Theoretical model for laser ablation outcome predictions in brain: calibration and validation on clinical MR thermometry images.

PURPOSE: Neurosurgical laser ablation is experiencing a renaissance. Computational tools for ablation planning aim to further improve the intervention. Here, global optimisation and inverse problems are demonstrated to train a model that predicts maximum laser ablation extent. METHODS: A closed-form steady state model is trained on and then subsequently compared to N = 20 retrospective clinical MR thermometry datasets. Dice similarity coefficient (DSC) is calculated to provide a measure of region overlap between the 57 °C isotherms of the thermometry data and the model-predicted ablation regions; 57 °C is a tissue death surrogate at thermal steady state. A global optimisation scheme samples the dominant model parameter sensitivities, blood perfusion (ω) and optical parameter (µeff) values, throughout a parameter space totalling 11 440 value-pairs. This represents a lookup table of µeff-ω pairs with the corresponding DSC value for each patient dataset. The µeff-ω pair with the maximum DSC calibrates the model parameters, maximising predictive value for each patient. Finally, leave-one-out cross-validation with global optimisation information trains the model on the entire clinical dataset, and compares against the model naïvely using literature values for ω and µeff. RESULTS: When using naïve literature values, the model's mean DSC is 0.67 whereas the calibrated model produces 0.82 during cross-validation, an improvement of 0.15 in overlap with the patient data. The 95% confidence interval of the mean difference is 0.083-0.23 (p < 0.001). CONCLUSIONS: During cross-validation, the calibrated model is superior to the naïve model as measured by DSC, with +22% mean prediction accuracy. Calibration empowers a relatively simple model to become more predictive.

Automating neurosurgical tumor resection surgery: Volumetric laser ablation of cadaveric porcine brain with integrated surface mapping.

OBJECTIVE: Current surgical instruments for soft tissue resection including neurosurgical procedures rely on the accuracy and precision of the human operator and are fundamentally constrained by the human hand. Automated surgical action with the integration of intraoperative data sources can enable highly accurate and fast tissue manipulation using laser ablation. This study presents the first experiments with a prototype designed for automated tumor resection via laser ablation. We demonstrate targeted soft tissue resection in porcine brain with an integrated device that combines 3D scanning capabilities with a steerable surgical laser and discuss implications for future automated robotic neurosurgical procedures. STUDY DESIGN AND METHODS: A device consisting of a two-axis galvanometer for steering a cutting laser and a 3D surface profiler is used to perform volumetric removal of tissue of ex vivo porcine brain. Three-dimensional surface profiles are gathered between cuts and used to estimate ablation rate. RESULTS: Volumetric ablation of porcine brain tissue is performed and subsequently surface profiled. The average ablation rates across the area cutting areas were 2.6 mm3 /s and 3.7 mm3 /s for the initial and subsequent cuts, respectively. A Kruskal-Wallis and post-hoc Tukey test show statistical significance between the initial and subsequent cuts. Accuracy between cuts when benchmarked against a human surgeon varied from 47 to 88%. CONCLUSION: A feed-forward volumetric resection is demonstrated with sensing and cutting housed within a single device, thereby opening the potential for automated soft tissue resection as necessary during the surgical removal of pathologic tissues. High variance around target cut depths motivates future work in developing a closed-loop ablation tool as well as characterization of laser-tissue interactions for predictive modelling. Objective Lasers Surg. 50:1017-1024, 2018. © 2018 Wiley Periodicals, Inc.

A Ten-Year Kuala Lumpur Review on Laser Posterior Cordectomy for Bilateral Vocal Fold Immobility.

Bilateral vocal fold immobility (BVFI) is commonly caused by injury to the recurrent laryngeal nerve (RLN) and leads to stridor and dyspnea of varying onsets. A retrospective study was done at the Department of Otorhinolaryngology of Universiti Kebangsaan Malaysia Medical Centre on laser microsurgical posterior cordectomy for BVFI. The objectives were to identify the average duration of onset of stridor from the time of insult and to evaluate the outcome of laser posterior cordectomy as a surgical option. From 1997 to 2007, a total of 31 patients with BVFI were referred for surgery. Twelve patients had tracheostomy done prior to the procedure, whereas 19 patients were without tracheostomy. Ten patients were successfully decannulated, and only 4 patients had complications related to the procedure. The minimum onset of stridor was 7 months, maximum onset of stridor was 28 years, and the mean onset of stridor was 8.7 years. The commonest complication observed was posterior glottic adhesion following bilateral posterior cordectomy. Laser endolaryngeal posterior cordectomy is an excellent surgical option as it enables successful decannulation or avoidance of tracheostomy in patients with BVFI. The onset of stridor took years after the insult to the recurrent laryngeal nerves.

Tissue post-classification using the measured acoustic signals during 355 nm laser atherectomy procedures.

The current laser atherectomy technologies to treat patients with challenging (to-cross) total chronic occlusions with a step-by-step (SBS) approach (without leading guide wire), are lacking real-time signal monitoring of the ablated tissues, and carry the risk for vessel perforation. We present first time post-classification of ablated tissues using acoustic signals recorded by a microphone placed nearby during five atherectomy procedures using 355 nm solid-state Auryon laser device performed with an SBS approach, some with highly severe calcification. Using our machine-learning algorithm, the classification results of these ablation signals recordings from five patients showed 93.7% classification accuracy with arterial vs nonarterial wall material. While still very preliminary and requiring a larger study and thereafter as commercial device, the results of these first acoustic post-classification in SBS cases are very promising. This study implies, as a general statement, that online recording of the acoustic signals using a noncontact microphone, may potentially serve for an online classification of the ablated tissue in SBS cases. This technology could be used to confirm correct positioning in the vasculature, and by this, to potentially further reduce the risk of perforation using 355 nm laser atherectomy in such procedures.

Integrated effects of fractional laser microablation and sonophoresis on skin immersion optical clearing in vivo.

This study is aimed to find an approach for effective skin optical clearing in vivo using polyethylene glycol 300 (PEG-300) as an optical clearing agent in combination with physical enhancers: fractional laser microablation (FLMA) and/or low-frequency sonophoresis. In this study albino outbred rats were used. Light attenuation coefficient and optical clearing potential (OCP) of these approaches were evaluated in upper (from ~70 to ~200 µm) and middle (from ~200 to ~400 µm) dermis separately using optical coherence tomography. In 30 minutes, OCP of sonophoresis in combination with FLMA and PEG-300 in the upper dermis was the maximal (2.3 ± 0.4) in comparison with other treatments in this time point. The most effective approach for optical clearing of middle dermis was PEG-300 and sonophoresis; but the maximal value of OCP (1.6 ± 0.1) was achieved only in 90 minutes.

In situ tissue classification during laser ablation using acoustic signals.

We suggest a novel method to classify the type of tissue that is being ablated, using the recorded acoustic sound waves during pulsed ultraviolet laser ablation. The motivation of the current research is tissue classification during vascular interventions, where the identification of the ablated tissue is vital. We classify the acoustic signatures using Mel-frequency cepstral coefficients (MFCCs) feature extraction with a Support Vector Machine (SVM) algorithm, and in addition, use a fully connected deep neural network (FC-DNN) algorithm. First, we classify three different liquids using our method as a preliminary proof of concept. Then, we classify ex vivo porcine aorta and bovine tendon tissues in the presence of saline. Finally, we classify ex vivo porcine aorta and bovine tendon tissues where the acoustic signals are recorded through chicken breast medium. The results for tissue classification in saline and through chicken breast both show high accuracy (>98%), based on tens of thousands of acoustic signals for each experiment. The experiments were conducted in a noisy and challenging setting that tries to imitate practical working conditions. The obtained results could pave the way towards practical tissue classification in various important medical procedures, achieving enhanced efficacy and safety.

Femtosecond pulsed laser ablation to enhance drug delivery across the skin.

Laser poration of the skin locally removes its outermost, barrier layer, and thereby provides a route for the diffusion of topically applied drugs. Ideally, no thermal damage would surround the pores created in the skin, as tissue coagulation would be expected to limit drug diffusion. Here, a femtosecond pulsed fiber laser is used to porate mammalian skin ex vivo. This first application of a hollow core negative curvature fiber (HC-NCF) to convey a femtosecond pulsed, visible laser beam results in reproducible skin poration. The effect of applying ink to the skin surface, prior to ultra-short pulsed ablation, has been examined and Raman spectroscopy reveals that the least, collateral thermal damage occurs in inked skin. Pre-application of ink reduces the laser power threshold for poration, an effect attributed to the initiation of plasma formation by thermionic electron emission from the dye in the ink. Poration under these conditions significantly increases the percutaneous permeation of caffeine in vitro. Dye-enhanced, plasma-mediated ablation of the skin is therefore a potentially advantageous approach to enhance topical/transdermal drug absorption. The combination of a fiber laser and a HC-NCF, capable of emitting and delivering femtosecond pulsed, visible light, may permit a compact poration device to be developed.

Real-time monitoring of incision profile during laser surgery using shock wave detection.

Lack of sensory feedback during laser surgery prevents surgeons from discerning the exact location of the incision, which increases duration and complexity of the treatment. In this study we demonstrate a new method for monitoring of laser ablation procedures. Real-time tracking of the exact three dimensional (3D) lesion profile is accomplished by detection of shock waves emanating from the ablation spot and subsequent reconstruction of the incision location using time-of-flight data obtained from multiple acoustic detectors. Here, incisions of up to 9 mm in depth, created by pulsed laser ablation of fresh bovine tissue samples, were successfully monitored in real time. It was further observed that, by utilizing as little as 12 detection elements, the incision profile can be characterized with accuracy below 0.5 mm in all three dimensions and in good agreement with histological examinations. The proposed method holds therefore promise for delivering high precision real-time feedback during laser surgeries.