPAL effect: where after a local treatment not only the target tumor but also the distant deposits will shrink

Methods

From 2008 until April 2016, 72 consecutive patients affected by pancreatic tumors were selected by a dedicated Tumor Board for receiving treatment with USgHIFU, for local tumor control and palliation. 64 % of patients were affected by pancreatic adenocarcinoma and 84 % of all the treated tumors were located at the level of pancreatic head. Majority of the patients had at least two lines of chemotherapy and 45 % of them received concurrent and/or consequent external RT. USgHIFU treatment was performed always during general anesthesia with GI catheter and abdominal compression with a dedicated water balloon in order to reduce the distance between the HIFU probe and the target and for push the bowel loop away from the acoustic treatment window. Patients were than evaluated by clinical and instrumental follow up.

Results

All the procedures were technically successful, with only one main complication due to a complete portal thrombosis developed 24 hrs after treatment. Objective response (OR) at MDCT, MRI and PET was 64 % with a disease control (DC) up to 90 % of all the patients. Pain was palliated in 23/27 of symptomatic patients. In four patients (4/46 with adenocarcinoma) the imaging follow up after the treatment revealed the shrinkage of metastases located in other sites: 2 retroperitoneal lymphnode (Figs. 40 and 41), 1 liver and 1 lung.

Conclusions

In advanced pancreatic carcinoma, HIFU can have a role in locally advanced unresectable disease. Based on our limited experience, HIFU could be also suggested in a metastatic setting (Stage IV), together with systemic therapy, with the potential benefit of being effective also outside the treated target (abscopal effect). There are few papers reporting the effect of HIFU as a booster of immune response in cancer patients, but there are still no data supporting the use of this non-invasive approach in advanced cancer patient just for this purpose. Specific dedicated clinical trial should be conducted for better understand the biological mechanism behind it.
Fig. 40 (abstract A39).
Fig. 40 (abstract A39).

Multiple retroperitoneal lymphnodes in patient with pancreatic cancer

Fig. 41 (abstract A39).
Fig. 41 (abstract A39).

18 months after HIFU, CT shows the complete response at the level of metastatic lymphnodes

A40 Characterizing the immune response to boiling histotripsy ablation of renal carcinoma in the Eker rat

George Schade, Yak-Nam Wang, Venu Pillarisetty, Joo Ha Hwang, Vera Khokhlova, Michael Bailey, Tatiana Khokhlova

University of Washington, Seattle, Washington, USA

Objectives

Boiling histotripsy (BH) is an experimental non-invasive Focused Ultrasound (US) technology. BH uses milliseconds-long US pulses at low duty cycle to mechanically homogenize targeted tissue. We aim to evaluate the adaptive immune response to BH ablation of spontaneous renal tumors in the Eker rat hereditary renal carcinoma (RCC) model.

Methods

Genotyped Eker rats (Tsc2 heterozygotes) were monitored for de novo RCCs with serial US until tumors were ≥8 mm. Syngeneic Wild-type (WT) (planned total n = 36) and Eker rats (planned total n = 48) were then randomly assigned to BH (n = 10 total to date) or an US SHAM procedure (n = 22 to date). BH was performed extracorporeally using US-guided small animal FUS system (VIFU-2000, Alpinion). The 1.5 MHz transducer was operated at duty cycle of 1 %, 10 ms pulses, 525-550 W electric power. Treatments targeted a ~0.5 cc area of the lower pole in WT rats and the largest RCC with a margin of normal kidney in the Eker rats. Blood samples were collected immediately before treatment and serially post-treatment. Rats were euthanized at 48 hrs, 7 days, 14 days, or 56 days following treatment. At euthanasia, ipsilateral and contralateral kidneys, hilar lymph nodes, and the spleen were collected. Intrarenal and circulating plasma cytokines were assessed using a 10 cytokine multiplex assay. Renal/tumor infiltrating leukocyte populations were assessed using immunohistochemistry. Leukocyte populations in tumor draining hilar lymph nodes and spleens were assessed with flow cytometry.

Results

BH treatment has been successful in all treated (n = 4 Eker, n = 6 WT to date) subjects, producing hypoechoic regions on US consistent with BH treatment effect. BH treatment was associated with significantly increased mean relative-plasma TNF-α vs. sham treatment at 0.25 (p = 0.02), 1 (p0.04), and 24 (p = 0.05) hours. At 48 hours, significant differences in intra-renal cytokines were observed in BH (n = 4) vs SHAM (n = 4) treated rats: IFN-gamma, IL-10, and IL-8 with trend towards differences in TNF-alpha and IL-6 (Fig. 42). On immunohistochemistry, BH treated Eker rats had increased CD8+ T-cells in both the treated and contralateral kidney compared to SHAM treated rats at 48 hours (Fig. 43). Additionally, increased infiltration of f4/80+ M1 macrophages into the treated kidney, was observed in 2/4 BH treated rats vs. SHAM at 48 hours. Longer-term data is pending at this time.

Conclusions

These data represent preliminary findings indicating differences in cytokines and tumor infiltrating leukocytes between BH treated and SHAM treated Eker rats up to 48 hours post-treatment. Assessment of longer-term immune effects of BH treatment and their significance is on-going and will be reported.
Fig. 42 (abstract A40).
Fig. 42 (abstract A40).

Intrarenal cytokine concentrations 48 hours after BH and SHAM treatment

Fig. 43 (abstract A40).
Fig. 43 (abstract A40).

Immunohistochemistry appearance of CD8+ T-cells in BH treated (*) tumor (T) kidney, in the BH treated contralateral kidney, and in SHAM treated

A41 Use of shock-wave exposures for accelerating thermal ablation of localized tissue volumes

Vera Khokhlova1, Ilya Sinilshchikov2, Petr Yuldashev2, Yulia Andriyakhina2, Wayne Kreider1, Adam Maxwell1, Tatiana Khokhlova1, Oleg Sapozhnikov1, Ari Partanen3

1University of Washington, Seattle, Washington, USA; 2M.V. Lomonosov Moscow State University, Moscow, Russian Federation; 3Philips, Bethesda, Maryland, USA

Objectives

In High Intensity Focused Ultrasound (HIFU) applications, nonlinear acoustic effects can result in the formation of high-amplitude shock fronts in focal waveforms, with amplitudes exceeding 100 MPa. The presence of such shocks leads to increased tissue heating which can be beneficial for HIFU thermal therapy. The goal of this work was to evaluate the efficacy of different shock-wave exposures to accelerate thermal ablation of tissue volumes while enabling safer conditions for intervening tissues.

Methods

Simulation studies were performed for a multi-element 1.2 MHz HIFU phased array of a clinical system (Fig. 44a, Sonalleve V1, Philips, Vantaa, Finland) for three different peak intensity levels at the array elements of 1.2, 8, and 15 W/cm2. A pulsing scheme was combined with discrete electronic steering of the array focus over a series of foci separated about 1 mm and arranged in 4 concentric circles (Fig. 44b). The circles were positioned in a plane at 25 mm depth in liver tissue of 50 mm thickness (Fig. 44a). The period between consecutive pulses was 20 ms. Pulse duration was varied to keep a constant time-average intensity at the array elements: 20 ms at 1.2 W/cm2, 3 ms at 8 W/cm2, and 1.6 ms at 15 W/cm2. The Westervelt equation combined with the bioheat equation was used for modeling temperature and thermal dose in tissue. Initial temperature in tissue was 20 °C, sonication was performed starting from the center and spiraling outward until a thermal dose of 1.76 s at 56 °C (equivalent to 240 CEM at 43 °C) was reached at each circle of the trajectory.

Results

The focal waveforms simulated in tissue for different peak intensities representing quasilinear sonication (1.2 W/cm2), sonication with a fully developed shock of 95 MPa at the focus (8 W/cm2), and sonication with higher focal shock amplitude of 118 MPa (15 W/cm2). Tissue ablation was achieved much faster at higher peak intensities with more clearly defined boundary between treated and untreated tissue. While temperature distributions and thermal dose contours in the focal plane were similar in shape for each trajectory and intensity level, corresponding distributions in the axial plane varied greatly. Slower heating at 1.2 W/cm2 resulted in strong heat diffusion in the axial direction and much larger ablation volumes. On the contrary, with rapid shock-wave heating, the ablated tissue volume followed the geometry of the targeted heat deposition. Although overall ablated volumes were smaller at higher peak intensities, the ablation rate was the highest at 15 W/cm2.

Conclusions

In comparison with conventional HIFU treatments, shock-wave exposures provide higher ablation rates at target sites with less heat diffusion to the surrounding tissues. Shock-wave heating regimes may therefore be clinically advantageous for accelerating thermal HIFU treatments, reducing the heating of surrounding tissues, and providing sharper margins of lesion volumes.
Fig. 44 (abstract A41).
Fig. 44 (abstract A41).

a Geometry of the numerical experiment: US beam is focused at the center of a 5 cm thick tissue layer. b Trajectory of the focus in the focal plane comprising 4 circles of 1, 2, 3, and 4 mm radii with 1 mm distance between the foci in each circle

A42 Effects of dosing and focal spacing in rapid ablation of large tissue volume using histotripsy with electronic focal steering

Jonathan Lundt, Steven Allen, Jonathan Sukovich, Timothy Hall, Charles Cain, Zhen Xu