Robotic Assisted MRI-Guided Interventional Interstitial MR-Guided Focused Ultrasound Ablation in a Swine Model

BACKGROUND

Ablative lesions are current treatments for epilepsy and brain tumors. Interstitial magnetic resonance (MR) guided focused ultrasound (iMRgFUS) may be an alternate ablation technique which limits thermal tissue charring as compared to laser therapy (LITT) and can produce larger ablation patterns nearer the surface than transcranial MR guided focused ultrasound (tcMRgFUS).

OBJECTIVE

To describe our experience with interstitial focused ultrasound (iFUS) ablations in swine, using MR-guided robotically assisted (MRgRA) delivery.

METHODS

In an initial 3 animals, we optimized the workflow of the robot in the MR suite and made modifications to the robotic arm to allow range of motion. Then, 6 farm pigs (4 acute, 2 survival) underwent 7 iMRgFUS ablations using MRgRA. We altered dosing to explore differences between thermal dosing in brain as compared to other tissues. Imaging was compared to gross examination.

RESULTS

Our work culminated in adjustments to the MRgRA, iMRgFUS probes, and dosing, culminating in 2 survival surgeries; swine had ablations with no neurological sequelae at 2 wk postprocedure. Immediately following iMRgFUS therapy, diffusion-weighted imaging, and T1 weighted MR were accurate reflections of the ablation volume. T2 and fluid-attenuated inversion-recovery (FLAIR) images were accurate reflections of ablation volume 1-wk postprocedure.

CONCLUSION

We successfully performed MRgRA iFUS ablation in swine and found intraoperative and postoperative imaging to correlate with histological examination. These data are useful to validate our system and to guide imaging follow-up for thermal ablation lesions in brain tissue from our therapy, tcMRgFUS, and LITT.

Colony stimulating factor-1 receptor is a central component of the foreign body response to biomaterial implants in rodents and non-human primates

Host recognition and immune-mediated foreign body response to biomaterials can compromise the performance of implanted medical devices. To identify key cell and cytokine targets, here we perform in-depth systems analysis of innate and adaptive immune system responses to implanted biomaterials in rodents and non-human primates. While macrophages are indispensable to the fibrotic cascade, surprisingly neutrophils and complement are not. Macrophages, via CXCL13, lead to downstream B cell recruitment, which further potentiated fibrosis, as confirmed by B cell knockout and CXCL13 neutralization. Interestingly, colony stimulating factor-1 receptor (CSF1R) is significantly increased following implantation of multiple biomaterial classes: ceramic, polymer and hydrogel. Its inhibition, like macrophage depletion, leads to complete loss of fibrosis, but spares other macrophage functions such as wound healing, reactive oxygen species production and phagocytosis. Our results indicate that targeting CSF1R may allow for a more selective method of fibrosis inhibition, and improve biomaterial biocompatibility without the need for broad immunosuppression.

Abstract TP261: Clot Integration Factor for in-vitro Quantification of Stent-retriever Configuration Using Cone-beam CT

Objective: Mechanical thrombectomy using stent-retriever technology provides acute ischemic stroke patients with beneficial treatment of emergent large vessel occlusion. Still, the disparity between recanalization rates and clinical outcomes calls for enhanced device designs and treatment strategies with better reperfusion efficiency. Intuitively, sufficient device integration with the embolus is pursued to maximize chances of first-pass success, thereby limiting clot fragmentation and intimal trauma during extensive clot manipulation. Our aim was to develop an imaging-based measure of device integration in reproducible phantom experiments that could help identifying differences in aspects of thrombectomy procedures that may be related to angiographic and clinical outcomes.

Methods: Deployment variations of the Trevo(TM) ProVue/XP retriever were tested in an in-vitro model system that mimicked a MCA-occlusion with a silicone vascular replica and two visible clot models (soft elastic, and hard inelastic) with 8 trials/group. High-resolution cone-beam CT imaging was performed prior to retriever retraction. An image processing pipeline was devised that used level-set segmentation, path-tracing, and Steiner circumellipse fitting to extract and determine the interior volumes of the clot and the three visible wires. Clot Integration Factor (CIF) was calculated as the ratio of the volume of clot-device intersection to the clot volume.

Results: Example of the device, its wires, and the clot: Average clot volumes were 90.4±12.2mm3. CIF was significantly different for two deployment variations when the device engaged a hard clot (difference between means, 95%CI=[0.003,0.187], p=0.043), but not a soft clot model (95%CI=[-0.152,0.263], p=0.567).

Conclusion: In-vitro imaging-based quantification of clot integration can detect differences in deployment configuration relative to a clot, which may support procedural and design improvements.

Long-term glycemic control using polymer-encapsulated human stem cell-derived beta cells in immune-competent mice

The transplantation of glucose-responsive, insulin-producing cells offers the potential for restoring glycemic control in diabetic patients¹. Pancreas transplantation and the infusion of cadaveric islets are currently implemented clinically², but are limited by the adverse effects of lifetime immunosuppression and the limited supply of donor tissue³. The latter concern may be addressed by recently described glucose responsive mature β-cells derived from human embryonic stem cells; called SC-β, these cells may represent an unlimited human cell source for pancreas replacement therapy⁴. Strategies to address the immunosuppression concern include immunoisolation of insulin-producing cells with porous biomaterials that function as an immune barrier^5,6. However, clinical implementation has been challenging due to host immune responses to implant materials⁷. Here, we report the first long term glycemic correction of a diabetic, immune-competent animal model with human SC-β cells. SC-β cells were encapsulated with alginate-derivatives capable of mitigating foreign body responses in vivo, and implanted into the intraperitoneal (IP) space of streptozotocin-treated (STZ) C57BL/6J mice. These implants induced glycemic correction until removal at 174 days without any immunosuppression. Human C-peptide concentrations and in vivo glucose responsiveness demonstrate therapeutically relevant glycemic control. Implants retrieved after 174 days contained viable insulin-producing cells.

Neutrophil Responses to Sterile Implant Materials

In vivo implantation of sterile materials and devices results in a foreign body immune response leading to fibrosis of implanted material. Neutrophils, one of the first immune cells to be recruited to implantation sites, have been suggested to contribute to the establishment of the inflammatory microenvironment that initiates the fibrotic response. However, the precise numbers and roles of neutrophils in response to implanted devices remains unclear. Using a mouse model of peritoneal microcapsule implantation, we show 30–500 fold increased neutrophil presence in the peritoneal exudates in response to implants. We demonstrate that these neutrophils secrete increased amounts of a variety of inflammatory cytokines and chemokines. Further, we observe that they participate in the foreign body response through the formation of neutrophil extracellular traps (NETs) on implant surfaces. Our results provide new insight into neutrophil function during a foreign body response to peritoneal implants which has implications for the development of biologically compatible medical devices.

Size- and shape-dependent foreign body immune response to materials implanted in rodents and non-human primates

The efficacy of implanted biomedical devices is often compromised by host recognition and subsequent foreign body responses. Here, we demonstrate the role of the geometry of implanted materials on their biocompatibility in vivo. In rodent and non-human primate animal models, implanted spheres 1.5 mm and above in diameter across a broad spectrum of materials, including hydrogels, ceramics, metals and plastics, significantly abrogated foreign body reactions and fibrosis when compared with smaller spheres. We also show that for encapsulated rat pancreatic islet cells transplanted into streptozotocin-treated diabetic C57BL/6 mice, islets prepared in 1.5-mm alginate capsules were able to restore blood-glucose control for up to 180 days, a period more than five times longer than for transplanted grafts encapsulated within conventionally sized 0.5-mm alginate capsules. Our findings suggest that the in vivo biocompatibility of biomedical devices can be significantly improved simply by tuning their spherical dimensions.

Effects of serum deprivation on the mechanical properties of adherent vascular smooth muscle cells

Vascular smooth muscle cell (VSMC) function plays a key role in regulating the development and progression of vascular lesions. Among the more significant phenomena that occur during the development of these lesions is the phenotypic switching of VSMCs from a contractile to a synthetic state. A better understanding of the concurrent changes to VSMC mechanical properties that occur with phenotypic shifts can help to elucidate the role of VSMC mechanics in the development of vascular diseases. In the current study, the mechanical properties of adherent cultured rat aortic VSMCs were assessed by atomic force microscopy. Serum starvation was used to induce a phenotypic shift in vitro. It was concluded that serum starvation led to a statistically significant increase in apparent elastic modulus after 5 days, as well as a statistically significant decrease in hysteresis after culture for 3 days. If this trend of VSMC mechanical properties changing concurrently with phenotypic shifts were to hold true in vivo, such changes could affect the processes of mechanotransduction and/or arterial mechanical properties, thereby contributing to the progression of vascular disease.

Syndecan-4 is a primary-response gene induced by basic fibroblast growth factor and arterial injury in vascular smooth muscle cells

Syndecans are a family of transmembrane proteoglycans that have been implicated in cell-extracellular matrix adhesion and growth factor binding. We reported previously that syndecan-1 expression by cultured rate vascular smooth muscle cells (VSMCs) is induced by serum- or platelet-derived growth factor (PDGF). We now report that syndecan-4 mRNA is rapidly induced in cultured VSMCs in response to basic fibroblast growth factor (bFGF) or serum stimulation. In the presence of cycloheximide, induction of syndecan-4 mRNA was enhanced. These characteristics identified syndecan-4 as a primary-response gene product in VSMCs. In contrast, syndecan-1 mRNA expression in response to serum was completely blocked in the presence of cycloheximide. We also examined the expression of syndecan mRNAs in VSMCs in response to balloon catheter injury in vivo. A reverse transcriptase-polymerase chain reaction technique was developed that enabled us to amplify all four syndecan mRNAs in a single reaction tube and determine relative changes in their expression. All four syndecan mRNAs were detected in uninjured rat carotid arteries. In endothelium-denuded arteries, the medial layer (presumably VSMCs) accounted for 70% to 90% of the syndecan mRNAs in the vessel wall. The levels of syndecan-2 and syndecan-3 mRNAs were not altered significantly after balloon injury. In contrast, syndecan-4 mRNA was increased at early times after injury but then decreased to control level by 7 days. Syndecan-1 mRNA levels showed a slower but prolonged increase that reached a maximum at 7 days after injury. Immunostaining with anti-syndecan-4 antibodies demonstrated a rapid increase in syndecan-4 proteoglycan expression in the injured carotid artery.

TRISS unexpected survivors--a statistical phenomenon or a clinical reality?

Data from patients treated in Pennsylvania-accredited trauma centers during 1989 were analyzed. TRISS expected and unexpected survivors (1.6% of all survivors) differed in many ways. Unexpected survivors were more than twice as likely to have been transferred from a nondesignated trauma center (45.8% vs. 22.8%, p < 0.001). Unexpected survivors had significantly higher frequencies of motor vehicle injuries (56.2% vs. 38.3%, p < 0.001), pedestrian injuries (9.6% vs. 5.4%, p < 0.01), and gunshot wounds (7.3% vs. 4.7%, p < 0.01). Expected survivors were injured more frequently in falls (26.1% vs. 10.8%, p < 0.001) and were less frequently male (64.5% vs. 75%, p < 0.001). Unexpected survivors had significantly longer average hospital stay (29.6 s vs. 9.3 days, p < 0.001) and more frequent (98.8% vs. 36.8%, p < 0.001) and longer average stays in the ICU (13.3 s vs. 4.1 days, p < 0.001). The percentage of unexpected survivors discharged to rehabilitation centers (61.9%) was significantly greater than that for expected survivors (8.7%), (p < 0.001). Unexpected survivors were more frequently judged "completely dependent" in five measures of functional disability than expected survivors. We conclude that unexpected survivors are a seriously injured and clinically relevant patient set, not just a statistical phenomenon.