MR temperature mapping of focused ultrasound surgery

Deep lying soft tissue tumors may be treated by a nonincisional surgical procedure executed inside an MR imaging system using a thermal effect delivered by a focused ultrasound transducer. A prototype system is constructed to assess MRI thermal monitoring and the localization of the heat zone in muscle. The temperature distribution of the focal spot is imaged with MRI while mechanically moving the transducer with an hydraulic 3-axis positioner. Acoustic power is applied with a spherical shell transducer using 1- to 10-s duration pulses at frequencies of 1.5 MHz to selectively coagulate tissue at 60-70°C. The procedure is monitored with a series of fast second gradient echo, T₁-weighted, temperature sensitive MR sequences. Acquisitions are optimized for high temperature sensitive images that yield the thermal diffusivity, heat flow time constant and the focal spot size in muscle. MR temperature maps of muscle provide localization and dosimetry both in the focal region and near field.     

Plasma atrial natriuretic factor during cold-induced diuresis

Summary The purpose of this study was to evaluate the possible contribution of atrial natriuretic factor (ANF) to cold-induced diuresis. Seven healthy men, dressed in shorts, were exposed to a cold environment (+12°C) for 90 min, and also to a thermoneutral environment. Exposure to cold increased urine output and sodium excretion significantly but plasma ANF concentration remained unchanged. The increase in urinary potassium excretion during cold exposure was not significant (P=0.0636) and plasma renin activity did not change either. Exposure to cold increased mean arterial pressure significantly but it did not affect heart rate. We concluded that acute exposure to the cold environment induced a diuretic response, which was a solute diuresis in its nature. Our results did not give support to the hypothesis that ANF might be involved in the renal response to cold exposure.     

Simultaneous magnetic resonance phase and magnitude temperature maps in muscle

Noninvasive magnetic resonance temperature maps that are used to monitor thermal ablation of tissue are described. In magnetic resonance images, thermally induced proton nuclear magnetic resonance frequency shifts, and changes in the longitudinal relaxation time produce both phase and magnitude changes in the MR signal. Temperature maps with improved sensitivity are derived from the complex-difference nuclear magnetic resonance signal. Bovine muscle specimens were heated with focused ultrasound to model thermal surgery and create a known thermal distribution to test the method. Resulting MR images acquired in 2 s produce temperature maps with 1 mm resolution and 2°C temperature sensitivity. The temperature sensitivity was increased by extending the acquisition to 5 s, by decreasing the receiver bandwidth, and increasing the echo time.     

The CDRH Helix: an in vivo evaluation

The Helix is an electromagnetic heating device used to induce regional/systemic hyperthermia for cancer therapy. It is a resonant device operating at about 82 MHz with an aperture size of 60 cm x 40 cm (elliptical) x 40 cm long. The Helix deposits power in tissues (or phantoms) by producing a predominantly axial electric field within its radiating aperture. Five pig experiments were performed to provide in vivo verification of specific absorption rate (SAR) measurements and electric field measurements which were obtained earlier in tissue-equivalent phantom and 0.9% saline, respectively. In addition to verifying the power deposition patterns found in phantoms, the pig experiments provided valuable insight into the capabilities and limitations of electromagnetic regional heating. For example, a kidney with limited blood flow, simulating a necrotic tumor, heated very well-although the highest temperature was not always measured there. Also, fat heating may be a problem, since excessive temperatures in the fat were observed in approximately 20% of the heatings. This paper compares the in vivo temperature measurements in pigs with SARs and electric field measurements obtained in phantoms, and also provides a brief overview of results of the Helix in clinical situations.     

Dexmedetomidine as an Anesthetic Adjunct in Coronary Artery Bypass Grafting

Background: Alpha2 -Adrenergic agonists decrease sympathetic tone with ensuing attenuation of neuroendocrine and hemodynamic responses to anesthesia and surgery. The effects of dexmedetomidine, a highly specific alpha2 -adrenergic agonist, on these responses have not been reported in patients undergoing coronary artery bypass grafting.

Methods: Eighty patients scheduled for elective coronary artery bypass grafting received, in a double-blind manner, either a saline placebo or a dexmedetomidine infusion, initially 50 ng [center dot] kg-1 [center dot] min-1 for 30 min before induction of anesthesia with fentanyl, and then 7 ng [center dot] kg-1 [center dot] min-1 until the end of surgery. Filling pressures, blood pressure, and heart rate were controlled by intravenous fluid and by supplemental anesthetics and vasoactive drugs.

Results: Compared with placebo, dexmedetomidine decreased plasma norepinephrine concentrations by 90%, attenuated the increase of blood pressure during anesthesia (3 vs. 24 mmHg) and surgery (2 vs. 14 mmHg), but increased slightly the need for intravenous fluid challenge (29 vs. 20 patients) and induced more hypotension during cardiopulmonary bypass (9 vs. 0 patients). Dexmedetomidine decreased the incidence of intraoperative (2 vs. 13 patients) and postoperative (5 vs. 16 patients) tachycardia. Dexmedetomidine also decreased the need for additional doses of fentanyl (3.1 vs. 5.4), the increments of enflurane (4.4 vs. 5.6), the need for beta blockers (3 vs. 11 patients), and the incidence of fentanyl-induced muscle rigidity (15 vs. 33 patients) and postoperative shivering (13 vs. 23 patients).     

Predictors of individual adaptation to high‐volume or high‐intensity endurance training in recreational endurance runners

The aim of this study was to investigate factors that can predict individual adaptation to high‐volume or high‐intensity endurance training. After the first 8‐week preparation period, 37 recreational endurance runners were matched into the high‐volume training group (HVT) and high‐intensity training group (HIT). During the next 8‐week training period, HVT increased their running training volume and HIT increased training intensity. Endurance performance characteristics, heart rate variability (HRV), and serum hormone concentrations were measured before and after the training periods. While HIT improved peak treadmill running speed (RS_peak) 3.1 ± 2.8% (P < 0.001), no significant changes occurred in HVT (RS_peak: 0.5 ± 1.9%). However, large individual variation was found in the changes of RS_peak in both groups (HVT: ?2.8 to 4.1%; HIT: 0–10.2%). A negative relationship was observed between baseline high‐frequency power of HRV (HFP_night) and the individual changes of RS_peak (r = ?0.74, P = 0.006) in HVT and a positive relationship (r = 0.63, P = 0.039) in HIT. Individuals with lower HFP showed greater change of RS_peak in HVT, while individuals with higher HFP responded well in HIT. It is concluded that nocturnal HRV can be used to individualize endurance training in recreational runners.     

Apoptosis in ultrasound-produced threshold lesions in the rabbit brain

Focused ultrasound (US) surgery has been used to induce high temperature elevations in tissue to coagulate the proteins and kill the tissue. The introduction of noninvasive online temperature monitoring has made it possible to induce well-controlled thermal exposures. In this study, we used magnetic resonance imaging (MRI) thermometry to monitor thermal exposures near the threshold of tissue damage, and then investigated if apoptosis was induced. Rabbit brains were sonicated with an eight-sector phased array to create a large region of uniform temperature elevation at the end of a 30-s sonication. Histological examination demonstrated that apoptosis was induced in some cells. At 4 h after the sonications, the apoptotic cells constituted 9 +/- 7% of identifiable cells. By 48 h after the sonications, the number of apoptotic cells had increased up to 17 +/- 9%. The impact of this finding for therapy needs to be explored further.     

MRI-guided ultrasonic heating allows spatial control of exogenous luciferase in canine prostate

The need for efficient and controlled delivery is one of the major obstacles to clinical use of gene therapy. In this study, we investigated the use of magnetic resonance imaging-monitored ultrasound (US) to induce expression of luciferase after local injection of the construct Ad-HSP-Luc, an adenoviral vector containing a transgene encoding firefly luciferase under the control of the human hsp70B promoter. The hsp promoter allows induction of the associated transgene only in areas that are subsequently heated after infection. US imaging was used to guide the injection of purified virus into both lobes of the prostates of three beagles. At 48 h after injection, the left lobe of the prostate was heated using a 1.5-MHz US transducer driven by a multichannel radiofrequency system and employing an magnetic resonance imaging guidance system. High levels of luciferase expression were observed only in areas exposed to ultrasonic heating. This study demonstrates the feasibility of using ultrasonic heating to control transgene expression spatially using a minimally-invasive approach.     

MR imaging-controlled focused ultrasound ablation: a noninvasive image-guided surgery

The history of MR-guided FUS demonstrates the need for merging advanced therapy technology with advanced imaging. Without the ability of MR imaging to localize the tumor margins and without the temperature-sensitive imaging that provides the closed-loop control of energy deposition, this method is inadequate for most clinical applications. Given these limitations,high-intensity focused ultrasound initially appeared to have a narrow application area and was not able to compete with other surgical or ablation methods. Today, MR imaging-guided FUS has become a safe and effective means of performing probe-delivered thermal ablations and minimally invasive surgery. Moreover, it has the potential to replace treatments that use ionizing radiation such as radiosurgery and brachytherapy. Although the cost of integrating"big ticket" MR imaging systems with complex and expensive phased arrays is high, this expenditure will largely be offset by eliminating hospitalization and anesthesia and by reducing complications. In effect, an investment in this emerging technology will ultimately redound to the benefit of the health care delivery system and, most important, to the patient. The FUS system provides a safe, repeatable treatment approach for benign tumors (eg, uterine fibroid and breast fibroadenoma) that do not require an aggressive approach. MR-guided FUS can also be used for debulking cancerous tissue. It has already been tested as a breast cancer treatment; its application for other malignancies in the brain, liver, and prostate is under development. MR-guided FUS offers an attractive alternative to conventional surgery because it incorporates intraoperative MR imaging, which provides far more precise target definition than is possible with the surgeon's direct visualization of the lesion. MR-guided FUS is undeniably the most promising interventional MR imaging method in the field of image-guided therapy today. It is applicable not only in the thermal coagulative treatment of tumors but also in several other medical situations for which invasive surgery or radiation may not be treatment options. The use of FUS for treating vascular malformation or functional disorders of the brain is also exciting. It is uniquely applicable for image-guided therapy using targeted drug delivery methods and gene therapy. Further advances in this technology will no doubt improve energy deposition and reduce treatment times. In the near future, FUS will offer a viable alternative to conventional surgery and radiation therapy; in the longer-term, it may also enable a host of targeted treatment methods aimed at eradicating or arresting heretofore intractable diseases such as certain brain malignancies and forms of epilepsy.