Real-time monitoring of focused ultrasound blood-brain barrier opening via subharmonic acoustic emission detection: implementation of confocal dual-frequency piezoelectric transducers

1/2 order subharmonic waves of two cavitation bubbles

In the work, the 1/2 order subharmonic wave of two coupling cavitation bubbles is investigated numerically via Fourier spectrum analysis. By analyzing the dynamics of bubble, we find that the mutual interaction between bubbles can affect the appearance of 1/2 order subharmonic. The results of parameter dependence show that the intensity of 1/2 order subharmonic would be promoted or inhibited with the increase of mutual interaction. The higher the driving amplitude or the smaller the distance between bubbles, the stronger the mutual interaction is, and also the greater the promotion or suppression of the 1/2 order subharmonic is. Moreover, while the 1/2 order subharmonic occurs, the energy of bubble would alternate between two different peaks, and the temperature inside bubble has a similar fluctuation while the bubble collapses. This qualitative analysis suggests that the bubble's dynamics for multi-bubble case is complex. Understanding the generation of subharmonic of bubble's dynamics is of great significance for helpful applying of cavitation bubble.

A High Sensitivity CMUT-Based Passive Cavitation Detector for Monitoring Microbubble Dynamics During Focused Ultrasound Interventions

Tracking and controlling microbubble (MB) dynamics in the human brain through acoustic emission (AE) monitoring during transcranial focused ultrasound (tFUS) therapy are critical for attaining safe and effective treatments. The low-amplitude MB emissions have harmonic and ultra-harmonic components, necessitating a broad bandwidth and low-noise system for monitoring transcranial MB activity. Capacitive micromachined ultrasonic transducers (CMUTs) offer high sensitivity and low noise over a broad bandwidth, especially when they are tightly integrated with electronics, making them a good candidate technology for monitoring the MB activity through human skull. In this study, we designed a 16-channel analog front-end (AFE) electronics with a low-noise transimpedance amplifier (TIA), a band-gap reference circuit, and an output buffer stage. To assess AFE performance and ability to detect MB AE, we combined it with a commercial CMUT array. The integrated system has 12.3 - [Formula: see text] receive sensitivity with 0.085 - [Formula: see text] minimum detectable pressure (MDP) up to 3 MHz for a single element CMUT with 3.78 [Formula: see text] area. Experiments with free MBs in a microfluidic channel demonstrate that our system is able to capture key spectral components of MBs' harmonics when sonicated at clinically relevant frequencies (0.5 MHz) and pressures (250 kPa). Together our results demonstrate that the proposed CMUT system can support the development of novel passive cavitation detectors (PCD) to track MB activity for attaining safe and effective focused ultrasound (FUS) treatments.

Cavitation monitoring, treatment strategy, and acoustic simulations of focused ultrasound blood-brain barrier disruption in patients with glioblastoma

PURPOSE

We report our experience disrupting the blood-brain barrier (BBB) to improve drug delivery in glioblastoma patients receiving temozolomide chemotherapy. The goals of this retrospective analysis were to compare MRI-based measures of BBB disruption and vascular damage to the exposure levels, acoustic emissions data, and acoustic simulations. We also simulated the cavitation detectors.

METHODS

Monthly BBB disruption (BBBD) was performed using a 220 kHz hemispherical phased array focused ultrasound system (Exablate Neuro, InSightec) and Definity microbubbles (Lantheus) over 38 sessions in nine patients. Exposure levels were actively controlled via the cavitation dose obtained by monitoring subharmonic acoustic emissions. The acoustic field and sensitivity profile of the cavitation detection system were simulated. Exposure levels and cavitation metrics were compared to the level of BBBD evident in contrast-enhanced MRI and to hypointense regions in T2*-weighted MRI.

RESULTS

Our treatment strategy evolved from using a relatively high cavitation dose goal to a lower goal and longer sonication duration and ultimately resulted in BBBD across the treatment volume with minimal petechiae. Subsonication-level feedback control of the exposure using acoustic emissions also improved consistency. Simulations of the acoustic field suggest that reflections and standing waves appear when the focus is placed near the skull, but their effects can be mitigated with aberration correction. Simulating the cavitation detectors suggest variations in the sensitivity profile across the treatment volume and between patients. A correlation was observed with the cavitation dose, BBBD and petechial hemorrhage in 8/9 patients, but substantial variability was evident. Analysis of the cavitation spectra found that most bursts did not contain wideband emissions, a signature of inertial cavitation, but biggest contribution to the cavitation dose - the metric used to control the procedure - came from bursts with wideband emissions.

CONCLUSION

Using a low subharmonic cavitation dose with a longer duration resulted in BBBD with minimal petechiae. The correlation between cavitation dose and outcomes demonstrates the benefits of feedback control based on acoustic emissions, although more work is needed to reduce variability. Acoustic simulations could improve focusing near the skull and inform our analysis of acoustic emissions. Monitoring additional frequency bands and improving the sensitivity of the cavitation detection could provide signatures of microbubble activity associated with BBB disruption that were undetected here and could improve our ability to achieve BBB disruption without vascular damage.

Numerical investigation of the effect of bubble properties on the linear resonance frequency shift due to inter-bubble interactions in ultrasonically excited lipid coated microbubbles

Ultrasonically excited microbubbles (MBs) have numerous applications in various fields, such as drug delivery, and imaging. Ultrasonically excited MBs are known to be nonlinear oscillators that generate secondary acoustic emissions in the media when excited by a primary ultrasound wave. The propagation of acoustic waves in the liquid is limited to the speed of sound, resulting in each MB receiving the primary and secondary waves at different times depending on their distance from the ultrasound source and the distance between MBs. These delays are referred to as primary and secondary delays, respectively. A previous study demonstrated that the inclusion of secondary delays in a model describing the interactions between MBs exposed to ultrasound results in an increase in the linear resonance frequency of MBs as they approach each other. This work investigates the impact of various MB properties on the change in linear resonance frequency resulting from changes in inter-bubble distances. The effects of shell properties, including the initial surface tension, surface dilatational viscosity of the shell monolayer, elastic compression modulus of the shell, and the initial radius of the MBs, are examined. MB size is a significant factor influencing the rate of linear resonance frequency increase with increasing concentration. Moreover, it is found that the shell properties of MBs play a negligible role in the rate of change in linear resonance frequency of MBs as the inter-bubble distances change.The findings of this study have implications for various applications of MBs in the biomedical field. By understanding the impact of inter-bubble distances and shell properties on the linear resonance frequency of MBs, the utilization of MBs in applications reliant on their resonant behavior can be optimized.

Focused Ultrasound Blood-Brain Barrier Opening Arrests the Growth and Formation of Cerebral Cavernous Malformations

BACKGROUND

Cerebral cavernous malformations (CCM) are vascular lesions within the central nervous system, consisting of dilated and hemorrhage-prone capillaries. CCMs can cause debilitating neurological symptoms, and surgical excision or stereotactic radiosurgery are the only current treatment options. Meanwhile, transient blood-brain barrier opening (BBBO) with focused ultrasound (FUS) and microbubbles is now understood to exert potentially beneficial bioeffects, such as stimulation of neurogenesis and clearance of amyloid-β. Here, we tested whether FUS BBBO could be deployed therapeutically to control CCM formation and progression in a clinically-representative murine model.

METHODS

CCMs were induced in mice by postnatal, endothelial-specific Krit1 ablation. FUS was applied for BBBO with fixed peak-negative pressures (PNPs; 0.2-0.6 MPa) or passive cavitation detection-modulated PNPs. Magnetic resonance imaging (MRI) was used to target FUS treatments, evaluate safety, and measure longitudinal changes in CCM growth after BBBO.

RESULTS

FUS BBBO elicited gadolinium accumulation primarily at the perilesional boundaries of CCMs, rather than lesion cores. Passive cavitation detection and gadolinium contrast enhancement were comparable in CCM and wild-type mice, indicating that Krit1 ablation does not confer differential sensitivity to FUS BBBO. Acutely, CCMs exposed to FUS BBBO remained structurally stable, with no signs of hemorrhage. Longitudinal MRI revealed that FUS BBBO halted the growth of 94% of CCMs treated in the study. At 1 month, FUS BBBO-treated lesions lost, on average, 9% of their pre-sonication volume. In contrast, non-sonicated control lesions grew to 670% of their initial volume. Lesion control with FUS BBBO was accompanied by a marked reduction in the area and mesenchymal appearance of Krit mutant endothelium. Strikingly, in mice receiving multiple BBBO treatments with fixed PNPs, de novo CCM formation was significantly reduced by 81%. Mock treatment plans on MRIs of patients with surgically inaccessible lesions revealed their lesions are amenable to FUS BBBO with current clinical technology.

CONCLUSIONS

Our results establish FUS BBBO as a novel, non-invasive modality that can safely arrest murine CCM growth and prevent their de novo formation. As an incisionless, MR image-guided therapy with the ability to target eloquent brain locations, FUS BBBO offers an unparalleled potential to revolutionize the therapeutic experience and enhance the accessibility of treatments for CCM patients.

Enhanced Stable Cavitation and Nonlinear Acoustic Properties of Poly(butyl cyanoacrylate) Polymeric Microbubbles after Bioconjugation

Microbubbles (MB) are used as ultrasound (US) contrast agents in clinical settings because of their ability to oscillate upon exposure to acoustic pulses and generate nonlinear responses with a stable cavitation profile. Polymeric MB have recently attracted increasing attention as molecular imaging probes and drug delivery agents based on their tailorable acoustic responses, high drug loading capacity, and surface functionalization capabilities. While many of these applications require MB to be functionalized with biological ligands, the impact of bioconjugation on polymeric MB cavitation and acoustic properties remains poorly understood. Hence, we here evaluated the effects of MB shell hydrolysis and subsequent streptavidin conjugation on the acoustic behavior of poly(butyl cyanoacrylate) (PBCA) MB. We show that upon biofunctionalization, MB display higher acoustic stability, stronger stable cavitation, and enhanced second harmonic generation. Furthermore, functionalized MB preserve the binding capabilities of streptavidin conjugated on their surface. These findings provide insights into the effects of bioconjugation chemistry on polymeric MB acoustic properties, and they contribute to improving the performance of polymer-based US imaging and theranostic agents.

Improved source localization in passive acoustic mapping using delay-multiply-and-sum beamforming with virtually augmented aperture

High-intensity focused ultrasound (HIFU) is a promising non-invasive treatment method whose applications include tissue ablation, hemostasis, thrombolysis and blood-brain barrier opening etc. Its therapeutic effects come from the thermal necrosis and the mechanical destruction associated with acoustic cavitation. Passive acoustic mapping (PAM) is capable of simultaneous monitoring of HIFU-induced cavitation events using only receive beamforming. Nonetheless, conventional time exposure acoustics (TEA) algorithm has poor spatial resolution and suffers from the X-shaped artifacts. These factors lead to difficulties in precise localization of cavitation source. In this study, we proposed a novel adaptive PAM method which combines Delay-Multiply-and-Sum (DMAS) beamforming with virtual augmented aperture (VA) to overcome the problem. In DMAS-VA beamforming, the magnitude of each channel waveform is scaled by p-th root while the phase is multiplied by L. The p and L correspond respectively to the degree of signal coherence in DMAS beamforming and the augmentation factor of aperture size. After channel sum, p-th power is applied to restore the dimensionality of source strength and then the PAM image is reconstructed by accumulating the signal power over the observation time. Based on simulation and experimental results, the proposed DMAS-VA has better image resolution and image contrast compared with the conventional TEA. Moreover, since the VA method may introduce grating lobes into PAM because of the virtually augmented pitch size, DMAS coherent factor (DCF) is further developed to alleviate these image artifacts. Results indicate that, with DCF weighting, the PAM image of DMAS-VA beamforming could be constructed without detectable image artifacts from grating lobes and false main lobes.

State of the art on microbubble cavitation monitoring and feedback control for blood-brain-barrier opening using focused ultrasound

Focused ultrasound (FUS) is a non-invasive and highly promising method for targeted and reversible blood-brain barrier permeabilization. Numerous preclinical studies aim to optimize the localized delivery of drugs using this method in rodents and non-human primates. Several clinical trials have been initiated to treat various brain diseases in humans using simultaneous BBB permeabilization and drug injection. This review presents the state of the art ofin vitroandin vivocavitation control algorithms for BBB permeabilization using microbubbles (MB) and FUS. Firstly, we describe the different cavitation states, their physical significance in terms of MB behavior and their translation into the spectral composition of the backscattered signal. Next, we report the different indexes calculated and used during the ultrasonic monitoring of cavitation. Finally, the differentin vitroandin vivocavitation control strategies described in the literature are presented and compared.

Effect of pulse parameters on ablation efficiency in dual-frequency HIFU therapy

High-intensity focused ultrasound (HIFU) has now been widely used to ablate various benign and malignant tumors. But it is still critical to increase the ablation efficiency in many clinical applications. Dual-frequency HIFU has been proven to be more efficient in ablation, but the principle on selecting the pulse parameters in this method remains to be explored. In this study, the in vitro lesion areas under different pulse repetition frequencies (PRFs), duty ratios, and frequency differences were compared, cavitation activity was also monitored during HIFU exposure. The results showed that different pulse parameters caused different types of lesions. In HIFU therapy, those pulse parameters that maximize the thermal effect, reduce heat dissipation and generate sufficient cavitation activities should be considered. But the method of evaluating or predicting the damage by using the cavitation dose is only applicable to mechanical damage.

Comparing Phantom and Animal Metrics Applied in the Determination of Focused Ultrasound Stable and Inertial Cavitation Levels

OBJECTIVE

The opening of the blood-brain barrier (BBB) to allow therapeutic drug passage can be achieved by inducing microbubble cavitation using focused ultrasound (FUS). This approach can be monitored through analysis of the received signal to distinguish between stable cavitation associated with safe BBB opening and inertial cavitation associated with blood vessel damage. In this study, FUS phantom and animal studies were used to evaluate the experimental conditions that generate several cross-consistent metrics having the potential to be combined for the reliable, automatic control of cavitation levels.

METHODS

Typical metrics for cavitation monitoring involve observing changes in the spectrum generated by applying the discrete Fourier transform (DFT) to the time domain signal detected using a hydrophone during FUS. A confocal hydrophone was used to capture emissions during a 10 ms FUS burst, sampled at 32 ns intervals, to produce 321,500 points and a high-resolution spectrum when transformed. The FUS spectra were analyzed to show the impact that equipment-transients and well-known DFT-related distortions had on the metrics used for cavitation control. A new approach, physical sparsification (PH-SP), was introduced to sharpen FUS spectral peaks and minimize the effect of these distortions.

DISCUSSION

It was demonstrated that the general spectral signal-to-noise ratio (SNR) could be improved by removing the initial noisy phantom hydrophone signal transient. Minor changes in the transient length digitally removed from the sampled values significantly changed the spectral bandwidths of all the harmonically related FUS signals. We evaluated signal processing techniques to minimize the impact these DFT-related distortions on area-under-the-curve (AUC) metric calculations, and we identified the advantages of using PH-SP and proposed new metrics when characterizing FUS spectral properties. The results show many second, third and sub-harmonic metrics provide cross-consistent evidence of changes between stable and inertial cavitation levels. Removing the first harmonic signal component with a hardware low-pass filter allowed the hydrophone gain to be boosted without introducing distortion, leading to an improved analysis of the sub-harmonic signal orders of magnitude smaller in intensity. Metrics that optimized the energy in the real component of the complex-valued PH-SP spectra provided a 32% increase in the sub-harmonic sensitivity compared to standard metrics.

CONCLUSION

A preliminary investigation of existing and proposed metrics showed that system noise could be large enough to mask the transition between stable and inertial cavitation. Strong narrowing of sub-harmonic peak shapes on applying physical sparsification (PH-SP) were seen in both phantom and animal studies. However, validating equivalent trends of the metrics with pressure were limited by the increased system noise level in the animal study combined with the natural variability between subjects studied. The combined use of hardware low-pass filters and physical sparsification to selectively removing distortions in the spectrum allowed the optimization of metrics for cavitation monitoring by improving the sub-harmonic sensitivity.

An optical and acoustic investigation of microbubble cavitation in small channels under therapeutic ultrasound conditions

Therapeutic focused ultrasound in combination with encapsulated microbubbles is being widely investigated for its ability to elicit bioeffects in the microvasculature, such as transient permeabilization for drug delivery or at higher pressures to achieve 'antivascular' effects. While it is well established that the behaviors of microbubbles are altered when they are situated within sufficiently small vessels, there is a paucity of data examining how the bubble population dynamics and emissions change as a function of channel (vessel) diameter over a size range relevant to therapeutic ultrasound, particularly at pressures relevant to antivascular ultrasound. Here we use acoustic emissions detection and high-speed microscopy (10 kframes/s) to examine the behavior of a polydisperse clinically employed agent (Definity®) in wall-less channels as their diameters are scaled from 1200 to 15 µm. Pressures are varied from 0.1 to 3 MPa using either a 5 ms pulse or a sequence of 0.1 ms pulses spaced at 1 ms, both of which have been previously employed in an in vivo context. With increasing pressure, the 1200 µm channel - on the order of small arteries and veins - exhibited inertial cavitation, 1/2 subharmonics and 3/2 ultraharmonics, consistent with numerous previous reports. The 200 and 100 µm channels - in the size range of larger microvessels less affected by therapeutic focused ultrasound - exhibited a distinctly different behavior, having muted development of 1/2 subharmonics and 3/2 ultraharmonics and reduced persistence. These were associated with radiation forces displacing bubbles to the distal wall and inducing clusters that then rapidly dissipated along with emissions. As the diameter transitioned to 50 and then 15 µm - a size regime that is most relevant to therapeutic focused ultrasound - there was a higher threshold for the onset of inertial cavitation as well as subharmonics and ultraharmonics, which importantly had more complex orders that are not normally reported. Clusters also occurred in these channels (e.g. at 3 MPa, the mean lateral and axial sizes were 23 and 72 µm in the 15 µm channel; 50 and 90 µm in the 50 µm channel), however in this case they occupied the entire lumens and displaced the wall boundaries. Damage to the 15 µm channel was observed for both pulse types, but at a lower pressure for the long pulse. Experiments conducted with a 'nanobubble' (<0.45 µm) subpopulation of Definity followed broadly similar features to 'native' Definity, albeit at a higher pressure threshold for inertial cavitation. These results provide new insights into the behavior of microbubbles in small vessels at higher pressures and have implications for therapeutic focused ultrasound cavitation monitoring and control.

Passive acoustic mapping with absolute time-of-flight information and delay-multiply-sum beamforming

BACKGROUND

Passive acoustic mapping (PAM) is showing increasing application potential in monitoring ultrasound therapy by spatially resolving cavitation activity. PAM with the relative time-of-flight information leads to poor axial resolution when implemented with ultrasound diagnostic transducers. Through utilizing the absolute time-of-flight information preserved by the transmit-receive synchronization and applying the common delay-sum (DS) beamforming algorithm, PAM axial resolution can be greatly improved in the short-pulse excitation scenario, as with active ultrasound imaging. However, PAM with the absolute time-of-flight information (referred as AtPAM) suffers from low imaging resolution and weak interference suppression when the DS algorithm is applied.

PURPOSE

This study aims to propose an enhanced AtPAM algorithm based on delay-multiply-sum (DMS) beamforming, to address the shortcomings of the DS-based AtPAM algorithm.

METHODS

In DMS beamforming, the element signals delayed by the absolute time delays are first processed with a signed square-root operation and then multiplied in pairs and finally summed, the resulting beamformed output is further band-pass filtered. The performances of DS- and DMS-based AtPAMs are compared by experiments, in which an ultrasound diagnostic transducer (a linear array) is employed to passively sense the wire signals generated by an unfocused ultrasound transducer and the cavitation signals generated by a focused therapeutic ultrasound transducer in a flow phantom. The AtPAM image quality is assessed by main-lobe width (MLW), intensity valley value (IVV), area of pixels (AOP), signal-to-interference ratio (SIR), and signal-to-noise ratio (SNR).

RESULTS

The single-wire experimental results show that compared to the DS algorithm, the DMS algorithm leads to an enhanced AtPAM image with a decreased transverse MLW of 0.15 mm and an improved SIR and SNR of 31.50 and 18.77 dB. For the four-wire images, the transverse (axial) IVV is decreased by 18.37 dB (13.11 dB) and the SIR (the SNR) is increased by 26.13 dB (18.47 dB) when using the DMS algorithm. The cavitation activity is better highlighted by DMS-based AtPAM, which decreases the AOP by 0.81 mm² (-10-dB level) and 4.43 mm² (-20-dB level) and increases the SIR and SNR by 20.14 and 10.48 dB respectively. The pixel distributions of AtPAM images of both wires and cavitation activity also indicate a better suppression of the DMS algorithm in sidelobe and noise.

CONCLUSIONS

The experimental results illustrate that the DMS algorithm can improve the image quality of AtPAM compared to the DS algorithm. DMS-based AtPAM is beneficial for detecting cavitation activity during short-pulse ultrasound exposure with high resolution, and further for monitoring short-pulse ultrasound therapy.

A PVDF Receiver for Acoustic Monitoring of Microbubble-Mediated Ultrasound Brain Therapy

The real-time monitoring of spectral characteristics of microbubble (MB) acoustic emissions permits the prediction of increases in blood-brain barrier (BBB) permeability and of tissue damage in MB-mediated focused ultrasound (FUS) brain therapy. Single-element passive cavitation detectors provide limited spatial information regarding MB activity, greatly affecting the performance of acoustic control. However, an array of receivers can be used to spatially map cavitation events and thus improve treatment control. The spectral content of the acoustic emissions provides additional information that can be correlated with the bio-effects, and wideband receivers can thus provide the most complete spectral information. Here, we develop a miniature polyvinylidene fluoride (PVDF thickness = 110 μm, active area = 1.2 mm2) broadband receiver for the acoustic monitoring of MBs. The receiver has superior sensitivity (2.36-3.87 V/MPa) to those of a commercial fibre-optic hydrophone in the low megahertz frequency range (0.51-5.4 MHz). The receiver also has a wide -6 dB acceptance angle (54 degrees at 1.1 MHz and 13 degrees at 5.4 MHz) and the ability to detect subharmonic and higher harmonic MB emissions in phantoms. The overall acoustic performance of this low-cost receiver indicates its suitability for the eventual use within an array for MB monitoring and mapping in preclinical studies.

Spatially targeted brain cancer immunotherapy with closed-loop controlled focused ultrasound and immune checkpoint blockade

Despite the challenges in treating glioblastomas (GBMs) with immune adjuvants, increasing evidence suggests that targeting the immune cells within the tumor microenvironment (TME) can lead to improved responses. Here, we present a closed-loop controlled, microbubble-enhanced focused ultrasound (MB-FUS) system and test its abilities to safely and effectively treat GBMs using immune checkpoint blockade. The proposed system can fine-tune the exposure settings to promote MB acoustic emission-dependent expression of the proinflammatory marker ICAM-1 and delivery of anti-PD1 in a mouse model of GBM. In addition to enhanced interaction of proinflammatory macrophages within the PD1-expressing TME and significant improvement in survival (P < 0.05), the combined treatment induced long-lived memory T cell formation within the brain that supported tumor rejection in rechallenge experiments. Collectively, our findings demonstrate the ability of MB-FUS to augment the therapeutic impact of immune checkpoint blockade in GBMs and reinforce the notion of spatially tumor-targeted (loco-regional) brain cancer immunotherapy.

Guiding and monitoring focused ultrasound mediated blood-brain barrier opening in rats using power Doppler imaging and passive acoustic mapping

The blood-brain barrier (BBB) prevents harmful toxins from entering brain but can also inhibit therapeutic molecules designed to treat neurodegenerative diseases. Focused ultrasound (FUS) combined with microbubbles can enhance permeability of BBB and is often performed under MRI guidance. We present an all-ultrasound system capable of targeting desired regions to open BBB with millimeter-scale accuracy in two dimensions based on Doppler images. We registered imaging coordinates to FUS coordinates with target registration error of 0.6 ± 0.3 mm and used the system to target microbubbles flowing in cellulose tube in two in vitro scenarios (agarose-embedded and through a rat skull), while receiving echoes on imaging transducer. We created passive acoustic maps from received echoes and found error between intended location in imaging plane and location of pixel with maximum intensity after passive acoustic maps reconstruction to be within 2 mm in 5/6 cases. We validated ultrasound-guided procedure in three in vivo rat brains by delivering MRI contrast agent to cortical regions of rat brains after BBB opening. Landmark-based registration of vascular maps created with MRI and Doppler ultrasound revealed BBB opening inside the intended focus with targeting accuracy within 1.5 mm. Combined use of power Doppler imaging with passive acoustic mapping demonstrates an ultrasound-based solution to guide focused ultrasound with high precision in rodents.

Investigation of hardware and software techniques to enhance the characteristics of focused ultrasound (FUS) spectra

Objective. Microbubble cavitation generated by focused ultrasound (FUS) can induce safe blood-brain-barrier (BBB) opening allowing therapeutic drug passage. Spectral changes in the hydrophone sensor signal are currently used to distinguish stable cavitation from inertial cavitation that can damage the BBB. Gibbs’ ringing, peak intensity loss and peak width increase are well-known distortions evident when using the discrete Fourier transform (DFT) to transform data containing a few hundred points. We investigate overcoming the fact that FUS time signals (10 ms providing 312 500 points sampled at 32 ns intervals) can generate such sharp spectral peaks that variations in their DFT-related distortions can significantly impact the values of the key metrics used for cavitation characterization. Approach. We introduce low-pass filter hardware to improve how the analogue to digital convertor handles high-frequency noise components and the orders of magnitude differences between FUS harmonic intensities. We investigate the enhanced FUS spectral stability and resolution obtained from a new technique, physical sparsification (PH-SP), customized to the a-priori information that all key FUS components are harmonically related. Results are compared with standard DFT optimizations involving time data windowing and Fourier interpolation. Main results. A new simulation model showed peak intensity, widths and metrics modified by small changes in the transformed signal’s length when removing the noisy starting transient of the FUS hydrophone signal or following minor excitation frequency or sampling rate adjustments. 25%–60% area-under-the-curve changes occurred in phantom studies at different pressure levels. Spectral peak sharpness was best optimized and stabilized with PH-SP. Significance. Special FUS characteristics mean starting transients and minor variations in experimental procedures lead to significant changes in the spectral metrics used to monitor cavitation levels. Customizing PH-SP to these characteristics led to sharper, more stable spectra with the potential to track the impact of microbubble environment changes.

The role of primary and secondary delays in the effective resonance frequency of acoustically interacting microbubbles

Acoustically excited microbubbles (MBs) are known to be nonlinear oscillators with complex dynamics. This has enabled their use in a wide range of applications from medicine to industry and underwater acoustics. To better utilize their potential in applications and possibly invent new ones a comprehensive understanding of their dynamics is required. In this work, we explore the effect of bubble-bubble interactions on the resonance frequency of MB suspensions. MBs oscillate in response to an external acoustic wave and since bubbles in a cluster are at different locations compared to the excitation source, they are excited at different times. In this work we refer to these delays as primary delays. Interactions between the scattered pressure fields from adjacent bubbles have also been shown to alter the dynamics of MBs that exist within clusters. These secondary waves generated by MBs reach MBs in their proximity at different times that depend on their spatial location in the cluster. Here we refer to these delays as secondary delays. Inclusion of the secondary delays modifies the class of the differential equations governing the oscillations of interacting MBs in a cluster from ordinary differential equations to neutral delay differential equations. Previous work has not considered the all the delays associated with the bubble distances when modeling the interactions between bubbles. In this work we investigate the effect of both the primary and secondary delays on the effective resonance frequency of MB clusters. It is shown that primary delays cause spreading the resonance frequency of identical MBs within a range where the closest MB to the acoustic source exhibits the lowest resonance frequency and the furthest MB resonates at the highest frequency. This range has been shown to be up to 0.12 MHz for the examples investigated in this work. The effect of secondary delays is shown to be very significant. In the absence of secondary delays, the ordinary differential equation model predicts a decrease of up to 26% in the resonance frequency of 4 identical interacting MBs as the inter-bubble distances are decreased. However, we show that inclusion of the secondary delays result in the increase of the resonance frequency of MBs if they are situated close to each other. This increase is shown to be significant and for the case of 4 identical interacting MBs we show an increase of 58% in the resonance frequency.

An Ultrasound-Guided Hemispherical Phased Array for Microbubble-Mediated Ultrasound Therapy

GOAL

To develop a low-cost magnetic resonance imaging (MRI)-free transcranial focused ultrasound (FUS) system for microbubble-mediated therapy.

METHODS

A 128-element 11 MHz array for skull localization was integrated within a 256-module multi-frequency (306/612/1224 kHz) dual-mode phased array. The system's transcranial transmit and receive performance was evaluated with ex-vivo human skullcaps using phase aberration corrections calculated from computed tomography (CT)-based simulations via ultrasound-based (USCT) and landmark-based (LMCT) registrations, and a gold-standard fixed source emitter (FSE)-based method.

RESULTS

Displacement and rotation registration errors of 1.4 ± 0.4 mm and 2.1 ± 0.2 ^° were obtained using USCT, resulting in sub-millimeter transmit targeting errors driven at 306 kHz (0.9 ± 0.2 mm) and 612 kHz (0.9 ± 0.3 mm), and source localization errors of 1.0 ± 0.3 mm and 0.6 ± 0.2 mm at receive frequencies of 306 kHz and 612 kHz, respectively (mean ± SD). Similar errors were obtained using LMCT and no significant differences between these two approaches were found on either transmit (p = 0.64/0.99) or receive (p = 0.45/0.36) at 306 kHz/612kHz. During volumetric multi-point exposures, approximately 70% and 60% of the transmit frames in which microbubble activity was detected via FSE were recovered using USCT when imaging at the second-harmonic and half-harmonic, respectively, compared to 60% and 69% using LMCT.

CONCLUSION

This low-cost ultrasound-guided transcranial FUS system affords USCT skull registration with accuracy comparable to LMCT methods.

SIGNIFICANCE

Such systems have great potential to advance the adoption of microbubble-mediated FUS brain therapy by improving access to the technology.

Towards controlled drug delivery in brain tumors with microbubble-enhanced focused ultrasound

Brain tumors are particularly challenging malignancies, due to their location in a structurally and functionally distinct part of the human body - the central nervous system (CNS). The CNS is separated and protected by a unique system of brain and blood vessel cells which together prevent most bloodborne therapeutics from entering the brain tumor microenvironment (TME). Recently, great strides have been made through microbubble (MB) ultrasound contrast agents in conjunction with ultrasound energy to locally increase the permeability of brain vessels and modulate the brain TME. As we elaborate in this review, this physical method can effectively deliver a wide range of anticancer agents, including chemotherapeutics, antibodies, and nanoparticle drug conjugates across a range of preclinical brain tumors, including high grade glioma (glioblastoma), diffuse intrinsic pontine gliomas, and brain metastasis. Moreover, recent evidence suggests that this technology can promote the effective delivery of novel immunotherapeutic agents, including immune check-point inhibitors and chimeric antigen receptor T cells, among others. With early clinical studies demonstrating safety, and several Phase I/II trials testing the preclinical findings underway, this technology is making firm steps towards shaping the future treatments of primary and metastatic brain cancer. By elaborating on its key components, including ultrasound systems and MB technology, along with methods for closed-loop spatial and temporal control of MB activity, we highlight how this technology can be tuned to enable new, personalized treatment strategies for primary brain malignancies and brain metastases.

Improving temporal stability of stable cavitation activity of circulating microbubbles using a closed-loop controller based on pulse-length regulation

Stable cavitation (SC) has shown great potential for novel therapeutic applications. The spatiotemporal distribution of the SC activity of microbubbles circulating in a target region is not only correlated with the uniformity of treatment, but also with some undesirable effects. Therefore, it is important to achieve controllable and desirable SC activity in target regions for improved therapeutic efficiency and biosafety. This study proposes a closed-loop feedback controller based on pulse length (PL) regulation to improve the temporal stability of SC activity. Microbubbles circulating in a physiological flowing phantom were exposed to a 1 MHz focused transducer. The SC signals produced were initially received by another 7.5 MHz plane transducer, followed by high-speed signal acquisition and real-time processing. Based on the real-time-measured SC intensity excited by the current acoustic pulse, the proposed closed-loop feedback controller used three proportional coefficients to regulate the peak negative pressure (PNP) and PL of the next acoustic pulse during the acceleration and stable stages, respectively. The results show that the rise time and the temporal stability of the SC intensity of the microbubbles circulating in these two stages were improved significantly by the optimized proportional coefficients used in the proposed controller. Importantly, when compared with the traditional closed-loop feedback controller based on PNP regulation, the proposed closed-loop feedback controller based on PL regulation reduced the probability of a transition between stable and inertial cavitation, thus avoiding the risk of disadvantageous bioeffects in practical applications. These results demonstrate the effectiveness of the proposed PL-based closed-loop feedback controller and provide a feasible strategy for realization of controllable cavitation activity in applications.

Localized blood-brain barrier opening in infiltrating gliomas with MRI-guided acoustic emissions-controlled focused ultrasound

Pharmacological treatment of gliomas and other brain-infiltrating tumors remains challenging due to limited delivery of most therapeutics across the blood-brain barrier (BBB). Transcranial MRI-guided focused ultrasound (FUS), an emerging technology for noninvasive brain treatments, enables transient opening of the BBB through acoustic activation of circulating microbubbles. Here, we evaluate the safety and utility of transcranial microbubble-enhanced FUS (MB-FUS) for spatially targeted BBB opening in patients with infiltrating gliomas. In this Phase 0 clinical trial (NCT03322813), we conducted comparative and quantitative analyses of FUS exposures (sonications) and their effects on gliomas using MRI, histopathology, microbubble acoustic emissions (harmonic dose [HD]), and fluorescence-guided surgery metrics. Contrast-enhanced MRI and histopathology indicated safe and reproducible BBB opening in all patients. These observations occurred using a power cycling closed feedback loop controller, with the power varying by nearly an order of magnitude on average. This range underscores the need for monitoring and titrating the exposure on a patient-by-patient basis. We found a positive correlation between microbubble acoustic emissions (HD) and MR-evident BBB opening (P = 0.07) and associated interstitial changes (P < 0.01), demonstrating the unique capability to titrate the MB-FUS effects in gliomas. Importantly, we identified a 2.2-fold increase of fluorescein accumulation in MB-FUS-treated compared to untreated nonenhancing tumor tissues (P < 0.01) while accounting for vascular density. Collectively, this study demonstrates the capabilities of MB-FUS for safe, localized, controlled BBB opening and highlights the potential of this technology to improve the surgical and pharmacologic treatment of brain tumors.

Cavitation-modulated inflammatory response following focused ultrasound blood-brain barrier opening

Focused ultrasound (FUS) in combination with systemically injected microbubbles can be used to non-invasively open the blood-brain barrier (BBB) in targeted regions for a variety of therapeutic applications. Over the past two decades, preclinical research into the safety and efficacy of FUS-induced BBB opening has proven this technique to be transient and efficacious, propelling FUS-induced BBB opening into several clinical trials in recent years. However, as clinical trials further progress, the neuroinflammatory response to FUS-induced BBB opening needs to be better understood. In this study, we provide further insight into the relationship of microbubble cavitation and the resulting innate immune response to FUS-induced BBB opening. By keeping ultrasound parameters fixed (i.e. frequency, pressure, pulse length, etc.), three groups of mice were sonicated using a real-time cavitation controller until a target cavitation dose was reached (1 x 107 V2•s, 5 x 107 V2•s, 1 x 108 V2•s). The change in relative gene expression of the mouse inflammatory cytokines and receptors were evaluated at three different time-points (6 h, 24 h, and 72 h) after FUS. At both 6 and 24 h time-points, significant changes in relative gene expression of inflammatory cytokines and receptors were observed across all cavitation groups. However, the degree of changes in relative expression levels and the number of genes with significant changes in expression varied across the cavitation groups. Groups with a higher cavitation dose exhibited both greater changes in relative expression levels and greater number of significant changes. By 72 h post-opening, the gene expression levels returned to baseline in all cavitation dose groups, signifying a transient inflammatory response to FUS-induced BBB opening at the targeted cavitation dose levels. Furthermore, the real-time cavitation controller was able to produce consistent and significantly different BBB permeability enhancement volumes across the three different cavitation dose groups. These results indicate that cavitation monitoring and controlling during FUS-induced BBB opening can be used to potentially modulate or limit the degree of neuroinflammation, further emphasizing the importance of implementing cavitation controllers as FUS-induced BBB opening is translated into the clinic.

Focused Ultrasound Combined with Microbubbles in Central Nervous System Applications

The blood–brain barrier (BBB) protects the central nervous system (CNS) from invasive pathogens and maintains the homeostasis of the brain. Penetrating the BBB has been a major challenge in the delivery of therapeutic agents for treating CNS diseases. Through a physical acoustic cavitation effect, focused ultrasound (FUS) combined with microbubbles achieves the local detachment of tight junctions of capillary endothelial cells without inducing neuronal damage. The bioavailability of therapeutic agents is increased only in the area targeted by FUS energy. FUS with circulating microbubbles is currently the only method for inducing precise, transient, reversible, and noninvasive BBB opening (BBBO). Over the past decade, FUS-induced BBBO (FUS-BBBO) has been preclinically confirmed to not only enhance the penetration of therapeutic agents in the CNS, but also modulate focal immunity and neuronal activity. Several recent clinical human trials have demonstrated both the feasibility and potential advantages of using FUS-BBBO in diseased patients. The promising results support adding FUS-BBBO as a multimodal therapeutic strategy in modern CNS disease management. This review article explores this technology by describing its physical mechanisms and the preclinical findings, including biological effects, therapeutic concepts, and translational design of human medical devices, and summarizes completed and ongoing clinical trials.

On the threshold of 1/2 order subharmonic emissions in the oscillations of ultrasonically excited bubbles

The pressure threshold for 1/2 order subharmonic (SH) emissions and period doubling during the oscillations of ultrasonically excited bubbles is thought to be minimum when the bubble is sonicated with twice its resonance frequency (f_r). This estimate is based on studies that simplified or neglected the effects of thermal damping. In this work, the nonlinear dynamics of ultrasonically excited bubbles is investigated accounting for the thermal dissipation. Results are visualized using bifurcation diagrams as a function of pressure. Here we show that, and depending on the gas, the pressure threshold for 1/2 order SHs can be minimum at a frequency between 0.5f_r≤f≤0.6f_r. In this frequency range, the generation of 1/2 order SHs are due to the occurrence of 5/2 order ultra-harmonic resonance. The stability of such oscillations is size dependent. For an air bubble immersed in water, only bubbles bigger than 1 μm in diameter are able to emit non-destructive SHs in these frequency ranges.

Nonlinear dynamics and bifurcation structure of ultrasonically excited lipid coated microbubbles

In many applications, microbubbles (MBs) are encapsulated by a lipid coating to increase their stability. However, the complex behavior of the lipid coating including buckling and rupture sophisticates the dynamics of the MBs and as a result the dynamics of the lipid coated MBs (LCMBs) are not well understood. Here, we investigate the nonlinear behavior of the LCMBs by analyzing their bifurcation structure as a function of acoustic pressure. We show that, the LC can enhance the generation of period 2 (P2), P3, higher order subharmonics (SH), superharmonics and chaos at very low excitation pressures (e.g. 1 kPa). For LCMBs sonicated by their SH resonance frequency and in line with experimental observations with increasing pressure, P2 oscillations exhibit three stages: generation at low acoustic pressures, disappearance and re-generation. Within non-destructive oscillation regimes and by pressure amplitude increase, LCMBs can also exhibit two saddle node (SN) bifurcations resulting in possible abrupt enhancement of the scattered pressure. The first SN resembles the pressure dependent resonance phenomenon in uncoated MBs and the second SN resembles the pressure dependent SH resonance. Depending on the initial surface tension of the LCMBs, the nonlinear behavior may also be suppressed for a wide range of excitation pressures.

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

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

Real-Time Passive Acoustic Mapping Using Sparse Matrix Multiplication

Passive acoustic mapping enables the spatiotemporal monitoring of cavitation with circulating microbubbles during focused ultrasound (FUS)-mediated blood-brain barrier opening. However, the computational load for processing large data sets of cavitation maps or more complex algorithms limit the visualization in real-time for treatment monitoring and adjustment. In this study, we implemented a graphical processing unit (GPU)-accelerated sparse matrix-based beamforming and time exposure acoustics in a neuronavigation-guided ultrasound system for real-time spatiotemporal monitoring of cavitation. The system performance was tested in silico through benchmarking, in vitro using nonhuman primate (NHP) and human skull specimens, and demonstrated in vivo in NHPs. We demonstrated the stability of the cavitation map for integration times longer than 62.5 [Formula: see text]. A compromise between real-time displaying and cavitation map quality obtained from beamformed RF data sets with a size of 2000 ×128 ×30 (axial [Formula: see text]) was achieved for an integration time of [Formula: see text], which required a computational time of 0.27 s (frame rate of 3.7 Hz) and could be displayed in real-time between pulses at PRF = 2 Hz. Our benchmarking tests show that the GPU sparse-matrix algorithm processed the RF data set at a computational rate of [Formula: see text]/pixel/sample, which enables adjusting the frame rate and the integration time as needed. The neuronavigation system with real-time implementation of cavitation mapping facilitated the localization of the cavitation activity and helped to identify distortions due to FUS phase aberration. The in vivo test of the method demonstrated the feasibility of GPU-accelerated sparse matrix computing in a close to a clinical condition, where focus distortions exemplify problems during treatment. These experimental conditions show the need for spatiotemporal monitoring of cavitation with real-time capability that enables the operator to correct or halt the sonication in case substantial aberrations are observed.

Evaluation of the Uncertainty of Passive Cavitation Measurements for Blood-Brain Barrier Disruption Monitoring

Exposure to ultrasound combined with intravenous injection of microbubbles is a technique that can be used to temporarily disrupt the blood-brain barrier. Transcranial monitoring of cavitation can be done with one or more passive cavitation detectors (PCDs). However, the positioning of the PCDs relative to the cavitation site and the attenuation of these signals by the skull are two sources of error in the quantification of cavitation activity. The aim of this study was to evaluate in vitro the amplitude variation of cavitation signals that can be expected for an excised porcine skull model. The variation caused by the relative positioning of the PCD with respect to the cavitation site was quantified. A position-based correction of the signal amplitude was evaluated. Pig skull samples were used to assess variation in signal amplitude caused by bone. The overall coefficient of variation of the signals owing to these measurement biases was estimated at 30.8%.

A new safety index based on intrapulse monitoring of ultra-harmonic cavitation during ultrasound-induced blood-brain barrier opening procedures

Ultrasound-induced blood-brain barrier (BBB) opening using microbubbles is a promising technique for local delivery of therapeutic molecules into the brain. The real-time control of the ultrasound dose delivered through the skull is necessary as the range of pressure for efficient and safe BBB opening is very narrow. Passive cavitation detection (PCD) is a method proposed to monitor the microbubble activity during ultrasound exposure. However, there is still no consensus on a reliable safety indicator able to predict potential damage in the brain. Current approaches for the control of the beam intensity based on PCD employ a full-pulse analysis and may suffer from a lack of sensitivity and poor reaction time. To overcome these limitations, we propose an intra-pulse analysis to monitor the evolution of the frequency content during ultrasound bursts. We hypothesized that the destabilization of microbubbles exposed to a critical level of ultrasound would result in the instantaneous generation of subharmonic and ultra-harmonic components. This specific signature was exploited to define a new sensitive indicator of the safety of the ultrasound protocol. The approach was validated in vivo in rats and non-human primates using a retrospective analysis. Our results demonstrate that intra-pulse monitoring was able to exhibit a sudden appearance of ultra-harmonics during the ultrasound excitation pulse. The repeated detection of such a signature within the excitation pulse was highly correlated with the occurrence of side effects such as hemorrhage and edema. Keeping the acoustic pressure at levels where no such sign of microbubble destabilization occurred resulted in safe BBB openings, as shown by MR images and gross pathology. This new indicator should be more sensitive than conventional full-pulse analysis and can be used to distinguish between potentially harmful and safe ultrasound conditions in the brain with very short reaction time.

A Porcine Model of Transvertebral Ultrasound and Microbubble-Mediated Blood-Spinal Cord Barrier Opening

Blood-spinal cord barrier opening, using focused ultrasound and microbubbles, has the potential to improve drug delivery for the treatment of spinal cord pathologies. Delivering and detecting ultrasound through the spine is a challenge for clinical translation. We have previously developed short burst, phase keying exposures, which can be used in a dual-aperture configuration to address clinical scale targeting challenges. Here we demonstrate the use of these pulses for blood-spinal cord barrier opening, in vivo in pigs.

Methods: The spinal cords of Yorkshire pigs (n=8) were targeted through the vertebral laminae, in the lower thoracic to upper lumbar region using focused ultrasound (486 kHz) and microbubbles. Four animals were treated with a combination of pulsed sinusoidal exposures (1.0-4.0 MPa, non-derated) and pulsed short burst, phase keying exposures (1.0-2.0 MPa, non-derated). Four animals were treated using ramped short burst, phase keying exposures (1.8-2.1 MPa, non-derated). A 250 kHz narrowband receiver was used to detect acoustic emissions from microbubbles. Blood-spinal cord barrier opening was assessed by the extravasation of Evans blue dye. Histological analysis of the spinal cords was used to assess tissue damage and excised vertebral samples were used in benchtop experiments.

Results: Ramped short burst, phase keying exposures successfully modified the blood-spinal cord barrier at 16/24 targeted locations, as assessed by the extravasation of Evans blue dye. At 4 of these locations, opening was confirmed with minimal adverse effects observed through histology. Transmission measurements through excised vertebrae indicated a mean transmission of (47.0 ± 7.0 %) to the target.

Conclusions: This study presents the first evidence of focused ultrasound-induced blood-spinal cord barrier opening in a large animal model, through the intact spine. This represents an important step towards clinical translation.

Ultrasound-Responsive Cavitation Nuclei for Therapy and Drug Delivery

Therapeutic ultrasound strategies that harness the mechanical activity of cavitation nuclei for beneficial tissue bio-effects are actively under development. The mechanical oscillations of circulating microbubbles, the most widely investigated cavitation nuclei, which may also encapsulate or shield a therapeutic agent in the bloodstream, trigger and promote localized uptake. Oscillating microbubbles can create stresses either on nearby tissue or in surrounding fluid to enhance drug penetration and efficacy in the brain, spinal cord, vasculature, immune system, biofilm or tumors. This review summarizes recent investigations that have elucidated interactions of ultrasound and cavitation nuclei with cells, the treatment of tumors, immunotherapy, the blood-brain and blood-spinal cord barriers, sonothrombolysis, cardiovascular drug delivery and sonobactericide. In particular, an overview of salient ultrasound features, drug delivery vehicles, therapeutic transport routes and pre-clinical and clinical studies is provided. Successful implementation of ultrasound and cavitation nuclei-mediated drug delivery has the potential to change the way drugs are administered systemically, resulting in more effective therapeutics and less-invasive treatments.

A Single High-Intensity Shock Wave Pulse With Microbubbles Opens the Blood-Brain Barrier in Rats

Focused extracorporeal shockwave (FSW), one kind of focused high-intensity pulsed ultrasound, has been shown to induce blood-brain barrier (BBB) opening in targeted brain areas in rat animal models with minimal detrimental effects below threshold intensity levels or iterations. In the current study, we found that the thresholds could be further reduced by the addition of microbubbles (ultrasound contrast agents or UCA; SonoVue). FSW with 2 × 106 MBs/kg of UCA (20% of clinical dosage) at an intensity level of 0.1 (peak positive pressure 5.4 MPa; peak negative pressure -4.2 MPa; energy flux density 0.03 mJ/mm2) resulting in a 100% BBB opening rate without detectable hemorrhage or apoptosis in the brain. Significantly reduced free radical production was found compared with 0.5 MHz focused ultrasound at a peak negative pressure of 0.44 MPa (1% duty cycle and 4 × 107 MBs/kg of UCA). FSW devices offer advantages of commercial availability and high safety, and thus may facilitate future research and applications of focal BBB opening for oncological and pharmacological purposes.

Spatiotemporal Assessment of the Cellular Safety of Cavitation-Based Therapies by Passive Acoustic Mapping

Many useful therapeutic bio-effects can be generated using ultrasound-induced cavitation. However, cavitation is also capable of causing unwanted cellular and vascular damage, which should be monitored to ensure treatment safety. In this work, the unique opportunity provided by passive acoustic mapping (PAM) to quantify cavitation dose across an entire volume of interest during therapy is utilised to provide setup-independent measures of spatially localised cavitation dose. This spatiotemporally quantifiable cavitation dose is then related to the level of cellular damage generated. The cavitation-mediated destruction of equine red blood cells mixed with one of two types of cavitation nuclei at a variety of concentrations is investigated. The blood is placed within a 0.5-MHz ultrasound field and exposed to a range of peak rarefactional pressures up to 2 MPa, with 50 to 50,000 cycle pulses maintaining a 5% duty cycle. Two co-planar linear arrays at 90° to each other are used to generate 400-µm-resolution frequency domain robust capon beamforming PAM maps, which are then used to generate estimates of cavitation dose. A relationship between this cavitation dose and the levels of haemolysis generated was found which was comparable regardless of the applied acoustic pressure, pulse length, cavitation agent type or concentration used. PAM was then used to monitor cellular damage in multiple locations within a tissue phantom simultaneously, with the damage-cavitation dose relationship being similar for the two experimental models tested. These results lay the groundwork for this method to be applied to other measures of safety, allowing for improved ultrasound monitoring of cavitation-based therapies.

Ultrasound-induced microbubble cavitation via a transcanal or transcranial approach facilitates inner ear drug delivery

Ultrasound-induced microbubble (USMB) cavitation is widely used to promote drug delivery. Our previous study investigated USMB targeting the round window membrane by applying the ultrasound transducer to the tympanic bulla. In the present study, we further extended the use of this technology to enhance drug delivery to the inner ear by introducing the ultrasound transducer into the external auditory canal (EAC) or applying it to the skull. Using a 3-dimensional-printed diffusion apparatus mimicking the pathway for ultrasound passing through and reaching the middle ear cavity in vitro, the models simulating the transcanal and transcranial approach demonstrated 4.8-fold- and 3.7-fold-higher delivery efficiencies, respectively. In an in vivo model of guinea pigs, by filling tympanic bulla with microbubbles and biotin-FITC, USMB applied transcanally and transcranially induced 2.8-fold and 1.5-fold increases in biotin-FITC delivery efficiencies, respectively. In addition, the gentamicin uptake by cochlear and vestibular hair cells and gentamicin-induced hair cell loss were significantly enhanced following transcanal application of USMB. On the 28th day after transcanal USMB, safety assessment showed no significant changes in the hearing thresholds and the integrity of cochlea. These are the first results to our knowledge to demonstrate the feasibility and support the potential clinical application of applying USMB via EAC to facilitate drug delivery into the inner ear.

Amino acids nanocrystals for piezoelectric detection of ultra-low mechanical pressure

Developing biocompatible nano-materials with the ability to detect ultra-low mechanical pressure is promising for biomedical sensors. This paper reports the detection of pressure as low as 1 Pa in the environmental pressure of 1 atm (10^-3% pressure change) by nanocrystals of amino acids glycine and alanine through the piezoelectric effect. Piezoelectricity enables detection of pressure by a change of dielectric polarization when the material is subjected to external pressure. This work exploits the non-centro-symmetric structure of some amino acids and their weak hydrogen bonds to develop sensitive mechanical pressure sensors. The β-glycine and l-alanine nanocrystals were grown from aqueous solution inside porous alumina substrate. The nanocrystals exhibit pronounced preferred crystallographic orientation. The sensitive piezoelectric response to ultra-low mechanical pressure is discussed based on atomic and crystal symmetry considerations.

Subharmonic spherical bubble oscillations induced by parametric surface modes

A potential source of subharmonic bubble emissions is revealed experimentally by high-speed imaging. When an acoustic bubble is driven at sufficiently large pressure amplitudes, energy transfer from surface to volume oscillations can lead to the triggering of subharmonic spherical oscillations. This experimental evidence is in agreement with recent theoretical modeling of nonspherical bubble dynamics accounting for nonlinear mode coupling. Implications for the monitoring of stable cavitation activity are discussed.

The effect of transcranial focused ultrasound target location on the acoustic feedback control performance during blood-brain barrier opening with nanobubbles

Real-time acoustic feedback control based on harmonic emissions of stimulated microbubbles may be important for facilitating the clinical adoption of focused ultrasound (FUS)-induced blood-brain barrier (BBB) opening, both to ensure safe acoustic exposures, and to achieve repeatable and consistent opening. Previously our group demonstrated that successful BBB opening was achievable with both commercially available microbubbles and custom-made nanobubbles under acoustic feedback control. In a recent study, we demonstrated the acoustic control performance was not sensitive to the nanobubble concentration within 10⁹–10¹¹ bubbles/ml. The goal of this study was to examine the effect of the ultrasound target location in the rat brain on the acoustic control quality during BBB opening with nanobubbles. Temporal analysis of the received acoustic signals during each ultrasound pulse indicated that stable nanobubble oscillation was present throughout the entire 10 ms ultrasound exposure. The acoustic feedback control signals were very sensitive to the brain spatial location in rats. There appears to be a shared pattern of acoustic control stability in the brain across different animals, suggesting anatomical features are an underlying cause. The findings emphasize the importance of tuning acoustic feedback control algorithms for specific rodent brain regions of interest to ensure optimal performance.

Collective nonlinear behavior of interacting polydisperse microbubble clusters

Acoustically excited microbubbles (MBs) have shown to exhibit rich dynamics, enabling them to be employed in various applications ranging from chemistry to medicine. Exploiting the full potential of MBs for applications requires a good understanding of their complex dynamics. Improved understanding of MB oscillations can lead to further enhancement in optimizing their efficacy in many applications and also invent new ones. Oscillating MBs have been shown to generate secondary pressure waves that modify the dynamics of the MBs in their proximity. A modified Keller-Miksis equation is used to account for inter-bubble interactions. The oscillatory dynamics of each MB within clusters was computed by numerically solving the resulting system of coupled nonlinear second order differential equations in potential fluid flow. Frequency response analysis and bifurcation diagrams were employed to track the dynamics of interacting MBs. We start with investigating the effect of inter-bubble interactions for cases of three and four MBs over a wide range of acoustic and geometric parameters. Emergent collective behavior was observed which are dominated by the dynamics of the largest MB within the cluster. The emergent dynamics of smaller MBs within clusters can be characterized by constructive and destructive inter-bubble interactions. In constructive interactions, the radial oscillations of smaller MBs matched those of the largest MB and their oscillations are amplified. In destructive interactions, the oscillations of smaller bubbles are suppressed so that their oscillations match those of the largest MB. Furthermore, a special case of constructive interactions is presented where dominant MB (largest) can force smaller MBs into period doubling and subharmonic oscillations. The collective behavior is further investigated in large MB cluster and it is shown that largest MBs, even in small numbers can force smaller ones into period doubling and subharmonic oscillations.

Enhanced Detection of Bubble Emissions Through the Intact Spine for Monitoring Ultrasound-Mediated Blood-Spinal Cord Barrier Opening

OBJECTIVE

We previously developed short burst, phase keying (SBPK) focused ultrasound (FUS) to mitigate standing waves in the human vertebral canal. Here, we show microbubble emissions from these pulses can be detected through the human vertebral arch and that these pulses are effective for blood-spinal cord barrier (BSCB) opening.

METHODS

At f₀ = 514 kHz, circulating microbubbles were sonicated through ex vivo human vertebrae (60 kPa-1 MPa) using a dual-aperture approach and SBPK exposures engineered to incorporate pulse inversion (PI). Signals from a 250 kHz receiver were analyzed using PI, short-time Fourier analysis and the maximum projection over the pulse train. In rats (n = 14), SBPK FUS+microbubbles was applied to 3 locations/spinal cord at fixed pressures (∼0.20-0.47 MPa). MRI and histology were used to assess opening and tissue damage.

RESULTS

In human vertebrae between 0.2-0.4 MPa, PI amplified the microbubble/baseline ratio at f₀/2 and 2f₀ by 202 ± 40% (132-291%). This was maximal at 0.4 MPa, coinciding with the onset of broadband emissions. In vivo, opening was achieved at 40/42 locations, with mean MRI enhancement of 46 ± 32%(16%-178%). Using PI, f₀/2 was detected at 14/40 opening locations. At the highest pressures (f₀/2 present) histology showed widespread bleeding throughout the focal region. At the lowest pressures, opening was achieved without bleeding.

CONCLUSION

This study confirmed that PI can increase sensitivity to transvertebral detection of microbubble signals. Preliminary in vivo investigations show that SBPK FUS can increase BSCB permeability without tissue damage.

SIGNIFICANCE

SBPK is a clinically relevant pulse scheme and, in combination with PI, provides a means of mediating and monitoring BSCB opening noninvasively.

Feedback control of microbubble cavitation for ultrasound-mediated blood-brain barrier disruption in non-human primates under magnetic resonance guidance

Focused ultrasound (FUS) in combination with microbubbles is capable of noninvasive, site-targeted delivery of drugs through the blood-brain barrier (BBB). Although acoustic parameters are reproducible in small animals, their control remains challenging in primates due to skull heterogeneity. This study describes a 7-T magnetic resonance (MR)-guided FUS system designed for BBB disruption in non-human primates (NHP) with a robust feedback control based on passive cavitation detection (PCD). Contrast enhanced T₁-weighted MR images confirmed the BBB opening in NHP sonicated during 2 min with 500-kHz frequency, pulse length of 10 ms, and pulse repetition frequency of 5 Hz. The safe acoustic pressure range from 185 ± 22 kPa to 266 ± 4 kPa in one representative case was estimated from combining data from the acoustic beam profile with the BBB opening and hemorrhage profiles obtained from MR images. A maximum amount of MR contrast agent at focus was observed at 30 min after sonication with a relative contrast enhancement of 67% ± 15% (in comparison to that found in muscles). The feedback control based on PCD using relative spectra was shown to be robust, allowing comparisons across animals and experimental sessions. Finally, we also demonstrated that PCD can test acoustic coupling conditions, which improves the efficacy and safety of ultrasound transmission into the brain.

Passive cavitation mapping using dual apodization with cross-correlation in ultrasound therapy monitoring

Recently, passive acoustic mapping (PAM) has been successfully applied for dynamic monitoring of ultrasound therapy by beamforming acoustic emissions of cavitation activity during ultrasound exposure. The most widely used PAM algorithm in the literature is time exposure acoustics (TEA), which is a standard delay, sum, and integrate algorithm. However, it results in large point spread function (PSF) and serious imaging artifacts for the case where a narrow-aperture receiving array such as a standard B-mode linear array is used, therefore degrading the quality of cavitation image. To address these challenges, in this paper, we proposed a novel PAM algorithm namely dual apodization with cross-correlation (DAX)-based TEA, in which DAX was originally used as a reconstruction algorithm in medical ultrasound imaging. In the proposed algorithm, two sets of signals were beamformed by two receive apodization functions with alternating elements enabled, and the cross-correlation coefficient of the two signals served as a weighting factor that would be multiplied to the sum of the two signals. The performance of the proposed algorithm was tested on simulated channel data obtained using a multi-bubble model, and experiments were also performed in an in vitro vessel phantom with flowing microbubbles as cavitation nuclei. The reconstructed cavitation images were evaluated quantitatively using established quality metrics including full width at half maximum (FWHM), A_-6dB area, and signal-to-noise ratio (SNR). The results suggested that the proposed algorithm significantly outperformed the conventionally used TEA algorithm. This work may have the potential of providing a useful tool for highly accurate localization of cavitation activity during ultrasound therapy.

Dual-Frequency Ultrasound Induces Neural Stem/Progenitor Cell Differentiation and Growth Factor Utilization by Enhancing Stable Cavitation

Neural stem/progenitor cells (NSPCs) have the potential to serve as the basic materials for treating severe neural diseases and injuries. Ultrasound exposure is an effective therapy for nonunion fractures and healing fresh wounds through an easy and noninvasive application. According to the results of our preliminary study, low-intensity ultrasound (LIUS) promotes the attachment and differentiation of NSPCs. However, the parameters of and mechanisms by which LIUS induces NSPC differentiation remain unclear. To the best of our knowledge, no published studies have reported and compared the biological effects of dual-frequency and single-frequency LIUS on NSPCs. The purpose of this study is to systematically compare several LIUS parameters, including single-frequency, single-transducer dual-frequency ultrasound, burst, and continuous cycling stimulation at several intensities. Furthermore, synergistic effects of single-/dual-frequency LIUS combined with neural growth factor addition on NSPCs were also evaluated. Based on the results of the cytotoxicity assay, low-intensity (40 kPa) ultrasound does not damage NSPCs compared with that observed in the control group. The morphology and immunostaining results show that all experimental groups exposed to ultrasound exhibit neurite outgrowth and NSPC differentiation. In particular, dual-frequency ultrasound promotes NSPCs differentiation to a greater extent than single-frequency ultrasound. In addition, more complicated and denser neural networks are observed in the dual-frequency group. Neural growth factor addition increased the percentage of neurons formed, particularly in the groups stimulated with ultrasound. Among these groups, the dual-frequency group exhibited significant differences in the percentage of differentiated neurons compared with the single-frequency group. This study may the first to prove that dual-frequency LIUS exposure further enhances NSPC differentiation and the utilization of growth factors than single-frequency LIUS. Moreover, the result also revealed that dual-frequency ultrasound generated higher calcium ion influx and extended the channel opening time. A potential explanation is that dual-frequency ultrasound generates more stable cavitation than single-frequency LIUS, which may stimulate cell membrane mechanochannels and enhance calcium ion influx but does not damage them. This in vitro study may serve as a useful alternative for ultrasound therapy.

Advances in acoustic monitoring and control of focused ultrasound-mediated increases in blood-brain barrier permeability

Transcranial focused ultrasound (FUS) combined with intravenously circulating microbubbles can transiently and selectively increase blood-brain barrier permeability to enable targeted drug delivery to the central nervous system, and is a technique that has the potential to revolutionize the way neurological diseases are managed in medical practice. Clinical testing of this approach is currently underway in patients with brain tumors, early Alzheimer's disease, and amyotrophic lateral sclerosis. A major challenge that needs to be addressed in order for widespread clinical adoption of FUS-mediated blood-brain barrier permeabilization to occur is the development of systems and methods for real-time treatment monitoring and control, to ensure that safe and effective acoustic exposure levels are maintained throughout the procedures. This review gives a basic overview of the oscillation dynamics, acoustic emissions, and biological effects associated with ultrasound-stimulated microbubbles in vivo, and provides a summary of recent advances in acoustic-based strategies for detecting, controlling, and mapping microbubble activity in the brain. Further development of next-generation clinical FUS brain devices tailored towards microbubble-mediated applications is warranted and required for translation of this potentially disruptive technology into routine clinical practice.

Cavitation dose painting for focused ultrasound-induced blood-brain barrier disruption

Focused ultrasound combined with microbubble for blood-brain barrier disruption (FUS-BBBD) is a promising technique for noninvasive and localized brain drug delivery. This study demonstrates that passive cavitation imaging (PCI) is capable of predicting the location and concentration of nanoclusters delivered by FUS-BBBD. During FUS-BBBD treatment of mice, the acoustic emissions from FUS-activated microbubbles were passively detected by an ultrasound imaging system and processed offline using a frequency-domain PCI algorithm. After the FUS treatment, radiolabeled gold nanoclusters, ⁶⁴Cu-AuNCs, were intravenously injected into the mice and imaged by positron emission tomography/computed tomography (PET/CT). The centers of the stable cavitation dose (SCD) maps obtained by PCI and the corresponding centers of the ⁶⁴Cu-AuNCs concentration maps obtained by PET coincided within 0.3 ± 0.4 mm and 1.6 ± 1.1 mm in the transverse and axial directions of the FUS beam, respectively. The SCD maps were found to be linearly correlated with the ⁶⁴Cu-AuNCs concentration maps on a pixel-by-pixel level. These findings suggest that SCD maps can spatially "paint" the delivered nanocluster concentration, a technique that we named as cavitation dose painting. This PCI-based cavitation dose painting technique in combination with FUS-BBBD opens new horizons in spatially targeted and modulated brain drug delivery.

Closed-loop cavitation control for focused ultrasound-mediated blood-brain barrier opening by long-circulating microbubbles

Focused ultrasound (FUS) exposure in the presence of microbubbles (MBs) has been successfully used in the delivery of various sizes of therapeutic molecules across the blood-brain barrier (BBB). While acoustic pressure is correlated with the BBB opening size, real-time control of BBB opening to avoid vascular and neural damage is still a challenge. This arises mainly from the variability of FUS-MB interactions due to the variations of animal-specific metabolic environment and specific experimental setup. In this study, we demonstrate a closed-loop cavitation control framework to induce BBB opening for delivering large therapeutic molecules without causing macro tissue damages. To this end, we performed in mice long-term (5 min) cavitation monitoring facilitated by using long-circulating MBs. Monitoring the long-term temporal kinetics of the MBs under varying level of FUS pressure allowed to identify in situ, animal specific activity regimes forming pressure-dependent activity bands. This enables to determine the boundaries of each activity band (i.e. steady oscillation, transition, inertial cavitation) independent from the physical and physiological dynamics of the experiment. However, such a calibration approach is time consuming and to speed up characterization of the in situ, animal specific FUS-MB dynamics, we tested a novel method called 'pre-calibration' that closely reproduces the results of long-term monitoring but with a much shorter duration. Once the activity bands are determined from the pre-calibration method, an operation band can be selected around the desired cavitation dose. To drive cavitation in the selected operation band, we developed an adaptive, closed-loop controller that updates the acoustic pressure between each sonication based on measured cavitation dose. Finally, we quantitatively assessed the safety of different activity bands and validated the proposed methods and controller framework. The proposed framework serves to optimize the FUS pressure instantly to maintain the targeted cavitation level while improving safety control.

Theranostic Strategy of Focused Ultrasound Induced Blood-Brain Barrier Opening for CNS Disease Treatment

Focused Ultrasound (FUS) in combination with gaseous microbubbles has emerged as a potential new means of effective drug delivery to the brain. Recent research has shown that, under burst-type energy exposure with the presence of microbubbles, this modality can transiently permeate the blood-brain barrier (BBB). The bioavailability of therapeutic agents is site-specifically augmented only in the zone where the FUS energy is targeted. The non-invasiveness of this approach makes FUS-induced BBB opening a novel and attractive means to perform localized CNS therapeutic agent delivery. Over the past decade, FUS-BBB opening has been preclinically confirmed to successfully enhance CNS penetration of therapeutic agents including chemotherapeutic agents, therapeutic peptides, monoclonal antibodies, and nanoparticles. Recently, a number of clinical human trials have begun to explore clinical utility. This review article, explores this technology through its physical mechanisms, summarizes the existing preclinical findings (including current medical device designs and technical approaches), and summarizes current ongoing clinical trials.

Safety evaluation of frequent application of microbubble-enhanced focused ultrasound blood-brain-barrier opening

Focused ultrasound (FUS) with the presence of microbubbles induces blood brain barrier (BBB) opening in targeted areas and facilitates drug delivery. However, recent studies have indicated that FUS-BBB opening with excessive exposure levels may be associated with inflammatory response and cellular/tissue damage. Multiple weekly FUS exposures have been shown to be safe for human subjects. However the effect of more frequent FUS exposures is still unknown. This study examines whether frequent focused ultrasound blood brain barrier opening is associated with aggravated behavioral, histopathologic change or brain tissue damage. Two protocols of focused ultrasound blood brain barrier opening were devised using different microbubble doses (0.15 µl/kg and 0.4 µl/kg). Focused ultrasound exposure at a threshold level of BBB-opening, below-threshold level, or above level for intracerebral hemorrhage were delivered every 2 days. Animal behavioral and physiological changes were examined and recorded. Brain tissue was examined for hemorrhage and apoptosis. Results indicate that frequent exposure of excessive focused ultrasound (1.4 mechanical index) produced minor and short-term behavioral changes despite significant tissue damage, while frequent BBB opening with threshold or below-threshold FUS exposure (0.33-0.8 mechanical index) did not cause behavioral or histological change. Immunofluorescent examination of rat brain tissue indicated that excessive doses of microbubble administration induce an apparent cellular apoptotic response, which may be exacerbated by intracerebral hemorrhage. Experimental results suggest that frequent focused ultrasound blood brain barrier opening with sufficient ultrasound exposure level and a microbubble dose can be safe and pose minimal risk to brain tissue.