High speed imaging of bubble clouds generated in pulsed ultrasound cavitational therapy--histotripsy

Minimization of treatment time for in vitro 1.1 MHz destruction of Pseudomonas aeruginosa biofilms by high-intensity focused ultrasound

Medical implants are prone to colonization by bacterial biofilms. Normally, surgery is required to replace the infected implant. One promising noninvasive modality is to destroy biofilms with high-intensity focused ultrasound. In our study, Pseudomonas aeruginosa biofilms were grown on implant-mimicking graphite disks in a flow chamber for 3 days prior to exposing them to ultrasound pulses. Exposure time at each treatment location was varied between 5, 15 and 30s. Burst period was varied between 1, 3, 6 and 12 milliseconds (ms). The pulses were 20 cycles in duration at 1.1 MHz from a spherically focused transducer (f/1, 63 mm focal length), creating peak compressional and rarefactional pressures at the graphite disk surface of 30 and 13 MPa, respectively. P. aeruginosa were tagged with green fluorescent protein, and killed cells were visualized using propidium iodide before determining the extent of biofilm destruction. The exposure-induced temperature rise was measured to be less than 0.2°C at the focus, namely the interface between graphite disk and water. Then, the temperature rise was measured at the focus between the graphite disk and a tissue-mimicking phantom to evaluate therapy safety. Two thresholds, of bacteria destruction increase and of complete bacteria removal, respectively, were identified to divide our eight exposure conditions. Results indicated that 30-s exposure and 6-ms pulse period were sufficient to destroy the biofilms. However, the 15-s exposure and 3-ms pulse period were viewed as optimum when considering exposure time, efficacy, and safety.

Total variation versus wavelet-based methods for image denoising in fluorescence lifetime imaging microscopy

We report the first application of wavelet-based denoising (noise removal) methods to time-domain box-car fluorescence lifetime imaging microscopy (FLIM) images and compare the results to novel total variation (TV) denoising methods. Methods were tested first on artificial images and then applied to low-light live-cell images. Relative to undenoised images, TV methods could improve lifetime precision up to 10-fold in artificial images, while preserving the overall accuracy of lifetime and amplitude values of a single-exponential decay model and improving local lifetime fitting in live-cell images. Wavelet-based methods were at least 4-fold faster than TV methods, but could introduce significant inaccuracies in recovered lifetime values. The denoising methods discussed can potentially enhance a variety of FLIM applications, including live-cell, in vivo animal, or endoscopic imaging studies, especially under challenging imaging conditions such as low-light or fast video-rate imaging.

In vitro and in vivo high-intensity focused ultrasound thrombolysis

OBJECTIVES

To characterize the ability of high-intensity focused ultrasound to achieve thrombolysis in vitro and investigate the feasibility of this approach as a means of restoring blood flow in thrombus-occluded arteries in vivo.

MATERIALS AND METHODS

All experiments were approved by the Institutional Animal Care Committee. Thrombolysis was performed with a 1.51-MHz focused ultrasound transducer with pulse lengths of 0.1 to 10 milliseconds and acoustic powers up to 300 W. In vitro experiments were performed with blood clots formed from rabbit arterial blood and situated in 2-mm diameter tubing. Both single location and flow bypass recanalization experiments were conducted. In vitro clot erosion was assessed with 30-MHz ultrasound, with debris size measured with filters and a Coulter counter. In vivo clots were initiated in the femoral arteries of rabbits (n = 26). Cavitation signals from bubbles formed during exposure were monitored. In vivo flow restoration was assessed with 23-MHz Doppler ultrasound.

RESULTS

At a single location, in vitro clot erosion volumes increased with exposure power and pulse length, with debris size reducing with increasing pulse length. Flow bypass experiments achieved 99.2% clot erosion with 1.1% of debris above 0.5 mm in size. In vivo, 10 milliseconds pulses were associated with bleeding, but at 1 millisecond, it was feasible to achieve partial flow restoration in 6 of the 10 clots with only 1 of the 10 showing evidence of bleeding. In all cases, thrombolysis occurred only in the presence of cavitation.

CONCLUSION

High-intensity focused ultrasound thrombolysis is feasible as a means of restoring partial blood flow in thrombus-occluded arteries in the absence of thrombolytic agents. The potential for bleeding with this approach requires further investigation.

Endoscopic assessment and prediction of prostate urethral disintegration after histotripsy treatment in a canine model

BACKGROUND AND PURPOSE

Histotripsy is a nonthermal focused ultrasound technology that uses acoustic cavitation to homogenize tissue. Previous research has demonstrated that the prostatic urethra is more resistant to histotripsy effects than prostate parenchyma, a finding that may complicate the creation of transurethral resection of the prostate-like treatment cavities. The purpose of this study was to characterize the endoscopic appearance of the prostatic urethra during and after histotripsy treatment and to identify features that are predictive of urethral disintegration.

MATERIALS AND METHODS

Thirty-five histotripsy treatments were delivered in a transverse plane traversing the prostatic urethra in 17 canine subjects (1-3/prostate ≥1 cm apart). Real-time endoscopy was performed in the first four subjects to characterize development of acute urethral treatment effect (UTE). Serial postprocedure endoscopy was performed in all subjects to assess subsequent evolution of UTE.

RESULTS

Endoscopy during histotripsy was feasible with observation of intraurethral cavitation, allowing characterization of the real-time progression of UTE from normal to frank urethral disintegration. While acute urethral fragmentation occurred in 3/35 (8.6%) treatments, frank urethral disintegration developed in 24/35 (68.5%) within 14 days of treatment. Treating until the appearance of hemostatic pale gray shaggy urothelium was the best predictor of achieving urethral fragmentation within 14 days of treatment with positive and negative predictive values of 0.91 and 0.89, respectively.

CONCLUSION

Endoscopic assessment of the urethra may be a useful adjunct to prostatic histotripsy to help guide therapy to ensure urethral disintegration, allowing drainage of the homogenized adenoma and effective tissue debulking.

Experimental investigation of the effect of stiffness, exposure time and scan direction on the dimension of ultrasound histotripsy lesions

Histotripsy uses high-intensity focused ultrasound to create energetic bubble clouds inside tissue to liquefy a region and has the advantages of higher contrast B-mode monitoring and sharp borders. This study experimentally investigated the effects of stiffness, exposure time and scan direction on the size of histotripsy-induced lesions in agar samples. A targeted region 0.45 cm wide (lateral) and 0.6 cm deep (axial) was scanned with the step sizes of 0.075 cm and 0.3 cm, respectively. The single-element spherically focused source (1.1 MHz, 6.34 cm focal length, f/1) had the peak compressional and rarefactional pressures of approximately 102 and 17 MPa. Pulses consisted of 20-cycle sine wave tone bursts with a burst period of 3 ms and exposure time of 15, 30 or 60 s. Also, both inward and outward scan direction were tested along the beam axis. The liquefied lesions generally had a larger size than the initially targeted region with larger sizes corresponding to softer agar and longer exposure. There was not a statistically significant difference in the lesion size with scan direction.

In vitro comminution of model renal calculi using histotripsy

Shock wave lithotripsy (SWL) suffers from the fact that it can produce residual stone fragments of significant size (>2 mm). Mechanistically, cavitation has been shown to play an important role in the reduction of such fragments to smaller debris. In this study, we assessed the feasibility of using cavitationally-based pulsed ultrasound therapy (histotripsy) to erode kidney stones. Previous work has shown that histotripsy is capable of mechanically fractionating soft tissue into fine, acellular debris. Here, we investigated the potential for translating this technology to renal calculi through the use of a commonly accepted stone model. Stone models were sonicated using a 1-MHz focused transducer, with 5-cycle pulses delivered at a rate of 1 kHz. Pulses having peak negative pressures ranging from 3 to 21 MPa were tested. Results indicate that histotripsy is capable of effectively eroding the stone model, achieving an average stone erosion rate of 26 mg/min at maximum treatment pressure; substantial stone erosion was only observed in the presence of a dense cavitational bubble cloud. Sequential sieving of residual stone fragments indicated that debris produced by histotripsy was smaller than 100 μm in size, and treatment monitoring showed that both the cavitational bubble cloud and model stone appear as hyperechoic regions on B-mode imaging. These preliminary results indicate that histotripsy shows promise in its use for stone comminution, and an optimized erosion process may provide a potential adjunct to conventional SWL procedures.

Non-invasive pulsed cavitational ultrasound for fetal tissue ablation: feasibility study in a fetal sheep model

OBJECTIVES

Currently available fetal intervention techniques rely on invasive procedures that carry inherent risks. A non-invasive technique for fetal intervention could potentially reduce the risk of fetal and obstetric complications. Pulsed cavitational ultrasound therapy (histotripsy) is an ablation technique that mechanically fractionates tissue at the focal region using extracorporeal ultrasound. In this study, we investigated the feasibility of using histotripsy as a non-invasive approach to fetal intervention in a sheep model.

METHODS

The experiments involved 11 gravid sheep at 102-129 days of gestation. Fetal kidney, liver, lung and heart were exposed to ultrasound pulses (< 10 µs) delivered by an external 1-MHz focused ultrasound transducer at a 0.2-1-kHz pulse-repetition rate and 10-16 MPa peak negative pressure. Procedures were monitored and guided by real-time ultrasound imaging. Treated organs were examined by gross and histological inspection for location and degree of tissue injury.

RESULTS

Hyperechoic, cavitating bubble clouds were successfully generated in 19/31 (61%) treatment attempts in 27 fetal organs beneath up to 8 cm of overlying tissue and fetal bones. Histological assessment confirmed lesion locations and sizes corresponding to regions where cavitation was monitored, with no lesions found when cavitation was absent. Inability to generate cavitation was primarily associated with increased depth to target and obstructing structures such as fetal limbs.

CONCLUSION

Extracorporeal histotripsy therapy successfully created targeted lesions in fetal sheep organs without significant damage to overlying structures. With further improvements, histotripsy may evolve into a viable technique for non-invasive fetal intervention procedures.

Combined passive detection and ultrafast active imaging of cavitation events induced by short pulses of high-intensity ultrasound

The activation of natural gas nuclei to induce larger bubbles is possible using short ultrasonic excitations of high amplitude, and is required for ultrasound cavitation therapies. However, little is known about the distribution of nuclei in tissues. Therefore, the acoustic pressure level necessary to generate bubbles in a targeted zone and their exact location are currently difficult to predict. To monitor the initiation of cavitation activity, a novel all-ultrasound technique sensitive to single nucleation events is presented here. It is based on combined passive detection and ultrafast active imaging over a large volume using the same multi-element probe. Bubble nucleation was induced using a focused transducer (660 kHz, f-number = 1) driven by a high-power electric burst (up to 300 W) of one to two cycles. Detection was performed with a linear array (4 to 7 MHz) aligned with the single-element focal point. In vitro experiments in gelatin gel and muscular tissue are presented. The synchronized passive detection enabled radio-frequency data to be recorded, comprising high-frequency coherent wave fronts as signatures of the acoustic emissions linked to the activation of the nuclei. Active change detection images were obtained by subtracting echoes collected in the unnucleated medium. These indicated the appearance of stable cavitating regions. Because of the ultrafast frame rate, active detection occurred as quickly as 330 μs after the high-amplitude excitation and the dynamics of the induced regions were studied individually.

Histotripsy fractionation of prostate tissue: local effects and systemic response in a canine model

PURPOSE

Histotripsy is an extracorporeal ultrasound technology that uses cavitational mechanisms to produce nonthermal tissue destruction. Previously we reported the feasibility of histotripsy for prostate tissue fractionation and immediate debulking. In this study we characterized the local effects and systemic response after histotripsy treatment of prostate tissue in an in vivo canine model.

MATERIALS AND METHODS

Histotripsy was applied transabdominally to the prostate in 18 intact male canine subjects under general anesthesia. Acoustic bursts (4 μseconds) were delivered at a 300 Hz pulse repetition rate from a highly focused 750 kHz piezoelectric ultrasound transducer with a 15 cm aperture and 3 × 3 × 8 mm focal volume. Specimens of the prostate and surrounding structures were obtained at prescribed time points (0, 7, 28 or 56 days) after histotripsy. Blood and urine parameters were assessed periodically while clinical evaluation incorporating a validated veterinary pain scale was performed daily.

RESULTS

Conventional transrectal ultrasound facilitated targeting of the focal volume and provided real-time assessment of cavitation activity. Fractionation of the targeted volume and clearance of the resultant debris with urination produced a treatment cavity in each prostate. No acoustic collateral damage was seen and urothelialization of the treatment cavity developed within 28 days of treatment. Only transient laboratory value abnormalities and minimal hematuria were noted after treatment. Pain scores revealed only mild posttreatment discomfort.

CONCLUSIONS

Histotripsy produced consistent tissue fractionation and prostate debulking without collateral acoustic injury or clinical side effects and it was well tolerated in the canine model.

Active focal zone sharpening for high-precision treatment using histotripsy

The goal of this study is to develop a focal zone sharpening strategy that produces more precise lesions for pulsed cavitational ultrasound therapy, or histotripsy. Precise and well-confined lesions were produced by locally suppressing cavitation in the periphery of the treatment focus without affecting cavitation in the center. The local suppression of cavitation was achieved using cavitation nuclei preconditioning pulses to actively control cavitation in the periphery of the focus. A 1-MHz 513-element therapeutic array was used to generate both the therapy and the nuclei preconditioning pulses. For therapy, 10-cycle bursts at 100-Hz pulse repetition frequency with P-/P+ pressure of 21/76 MPa were delivered to the geometric focus of the therapeutic array. For nuclei preconditioning, a different pulse was delivered to an annular region immediately surrounding the focus before each therapy pulse. A parametric study on the effective pressure, pulse duration, and delivery time of the preconditioning pulse was conducted in red blood cell-gel phantoms, where cavitational damage was indicated by the color change resulting from local cell lysis. Results showed that a short-duration (20 μs) preconditioning pulse at a medium pressure (P-/P+ pressure of 7.2/13.6 MPa) delivered shortly before (30 μs) the therapy pulse substantially suppressed the peripheral damage by 77 ± 13% while complete fractionation in the focal center was maintained. High-speed imaging of the bubble cloud showed a substantial decrease in the maximum width of the bubble cloud by 48 ± 24% using focal zone sharpening. Experiments in ex vivo livers confirmed that highly confined lesions were produced in real tissues as well as in the phantoms. This study demonstrated the feasibility of active focal zone sharpening using cavitation nuclei preconditioning, allowing for increased treatment precision compared with the natural focal width of the therapy transducer.

Therapeutic ultrasound to noninvasively create intracardiac communications in an intact animal model

OBJECTIVE

To determine if pulsed cavitational ultrasound therapy (histotripsy) can accurately and safely generate ventricular septal defects (VSDs) through the intact chest of a neonatal animal, with the eventual goal of developing a noninvasive technique of creating intra-cardiac communications in patients with congenital heart disease.

BACKGROUND

Histotripsy is an innovative ultrasonic technique that generates demarcated, mechanical tissue fractionation utilizing high intensity ultrasound pulses. Previous work has shown that histotripsy can create atrial septal defects in a beating heart in an open-chest canine model.

METHODS

Nine neonatal pigs were treated with transcutaneous histotripsy targeting the ventricular septum. Ultrasound pulses of 5-μsec duration at a peak negative pressure of 13 MPa and a pulse repetition frequency of 1 kHz were generated by a 1 MHz focused transducer. The procedure was guided by real-time ultrasound imaging.

RESULTS

VSDs were created in all pigs with diameters ranging from 2 to 6.5 mm. Six pigs were euthanized within 2 hrs of treatment, while three were recovered and maintained for 2-3 days to evaluate lesion maturation and clinical side effects. There were only transient clinical effects and pathology revealed mild collateral damage around the VSD with no significant damage to other cardiac or extra-cardiac structures.

CONCLUSIONS

Histotripsy can accurately and safely generate VSDs through the intact chest in a neonatal animal model. These results suggest that with further advances, histotripsy can be a useful, noninvasive technique to create intracardiac communications, which currently require invasive catheter-based or surgical procedures, to clinically stabilize newborn infants with complex congenital heart disease.

Enhancing precision in time-domain fluorescence lifetime imaging

In biological applications of fluorescence lifetime imaging, low signals from samples can be a challenge, causing poor lifetime precision. We demonstrate how optimal signal gating (a method applied to the temporal dimension of a lifetime image) and novel total variation denoising models (a method applied to the spatial dimension of a lifetime image) can be used in time-domain fluorescence lifetime imaging microscopy (FLIM) to improve lifetime precision. In time-gated FLIM, notable fourfold precision improvements were observed in a low-light example. This approach can be employed to improve FLIM data while minimizing sample light exposure and increasing imaging speed.

Noninvasive creation of an atrial septal defect by histotripsy in a canine model

BACKGROUND

The primary objective of this study was to develop an image-guided, noninvasive procedure to create or enlarge an atrial septal defect for the treatment of neonates with hypoplastic left heart syndrome and an intact or restrictive atrial septum. Histotripsy is an innovative ultrasonic technique that produces nonthermal, mechanical tissue fractionation through the use of high-intensity ultrasound pulses. This article reports the pilot in vivo study to create an atrial septal defect through the use of extracardiac application of histotripsy in an open-chest canine model.

METHODS AND RESULTS

In 10 canines, the atrial septum was exposed to histotripsy by an ultrasound transducer positioned outside the heart. Ultrasound pulses of 6-microsecond duration at a peak negative pressure of 15 MPa and a pulse repetition frequency of 3.3 kHz were generated by a 1-MHz focused transducer. The procedure was guided and monitored by real-time ultrasound imaging. In 9 of 10 canines, an atrial septal defect was produced, and shunting across the atrial septum was visualized. Pathology of the hearts showed atrial septal defects with minimal damage to surrounding tissue. No damage was found on the epicardial surface of the heart or other structures.

CONCLUSIONS

Under real-time ultrasound guidance, atrial septal defects were successfully created with extracardiac histotripsy in a live canine model. Although further studies in an intact animal model are needed, these results provide promise of histotripsy becoming a valuable clinical tool.

Prostate histotripsy in an anticoagulated model

OBJECTIVES

To further explore the phenomenon of minimal bleeding after histotripsy by performing extensive prostate histotripsy treatments in anticoagulated canines. Histotripsy is a noninvasive ultrasound technology which induces microbubble formation (cavitation) within tissues producing mechanical tissue fractionation. During initial in vivo feasibility canine studies of prostate ablation, minimal hematuria was observed.

METHODS

Histotripsy was performed on 9 canine subjects pretreated with 6 mg of oral warfarin for 3-5 days using an extracorporeal 750 kHz therapeutic ultrasound transducer delivering acoustic pulses to the prostatic urethra and periurethral parenchyma. After 7-28 days, the subjects were euthanized, transrectal prostate ultrasound was performed, and the prostate was harvested. Serum hemoglobin and International Normalization Ratio were measured immediately before histotripsy treatment and at euthanasia.

RESULTS

Mean treatment International Normalization Ratio was 4.6 (median, 2.4; range, 1.2-11.3). There was no clinically significant change in hemoglobin concentration at euthanasia compared with baseline. At harvest, histologic sections of the prostate revealed a large cavity corresponding to the planned treatment volume incorporating the prostatic urethra and parenchyma in all subjects. Urine was clear within 2 days of treatment, and no blood clots were seen.

CONCLUSIONS

Despite therapeutic and supratherapeutic anticoagulation, histotripsy resulted in minimal bleeding despite significant fractionation and tissue debulking of the prostate. These results have prompted further studies to understand the mechanism of nonthermal hemostasis underlying histotripsy.

Size measurement of tissue debris particles generated from pulsed ultrasound cavitational therapy-histotripsy

Extensive mechanical tissue fractionation can be achieved using successive high intensity ultrasound pulses ("histotripsy"). Histotripsy has many potential medical applications where noninvasive tissue removal is desired (e.g., tumor ablation). There is a concern that debris generated by histotripsy-induced tissue fractionation might be an embolization hazard. The aim of this study is to measure the size distribution of these tissue debris particles. Histotripsy pulses were produced by a 513-element 1 MHz array transducer, an 18-element 750 kHz array transducer and a 788 kHz single element transducer. Peak negative pressures of 11 to 25 MPa, pulse durations of 3 to 50 cycles, pulse repetition frequencies of 100 Hz to 2 kHz were used. Tissue debris particles created by histotripsy were collected and measured with a particle sizing system. In the resulting samples, debris <6 microm in diameter constituted >99% of the total number of tissue particles. The largest particle generated by one of the parameter sets tested was 54 microm in diameter, which is smaller than the clinic filter size (100 microm) used to prevent embolization. The largest particles generated using other parameter sets were larger than 60 microm but the value could not be specified using our current setup. Exposures with shorter pulses produced lower percentages of large tissue debris (>30 microm) in comparison to longer pulses. These results suggest that the tissue debris particle size distribution is adjustable by altering acoustic parameters if necessary.

Evolution of bubble clouds induced by pulsed cavitational ultrasound therapy - histotripsy

Mechanical tissue fractionation can be achieved using successive, high-intensity ultrasound pulses in a process termed histotripsy. Histotripsy has many potential clinical applications where noninvasive tissue removal is desired. The primary mechanism for histotripsy is believed to be cavitation. Using fast-gated imaging, this paper studies the evolution of a cavitating bubble cloud induced by a histotripsy pulse (10 and 14 cycles) at peak negative pressures exceeding 21MPa. Bubble clouds are generated inside a gelatin phantom and at a tissue-water interface, representing two situations encountered clinically. In both environments, the imaging results show that the bubble clouds share the same evolutionary trend. The bubble cloud and individual bubbles in the cloud were generated by the first cycle of the pulse, grew with each cycle during the pulse, and continued to grow and collapsed several hundred microseconds after the pulse. For example, the bubbles started under 10 microm, grew to 50 microm during the pulse, and continued to grow 100 microm after the pulse. The results also suggest that the bubble clouds generated in the two environments differ in growth and collapse duration, void fraction, shape, and size. This study furthers our understanding of the dynamics of bubble clouds induced by histotripsy.

Gene transduction by sonoporation

Gene transduction technologies are essential tools for understanding of gene functions or gene cascades underlying embryogenesis. In this review, we introduce a gene transduction method using microbubble and ultrasound (hereafter referred to as sonoporation). Sonoporation is carried out with relatively simple procedures and easily transduces genes into mesenchymal cells without significant damage to target tissues. Therefore, sonoporation is effective for gene transduction to study the molecular mechanisms of morphogenesis.