Histotripsy beyond the intrinsic cavitation threshold using very short ultrasound pulses: microtripsy

Noninvasive thrombolysis using microtripsy: a parameter study

Histotripsy fractionates soft tissue by well-controlled acoustic cavitation using microsecond-long, high-intensity ultrasound pulses. The feasibility of using histotripsy as a noninvasive, drug-free, and image-guided thrombolysis method has been shown previously. A new histotripsy approach, termed microtripsy, has recently been investigated for the thrombolysis application to improve treatment accuracy and avoid potential vessel damage. In this study, we investigated the effects of pulse repetition frequency (PRF) on microtripsy thrombolysis. Microtripsy thrombolysis treatments using different PRFs (5, 50, and 100 Hz) and doses (20, 50, and 100 pulses) were performed on blood clots in an in vitro vessel flow model. To quantitatively evaluate the microtripsy thrombolysis effect, the location of focal cavitation, the incident rate of pre-focal cavitation on the vessel wall, the size and location of the resulting flow channel, and the generated clot debris particles were measured. The results demonstrated that focal cavitation was always well confined in the vessel lumen without contacting the vessel wall for all PRFs. Pre-focal cavitation on the front vessel wall was never observed at 5Hz PRF, but occasionally observed at PRFs of 50 Hz (1.2%) and 100 Hz (5.4%). However, the observed pre-focal cavitation was weak and did not significantly affect the focal cavitation. Results further demonstrated that, although the extent of clot fractionation per pulse was the highest at 5 Hz PRF at the beginning of treatment (<20 pulses), 100 Hz PRF generated the largest flow channels with a much shorter treatment time. Finally, results showed fewer large debris particles were generated at a higher PRF. Overall, the results of this study suggest that a higher PRF (50 or 100 Hz) may be a better choice for microtripsy thrombolysis to use clinically due to the larger resulting flow channel, shorter treatment time, and smaller debris particles.

Removal of residual cavitation nuclei to enhance histotripsy fractionation of soft tissue

Remanent bubble nuclei generated by primary cavitation collapse can limit the efficiency of histotripsy softtissue fractionation. When these residual bubbles persist from one histotripsy pulse to the next, they can seed the repetitive nucleation of cavitation bubbles at a discrete set of sites within the focal volume. This effect-referred to as cavitation memory- manifests in inefficient lesion formation, because certain sites within the focal volume are overtreated whereas others remain undertreated. Although the cavitation memory effect can be passively mitigated by using a low pulse repetition frequency (PRF) that affords remanent nuclei sufficient time for dissolution between successive pulses, this low PRF also results in slow lesion production. As such, it would be highly desirable to maintain the high per-pulse efficiency associated with low pulse rates when much higher PRFs are utilized. In this vein, we have developed a strategy for the active removal of the remanent bubble nuclei following primary cavitation collapse, using low-amplitude ultrasound sequences (termed bubble-removal sequences) to stimulate the aggregation and subsequent coalescence of these bubbles. In this study, bubbleremoval sequences were incorporated in high-PRF histotripsy treatment (100 Hz) of a red blood cell tissue-mimicking phantom that allows for the visualization of lesion development in real time. A series of reference treatments were also conducted at the low PRF of 1 Hz to provide a point of comparison for which cavitation memory effects are minimal. It was found that bubble-removal sequences as short as 1 ms are capable of maintaining the efficacious lesion development characteristics associated with the low PRF of 1 Hz when the much higher pulse rate of 100 Hz is used. These results were then extended to the treatment of a large volume within the tissue phantom, and optimal bubble-removal sequences identified for the singlefocal- spot case were utilized to homogenize a 10 × 10 mm region at high rate.

Damage in spherical cellular membrane generated by the shock waves: coarse-grained molecular dynamics simulation of lipid vesicle

Traumatic Brain Injury is a major health issue that is hard to diagnose since it often occurs without signs of external injuries. While it is well known that exposure of biological cells to shock waves causes damage to the cell membrane, it is currently unknown by which mechanisms damage is caused, and how it depends on physical parameters such as shock wave velocity, shock pulse duration, or shock pulse shape. In this computational study, we use a coarse-grained model of the lipid vesicle as a generic model of a cell membrane to elucidate the general principles of the cellular damage induced by the shock wave direct passage through the cranium. Results indicate that the extent of the liposome compression does not strongly depend on the pressure pulse and that liposome extension is very sensitive to the change in the negative pressure phase. The structural integrity of the vesicle is altered as pores form in the lipid membrane at overall pressure impulses generated by supersonic shock waves, which are greater than 5 Pa·s at single or repetitive exposure. Consequently, these permeability changes may lead to changes in the influx of sodium, potassium, and calcium ions.

Histotripsy Lesion Formation Using an Ultrasound Imaging Probe Enabled by a Low-Frequency Pump Transducer

When histotripsy pulses shorter than 2 cycles are applied, the formation of a dense bubble cloud relies only on the applied peak negative pressure (p-) exceeding the "intrinsic threshold" of the medium (absolute value of 26-30 MPa in most soft tissues). It has been found that a sub-threshold high-frequency probe pulse (3 MHz) can be enabled by a sub-threshold low-frequency pump pulse (500 kHz) where the sum exceeds the intrinsic threshold, thus generating lesion-producing dense bubble clouds ("dual-beam histotripsy"). Here, the feasibility of using an imaging transducer to provide the high-frequency probe pulse in the dual-beam histotripsy approach is investigated. More specifically, an ATL L7-4 imaging transducer (Philips Healthcare, Andover, MA, USA), pulsed by a V-1 Data Acquisition System (Verasonics, Redmond, WA, USA), was used to generate the high-frequency probe pulses. The low-frequency pump pulses were generated by a 20-element 345-kHz array transducer, driven by a custom high-voltage pulser. These dual-beam histotripsy pulses were applied to red blood cell tissue-mimicking phantoms at a pulse repetition frequency of 1 Hz, and optical imaging was used to visualize bubble clouds and lesions generated in the red blood cell phantoms. The results indicated that dense bubble clouds (and resulting lesions) were generated when the p- of the sub-threshold pump and probe pulses combined constructively to exceed the intrinsic threshold. The average size of the smallest reproducible lesions using the imaging probe pulse enabled by the sub-threshold pump pulse was 0.7 × 1.7 mm, whereas that using the supra-threshold pump pulse alone was 1.4 × 3.7 mm. When the imaging transducer was steered laterally, bubble clouds and lesions were steered correspondingly until the combined p- no longer exceeded the intrinsic threshold. These results were also validated with ex vivo porcine liver experiments. Using an imaging transducer for dual-beam histotripsy can have two advantages: (i) lesion steering can be achieved using the steering of the imaging transducer (implemented with the beamformer of the accompanying programmable ultrasound system), and (ii) treatment can be simultaneously monitored when the imaging transducer is used in conjunction with an ultrasound imaging system.

Noninvasive thrombolysis using histotripsy beyond the intrinsic threshold (microtripsy)

Histotripsy has been investigated as a noninvasive, drug-free, image-guided thrombolysis method that fractionates blood clots using acoustic cavitation alone. In previous histotripsy-mediated thrombolysis studies, cavitation clouds were generated using multi-cycle pulses and tended to form on vessel wall. To avoid potential cavitational damage to the vessel wall, a new histotripsy approach, termed microtripsy, has been recently discovered in which cavitation is generated via an intrinsic-threshold mechanism using single-cycle pulses. We hypothesize that microtripsy can generate and confine cavitation in vessel lumen without contacting the vessel wall, which results in recanalization within the clot and potentially eliminating vessel damage. To test our hypothesis, microtripsy was investigated for clot recanalization in an in vitro flow model. Clots were formed inside a vessel phantom (6.5 mm inner diameter) in line with a flow system. Microtripsy was applied by a 1-MHz transducer at a pulse repetition frequency of 50 Hz with a peak negative pressure (P-) of 30 MPa or 36 MPa. To create a flow channel through a clot, the cavitation focus was scanned through the clot at an interval of 0.3 or 0.7 mm. The treated clots were 3-D-scanned by a 20-MHz ultrasound probe to quantify the channels. Restored flow rates were measured and clot debris particles generated from the treatments were analyzed. In all treatments, the cavitation cloud was consistently generated in the center of the vessel lumen without contacting the vessel wall. After each treatment, a flow channel was successfully generated through and completely confined inside the clot. The channels had a diameter up to 60% of the vessel diameter, with restored flow up to 500 mL/min. The debris particles were small with more than 99.9% <10 μm and the largest at 153 um. Each clot (2 cm long) was recanalized within 7 min. The size of the flow channels increased by using higher P- and was significantly larger by using the 0.3 mm scan interval than those using 0.7 mm. The results in this study show the potential of this new microtripsy thrombolysis method for fast, precise, and effective clot recanalization, minimizing risks of vessel damage and embolism.

Effects of ultrasound frequency and tissue stiffness on the histotripsy intrinsic threshold for cavitation

Histotripsy is an ultrasound ablation method that depends on the initiation of a cavitation bubble cloud to fractionate soft tissue. Previous work has indicated that a cavitation cloud can be formed by a single pulse with one high-amplitude negative cycle, when the negative pressure amplitude directly exceeds a pressure threshold intrinsic to the medium. We hypothesize that the intrinsic threshold in water-based tissues is determined by the properties of the water inside the tissue, and changes in tissue stiffness or ultrasound frequency will have a minimal impact on the histotripsy intrinsic threshold. To test this hypothesis, the histotripsy intrinsic threshold was investigated both experimentally and theoretically. The probability of cavitation was measured by subjecting tissue phantoms with adjustable mechanical properties and ex vivo tissues to a histotripsy pulse of 1-2 cycles produced by 345-kHz, 500-kHz, 1.5-MHz and 3-MHz histotripsy transducers. Cavitation was detected and characterized by passive cavitation detection and high-speed photography, from which the probability of cavitation was measured versus pressure amplitude. The results revealed that the intrinsic threshold (the negative pressure at which probability = 0.5) is independent of stiffness for Young's moduli (E) <1 MPa, with only a small increase (∼2-3 MPa) in the intrinsic threshold for tendon (E = 380 MPa). Additionally, results for all samples revealed only a small increase of ∼2-3 MPa when the frequency was increased from 345 kHz to 3 MHz. The intrinsic threshold was measured to be between 24.7 and 30.6 MPa for all samples and frequencies tested in this study. Overall, the results of this study indicate that the intrinsic threshold to initiate a histotripsy bubble cloud is not significantly affected by tissue stiffness or ultrasound frequency in the hundreds of kilohertz to megahertz range.

Real-time feedback of histotripsy thrombolysis using bubble-induced color Doppler

Histotripsy thrombolysis is a non-invasive, drug-free, image-guided therapy that fractionates blood clots using well-controlled acoustic cavitation alone. Real-time quantitative feedback is highly desired during histotripsy thrombolysis treatment to monitor the progress of clot fractionation. Bubble-induced color Doppler (BCD) monitors the motion after cavitation generated by each histotripsy pulse, which has been found in gel and ex vivo liver tissue to be correlated with histotripsy fractionation. We investigated the potential of BCD to quantitatively monitor histotripsy thrombolysis in real time. To visualize clot fractionation, transparent three-layered fibrin clots were developed. Results indicated that a coherent motion follows the cavitation generated by each histotripsy pulse with a push and rebound pattern. The temporal profile of this motion expands and saturates as treatment progresses. A strong correlation exists between the degree of histotripsy clot fractionation and two metrics extracted from BCD: time of peak rebound velocity (tPRV) and focal mean velocity at a fixed delay (Vf,delay). The saturation of clot fractionation (i.e., treatment completion) matches well the saturations detected using tPRV and Vf,delay. The mean Pearson correlation coefficients between the progression of clot fractionation and the two BCD metrics were 93.1% and 92.6%, respectively. To validate BCD feedback in in vitro clots, debris volumes from histotripsy thrombolysis were obtained at different therapy doses and compared with Vf,delay. There is also good agreement between the increasing and saturation trends of debris volume and Vf,delay. Finally, a real-time BCD feedback algorithm to predict complete clot fractionation during histotripsy thrombolysis was developed and tested. This work illustrates the potential of BCD to monitor histotripsy thrombolysis treatment in real time.

Histotripsy methods in mechanical disintegration of tissue: towards clinical applications

In high intensity focused ultrasound (HIFU) therapy, an ultrasound beam is focused within the body to locally affect the targeted site without damaging intervening tissues. The most common HIFU regime is thermal ablation. Recently there has been increasing interest in generating purely mechanical lesions in tissue (histotripsy). This paper provides an overview of several studies on the development of histotripsy methods toward clinical applications. Two histotripsy approaches and examples of their applications are presented. In one approach, sequences of high-amplitude, short (microsecond-long), focused ultrasound pulses periodically produce dense, energetic bubble clouds that mechanically disintegrate tissue. In an alternative approach, longer (millisecond-long) pulses with shock fronts generate boiling bubbles and the interaction of shock fronts with the resulting vapour cavity causes tissue disintegration. Recent preclinical studies on histotripsy are reviewed for treating benign prostatic hyperplasia (BPH), liver and kidney tumours, kidney stone fragmentation, enhancing anti-tumour immune response, and tissue decellularisation for regenerative medicine applications. Potential clinical advantages of the histotripsy methods are discussed. Histotripsy methods can be used to mechanically ablate a wide variety of tissues, whilst selectivity sparing structures such as large vessels. Both ultrasound and MR imaging can be used for targeting and monitoring the treatment in real time. Although the two approaches utilise different mechanisms for tissue disintegration, both have many of the same advantages and offer a promising alternative method of non-invasive surgery.

Effects of tissue stiffness, ultrasound frequency, and pressure on histotripsy-induced cavitation bubble behavior

Histotripsy is an ultrasound ablation method that controls cavitation to fractionate soft tissue. In order to effectively fractionate tissue, histotripsy requires cavitation bubbles to rapidly expand from nanometer-sized initial nuclei into bubbles often larger than 50 µm. Using a negative pressure high enough to initiate a bubble cloud and expand bubbles to a sufficient size, histotripsy has been shown capable of completely fractionating soft tissue into acelluar debris resulting in effective tissue removal. Previous work has shown that the histotripsy process is affected by tissue mechanical properties with stiffer tissues showing increased resistance to histotripsy fractionation, which we hypothesize to be caused by impeded bubble expansion in stiffer tissues. In this study, the hypothesis that increases in tissue stiffness cause a reduction in bubble expansion was investigated both theoretically and experimentally. High speed optical imaging was used to capture a series of time delayed images of bubbles produced inside mechanically tunable agarose tissue phantoms using histotripsy pulses produced by 345 kHz, 500 kHz, 1.5 MHz, and 3 MHz histotripsy transducers. The results demonstrated a significant decrease in maximum bubble radius (Rmax) and collapse time (tc) with both increasing Young's modulus and increasing frequency. Furthermore, results showed that Rmax was not increased by raising the pressure above the intrinsic threshold. Finally, this work demonstrated the potential of using a dual-frequency strategy to modulate the expansion of histotripsy bubbles. Overall, the results of this study improve our understanding of how tissue stiffness and ultrasound parameters affect histotripsy-induced bubble behavior and provide a rational basis to tailor acoustic parameters for treatment of the specific tissues of interest.

Rapid prototyping fabrication of focused ultrasound transducers

Rapid prototyping (RP) fabrication techniques are currently widely used in diverse industrial and medical fields, providing substantial advantages in development time and costs in comparison to more traditional manufacturing processes. This paper presents a new method for the fabrication of high-intensity focused ultrasound transducers using RP technology. The construction of a large-aperture hemispherical transducer designed by computer software is described to demonstrate the process. The transducer was conceived as a modular design consisting of 32 individually focused 50.8-mm (2-in) PZT-8 element modules distributed in a 300-mm hemispherical scaffold with a geometric focus of 150 mm. The entire structure of the array, including the module housings and the hemispherical scaffold was fabricated through a stereolithography (SLA) system using a proprietary photopolymer. The PZT elements were bonded to the lenses through a quarter-wave tungsten-epoxy matching layer developed in-house specifically for this purpose. Modules constructed in this manner displayed a high degree of electroacoustic consistency, with an electrical impedance mean and standard deviation of 109 ± 10.2 Ω for the 32 elements. Time-of-flight measurements for individually pulsed modules mounted on the hemispherical scaffold showed that all pulses arrived at the focus within a 350 ns range, indicating a good degree of element alignment. Pressure profile measurements of the fully assembled transducer also showed close agreement with simulated results. The measured focal beam FWHM dimensions were 1.9 × 4.0 mm (1.9 × 3.9 mm simulated) in the transversal and axial directions respectively. Total material expenses associated with the construction of the transducer were approximately 5000 USD (as of 2011). The versatility and lower fabrication costs afforded by RP methods may be beneficial in the development of complex transducer geometries suitable for a variety of research and clinical applications.

Imaging feedback for histotripsy by characterizing dynamics of acoustic radiation force impulse (ARFI)-induced shear waves excited in a treated volume

Our previous study indicated that shear waves decay and propagate at a lower speed as they propagate into a tissue volume mechanically fractionated by histotripsy. In this paper, we hypothesize that the change in the shear dynamics is related to the degree of tissue fractionation, and can be used to predict histotripsy treatment outcomes. To test this hypothesis, lesions with different degrees of tissue fractionation were created in agar-graphite tissue phantoms and ex vivo kidneys with increasing numbers of therapy pulses, from 0 to 2000 pulses per treatment location. The therapy pulses were 3-cycle 750-kHz focused ultrasound delivered at a peak negative/positive pressure of 17/108 MPa and a repetition rate of 50 Hz. The shear waves were excited by acoustic radiation force impulse (ARFI) focused at the center of the lesion. The spatial and temporal behavior of the propagating shear waves was measured with ultrasound plane wave imaging. The temporal displacement profile at a lateral location 10 mm offset to the shear excitation region was detected with M-mode imaging. The decay and delay of the shear waves were quantitatively characterized on the temporal displacement profile. Results showed significant changes in two characteristics on the temporal displacement profile: the peak-to-peak displacement decayed exponentially with increasing numbers of therapy pulses; the relative time-to-peak displacement increased with increasing numbers of therapy pulses, and appeared to saturate at higher numbers of pulses. Correspondingly, the degree of tissues fractionation, as indicated by the percentage of structurally intact cell nuclei, decreased exponentially with increasing numbers of therapy pulses. Strong linear correlations were found between the two characteristics and the degree of tissue fractionation. These results suggest that the characteristics of the shear temporal displacement profile may provide useful feedback information regarding the treatment outcomes.

Synthesis of monopolar ultrasound pulses for therapy: the frequency-compounding transducer

In diagnostic ultrasound, broadband transducers capable of short acoustic pulse emission and reception can improve axial resolution and provide sufficient bandwidth for harmonic imaging and multi-frequency excitation techniques. In histotripsy, a cavitation-based ultrasound therapy, short acoustic pulses (<2 cycles) can produce precise tissue ablation wherein lesion formation only occurs when the applied peak negative pressure exceeds an intrinsic threshold of the medium. This paper investigates a frequency compounding technique to synthesize nearly monopolar (half-cycle) ultrasound pulses. More specifically, these pulses were generated using a custom transducer composed of 23 individual relatively-broadband piezoceramic elements with various resonant frequencies (0.5, 1, 1.5, 2, and 3 MHz). Each frequency component of the transducer was capable of generating 1.5-cycle pulses with only one high-amplitude negative half-cycle using a custom 23-channel high-voltage pulser. By varying time delays of individual frequency components to allow their principal peak negative peaks to arrive at the focus of the transducer constructively, destructive interference occurs elsewhere in time and space, resulting in a monopolar pulse approximation with a dominant negative phase (with measured peak negative pressure [P-]: peak positive pressure [P+] = 4.68: 1). By inverting the excitation pulses to individual elements, monopolar pulses with a dominant positive phase can also be generated (with measured P+: P- = 4.74: 1). Experiments in RBC phantoms indicated that monopolar pulses with a dominant negative phase were able to produce very precise histotripsy-type lesions using the intrinsic threshold mechanism. Monopolar pulses with a dominant negative phase can inhibit shock scattering during histotripsy, leading to more predictable lesion formation using the intrinsic threshold mechanism, while greatly reducing any constructive interference, and potential hot-spots elsewhere. Moreover, these monopolar pulses could have many potential benefits in ultrasound imaging, including axial resolution improvement, speckle reduction, and contrast enhancement in pulse inversion imaging.

Dual-beam histotripsy: a low-frequency pump enabling a high-frequency probe for precise lesion formation

Histotripsy produces tissue fractionation through dense energetic bubble clouds generated by short, high-pressure, ultrasound pulses. When using pulses shorter than 2 cycles, the generation of these energetic bubble clouds only depends on where the peak negative pressure (P-) exceeds the intrinsic threshold of the medium (26 to 30 MPa in soft tissue with high water content). This paper investigates a strategic method for precise lesion generation in which a low-frequency pump pulse is applied to enable a sub-threshold high-frequency probe pulse to exceed the intrinsic threshold. This pump-probe method of controlling a supra-threshold volume can be called dual-beam histotripsy. A 20-element dual-frequency (500-kHz and 3-MHz elements confocally aligned) array transducer was used to generate dual-beam histotripsy pulses in red blood cell phantoms and porcine hepatic tissue specimens. The results showed that when sub-intrinsic-threshold pump (500-kHz) and probe (3-MHz) pulses were applied together, dense bubble clouds (and resulting lesions) were only generated when their peak negative pressures combined constructively to exceed the intrinsic threshold. The smallest reproducible lesion varied with the relative amplitude between the pump and probe pulses, and, with a higher proportion of the probe pulse, smaller lesions could be generated. When the propagation direction of the probe pulse relative to the pump pulse was altered, the shape of the produced lesion changed based on the region that exceeded intrinsic threshold. Because the low-frequency pump pulse is more immune to attenuation and aberrations, and the high-frequency probe pulse can provide precision in lesion formation, this dual-beam histotripsy approach would be very useful in situations in which precise lesion formation is required through a highly attenuative and aberrative medium, such as transcranial therapy. This is particularly true if a small low-attenuation acoustic window is available for the high-frequency probe transducer.