Respiration based steering for high intensity focused ultrasound liver ablation.

PURPOSE: Respiratory motion makes hepatic ablation using high intensity focused ultrasound (HIFO) challenging. Previous HIFU liver treatment had required apnea induced during general anesthesia. We describe and test a system that allows treatment of the liver in the presence of breathing motion. METHODS: Mapping a signal from an external respiratory bellow to treatment locations within the liver allows the ultrasound transducer to be steered in real time to the target location. Using a moving phantom, three metrics were used to compare static, steered, and unsteered sonications: the area of sonications once a temperature rise of 15°C was achieved, the energy deposition required to reach that temperature, and the average rate of temperature rise during the first 10 s of sonication. Steered HIFU in vivo ablations of the porcine liver were also performed and compared to breath-hold ablations. RESULTS: For the last phantom metric, all groups were found to be statistically significantly different (P ≤ 0.003). However, in the other two metrics, the static and unsteered sonications were not statistically different (P > 0.9999). Steered in vivo HIFU ablations were not statistically significantly different from ablations during breath-holding. CONCLUSIONS: A system for performing HIFU steering during ablation of the liver with breathing motion is presented and shown to achieve results equivalent to ablation performed with breath-holding.

Improved sleep MRI at 3 tesla in patients with obstructive sleep apnea.

PURPOSE: To describe a real-time MR imaging platform for synchronous, multi-planar visualization of upper airway collapse in obstructive sleep apnea at 3 Tesla (T) to promote natural sleep with an emphasis on lateral wall visualization. MATERIALS AND METHODS: A real-time imaging platform was configured for sleep MR imaging which used a cartesian, partial k-space gradient-echo sequence with an inherent temporal resolution of 3 independent slices every 2 s. Combinations of axial, mid-sagittal, and coronal scan planes were acquired. The system was tested in five subjects with polysomnography-proven obstructive sleep apnea during sleep, with synchronous acquisition of respiratory effort and combined oral-nasal airflow data. RESULTS: Sleep was initiated and maintained to allow demonstration of sleep-induced, upper airway collapse as illustrated in two subjects when using a real-time, sleep MR imaging platform at 3T. Lateral wall collapse could not be visualized on mid-sagittal imaging alone and was best characterized on multiplanar coronal and axial imaging planes. CONCLUSION: Our dedicated sleep MR imaging platform permitted an acoustic environment of constant "white noise" which was conducive to sleep onset and sleep maintenance in obstructive sleep apnea patients at 3T. Apneic episodes, specifically the lateral walls, were more accurately characterized with synchronous, multiplanar acquisitions.

In vivo MR acoustic radiation force imaging in the porcine liver.

PURPOSE: High intensity focused ultrasound (HIFU) in the abdomen can be sensitive to acoustic aberrations that can exist in the beam path of a single sonication. Having an accurate method to quickly visualize the transducer focus without damaging tissue could assist with executing the treatment plan accurately and predicting these changes and obstacles. By identifying these obstacles, MR acoustic radiation force imaging (MR-ARFI) provides a reliable method for visualizing the transducer focus quickly without damaging tissue and allows accurate execution of the treatment plan. METHODS: MR-ARFI was used to view the HIFU focus, using a gated spin echo flyback readout-segmented echo-planar imaging sequence. HIFU spots in a phantom and in the livers of five live pigs under general anesthesia were created with a 550 kHz extracorporeal phased array transducer initially localized with a phase-dithered MR-tracking sequence to locate microcoils embedded in the transducer. MR-ARFI spots were visualized, observing the change of focal displacement and ease of steering. Finally, MR-ARFI was implemented as the principle liver HIFU calibration system, and MR-ARFI measurements of the focal location relative to the thermal ablation location in breath-hold and breathing experiments were performed. RESULTS: Measuring focal displacement with MR-ARFI was achieved in the phantom and in vivo liver. In one in vivo experiment, where MR-ARFI images were acquired repeatedly at the same location with different powers, the displacement had a linear relationship with power [y = 0.04x + 0.83 µm (R(2) = 0.96)]. In another experiment, the displacement images depicted the electronic steering of the focus inside the liver. With the new calibration system, the target focal location before thermal ablation was successfully verified. The entire calibration protocol delivered 20.2 J of energy to the animal (compared to greater than 800 J for a test thermal ablation). ARFI displacement maps were compared with thermal ablations during seven breath-hold ablations. The error was 0.83 ± 0.38 mm in the S/I direction and 0.99 ± 0.45 mm in the L/R direction. For six spots in breathing ablations, the mean error in the nonrespiration direction was 1.02 ± 0.89 mm. CONCLUSIONS: MR-ARFI has the potential to improve free-breathing plan execution accuracy compared to current calibration and acoustic beam adjustment practices. Gating the acquisition allows for visualization of the focal spot over the course of respiratory motion, while also being insensitive to motion effects that can complicate a thermal test spot. That MR-ARFI measures a mechanical property at the focus also makes it insensitive to high perfusion, of particular importance to highly perfused organs such as the liver.

Real-time MR thermometry for monitoring HIFU ablations of the liver.

A high-resolution and high-speed pulse sequence is presented for monitoring high-intensity focused ultrasound ablations in the liver in the presence of motion. The sequence utilizes polynomial-order phase saturation bands to perform outer volume suppression, followed by spatial-spectral excitation and three readout segmented echo-planar imaging interleaves. Images are processed with referenceless thermometry to create temperature-rise images every frame. The sequence and reconstruction were implemented in RTHawk and used to image stationary and moving sonications in a polyacrylamide gel phantom (62.4 acoustic W, 50 sec, 550 kHz). Temperature-rise images were compared between moving and stationary experiments. Heating spots and corresponding temperature-rise plots matched very well. The stationary sonication had a temperature standard deviation of 0.15 degrees C compared to values of 0.28 degrees C and 0.43 degrees C measured for two manually moved sonications at different velocities. Moving the phantom (while not heating) with respect to the transducer did not cause false temperature rises, despite susceptibility changes. The system was tested on nonheated livers of five normal volunteers. The mean temperature rise was -0.05 degrees C, with a standard deviation of 1.48 degrees C. This standard deviation is acceptable for monitoring high-intensity focused ultrasound ablations, suggesting real-time imaging of moving high-intensity focused ultrasound sonications can be clinically possible.

Reweighted ℓ1 referenceless PRF shift thermometry.

Temperature estimation in proton resonance frequency (PRF) shift MR thermometry requires a reference, or pretreatment, phase image that is subtracted from image phase during thermal treatment to yield a phase difference image proportional to temperature change. Referenceless thermometry methods derive a reference phase image from the treatment image itself by assuming that in the absence of a hot spot, the image phase can be accurately represented in a smooth (usually low order polynomial) basis. By masking the hot spot out of a least squares (ℓ(2)) regression, the reference phase image's coefficients on the polynomial basis are estimated and a reference image is derived by evaluating the polynomial inside the hot spot area. Referenceless methods are therefore insensitive to motion and bulk main field shifts, however, currently these methods require user interaction or sophisticated tracking to ensure that the hot spot is masked out of the polynomial regression. This article introduces an approach to reference PRF shift thermometry that uses reweighted ℓ(1) regression, a form of robust regression, to obtain background phase coefficients without hot spot tracking and masking. The method is compared to conventional referenceless thermometry, and demonstrated experimentally in monitoring HIFU heating in a phantom and canine prostate, as well as in a healthy human liver.

Hybrid referenceless and multibaseline subtraction MR thermometry for monitoring thermal therapies in moving organs.

PURPOSE: Magnetic resonance thermometry using the proton resonance frequency (PRF) shift is a promising technique for guiding thermal ablation. For temperature monitoring in moving organs, such as the liver and the heart, problems with motion must be addressed. Multi-baseline subtraction techniques have been proposed, which use a library of baseline images covering the respiratory and cardiac cycle. However, main field shifts due to lung and diaphragm motion can cause large inaccuracies in multi-baseline subtraction. Referenceless thermometry methods based on polynomial phase regression are immune to motion and susceptibility shifts. While referenceless methods can accurately estimate temperature within the organ, in general, the background phase at organ/tissue interfaces requires large polynomial orders to fit, leading to increased danger that the heated region itself will be fitted by the polynomial and thermal dose will be underestimated. In this paper, a hybrid method for PRF thermometry in moving organs is presented that combines the strengths of referenceless and multi-baseline thermometry. METHODS: The hybrid image model assumes that three sources contribute to image phase during thermal treatment: Background anatomical phase, spatially smooth phase deviations, and focal, heat-induced phase shifts. The new model and temperature estimation algorithm were tested in the heart and liver of normal volunteers, in a moving phantom HIFU heating experiment, and in numerical simulations of thermal ablation. The results were compared to multi-baseline and referenceless methods alone. RESULTS: The hybrid method allows for in vivo temperature estimation in the liver and the heart with lower temperature uncertainty compared to multi-baseline and referenceless methods. The moving phantom HIFU experiment showed that the method accurately estimates temperature during motion in the presence of smooth main field shifts. Numerical simulations illustrated the method's sensitivity to algorithm parameters and hot spot features. CONCLUSIONS: This new hybrid method for MR thermometry in moving organs combines the strengths of both multi-baseline subtraction and referenceless thermometry and overcomes their fundamental weaknesses.

Maximum linear-phase spectral-spatial radiofrequency pulses for fat-suppressed proton resonance frequency-shift MR Thermometry.

Conventional spectral-spatial pulses used for water-selective excitation in proton resonance frequency-shift MR thermometry require increased sequence length compared to shorter wideband pulses. This is because spectral-spatial pulses are longer than wideband pulses, and the echo time period starts midway through them. Therefore, for a fixed echo time, one must increase sequence length to accommodate conventional spectral-spatial pulses in proton resonance frequency-shift thermometry. We introduce improved water-selective spectral-spatial pulses for which the echo time period starts near the beginning of excitation. Instead of requiring increased sequence length, these pulses extend into the long echo time periods common to PRF sequences. The new pulses therefore alleviate the traditional tradeoff between sequence length and fat suppression. We experimentally demonstrate an 11% improvement in frame rate in a proton resonance frequency imaging sequence compared to conventional spectral-spatial excitation. We also introduce a novel spectral-spatial pulse design technique that is a hybrid of previous model- and filter-based techniques and that inherits advantages from both. We experimentally validate the pulses' performance in suppressing lipid signal and in reducing sequence length compared to conventional spectral-spatial pulses.

Anatomic measures of upper airway structures in obstructive sleep apnea.

OBJECTIVE: Determine if anatomic dimensions of airway structures are associated with airway obstruction in obstructive sleep apnea (OSA) patients. METHODS: Twenty-eight subjects with (n = 14) and without (n = 14) OSA as determined by clinical symptoms and sleep studies; volunteer sample. Skeletal and soft tissue dimensions were measured from radiocephalometry and magnetic resonance imaging. The soft palate thickness, mandibular plane-hyoid (MP-H) distance, posterior airway space (PAS) diameters and area, and tongue volume were calculated. RESULTS: Compared to controls, the OSA group demonstrated a significantly longer MP-H distance (P = 0.009) and shorter nasal PAS diameter (P = 0.02). The PAS area was smaller (P = 0.002) and tongue volume larger in the OSA group (P = 0.004). The MP-H distance, PAS measurements, and tongue volume are of clinical relevance in OSA patients. CONCLUSIONS: A long MP-H distance, and small PAS diameters and area are significant anatomic measures in OSA; however the most substantial parameter found was a large tongue volume.

Wireless mobile technology to improve workflow and feasibility of MR-guided percutaneous interventions.

PURPOSE: A wireless interactive display and control device combined with a platform-independent web-based user interface (UI) was developed to improve the workflow for interventional magnetic resonance imaging (iMRI). METHODS: The iMRI-UI enables image acquisition of up to three independent slices using various pulse sequences with different contrast weighting. Pulse sequence, scan geometry and related parameters can be changed on the fly via the iMRI-UI using a tablet computer for improved lesion detection and interventional device targeting. The iMRI-UI was validated for core biopsies with a liver phantom ([Formula: see text] [Formula: see text] 40) and Thiel soft-embalmed human cadavers ([Formula: see text] [Formula: see text] 24) in a clinical 1.5T MRI scanner. RESULTS: The iMRI-UI components and setup were tested and found conditionally MRI-safe to use according to current ASTM standards. Despite minor temporary touch screen interference at a close distance to the bore ([Formula: see text]20 cm), no other issues regarding quality or imaging artefacts were observed. The 3D root-mean-square distance error was [Formula: see text] (phantom)/[Formula: see text] mm (cadaver), and overall procedure times ranged between 12 and 22 (phantom)/20 and 55 min (cadaver). CONCLUSION: The wireless iMRI-UI control setup enabled fast and accurate interventional biopsy needle placements along complex trajectories and improved the workflow for percutaneous interventions under MRI guidance in a preclinical trial.

Preclinical feasibility of a technology framework for MRI-guided iliac angioplasty.

PURPOSE: Interventional MRI has significant potential for image guidance of iliac angioplasty and related vascular procedures. A technology framework with in-room image display, control, communication and MRI-guided intervention techniques was designed and tested for its potential to provide safe, fast and efficient MRI-guided angioplasty of the iliac arteries. METHODS: A 1.5-T MRI scanner was adapted for interactive imaging during endovascular procedures using new or modified interventional devices such as guidewires and catheters. A perfused vascular phantom was used for testing. Pre-, intra- and post-procedural visualization and measurement of vascular morphology and flow was implemented. A detailed analysis of X-ray fluoroscopic angiography workflow was conducted and applied. Two interventional radiologists and one physician in training performed 39 procedures. All procedures were timed and analyzed. RESULTS: MRI-guided iliac angioplasty procedures were successfully performed with progressive adaptation of techniques and workflow. The workflow, setup and protocol enabled a reduction in table time for a dedicated MRI-guided procedure to 6 min 33 s with a mean procedure time of 9 min 2 s, comparable to the mean procedure time of 8 min 42 s for the standard X-ray-guided procedure. CONCLUSIONS: MRI-guided iliac vascular interventions were found to be feasible and practical using this framework and optimized workflow. In particular, the real-time flow analysis was found to be helpful for pre- and post-interventional assessments. Design optimization of the catheters and in vivo experiments are required before clinical evaluation.

A feasibility study on monitoring the evolution of apparent diffusion coefficient decrease during thermal ablation.

PURPOSE: Evaluate whether a decrease in apparent diffusion coefficient (ADC), associated with loss of tissue viability (LOTV), can be observed during the course of thermal ablation of the prostate. METHODS: Thermal ablation was performed in a healthy in vivo canine prostate model (N = 2, ages: 5 yr healthy, mixed breed, weights: 13-14 kg) using a transurethral high-intensity ultrasound catheter and was monitored using a strategy that interleaves diffusion weighted images and gradient-echo images. The two sequences were used to measure ADC and changes in temperature during the treatment. Changes in temperature were used to compute expected changes in ADC. The difference between expected and measured ADC, ADCDIFF, was analyzed in regions ranging from moderate hyperthermia to heat fixation. A receiver operator characteristic (ROC) curve analysis was used to select a threshold of detection of LOTV. Time of threshold activation, tLOTV, was compared with time to reach CEM43 = 240, tDOSE. RESULTS: The observed relationship between temperature and ADC in vivo (2.2%/ °C, 1.94%-2.47%/ °C 95% confidence interval) was not significantly different than the previously reported value of 2.4%/ °C in phantom. ADCDIFF changes after correction for temperature showed a mean decrease of 25% in ADC 60 min post-treatment in regions where sufficient thermal dose (CEM43 > 240) was achieved. Following our ROC analysis, a threshold of 2.25% decrease in ADCDIFF for three consecutive time points was chosen as an indicator of LOTV. The ADCDIFF was found to decrease quickly (1-2 min) after reaching CEM43 = 240 in regions associated with heat fixation and more slowly (10-20 min) in regions that received slower heating. CONCLUSIONS: Simultaneous monitoring of ADC and temperature during treatment might allow for a more complete tissue viability assessment of ablative thermal treatments in the prostate. ADCDIFF decreases during the course of treatment may be interpreted as loss of tissue viability.

Wireless MR tracking of interventional devices using phase-field dithering and projection reconstruction.

PURPOSE: Device tracking is crucial for interventional MRI (iMRI) because conventional device materials do not contribute to the MR signal, may cause susceptibility artifacts and are generally invisible if moved out of the scan plane. A robust method for wireless tracking and dynamic guidance of interventional devices equipped with wirelessly connected resonant circuits (wRC) is presented. METHODS: The proposed method uses weak spatially-selective excitation pulses with very low flip angle (0.3°), a Hadamard multiplexed tracking scheme and employs phase-field dithering to obtain the 3D position of a wRC. RF induced heating experiments (ASTM protocol) and balloon angioplasties of the iliac artery were conducted in a perfused vascular phantom and three Thiel soft-embalmed human cadavers. RESULTS: Device tip tracking was interleaved with various user-selectable fast pulse sequences receiving a geometry update from the tracking kernel in less than 30ms. Integrating phase-field dithering significantly improved our tracking robustness for catheters with small diameters (4-6 French). The volume root mean square distance error was 2.81mm (standard deviation: 1.31mm). No significant RF induced heating (<0.6°C) was detected during heating experiments. CONCLUSION: This tip tracking approach provides flexible, fast and robust feedback loop, intuitive iMRI scanner interaction, does not constrain the physician and delivers very low specific absorption rates. Devices with wRC can be exchanged during a procedure without modifications to the iMRI setup or the pulse sequence. A drawback of our current implementation is that position information is available for a single tracking coil only. This was satisfactory for balloon angioplasties of the iliac artery, but further studies are required for complex navigation and catheter shapes before animal trials and clinical application.

Autonomous real-time interventional scan plane control with a 3-D shape-sensing needle.

This study demonstrates real-time scan plane control dependent on three-dimensional needle bending, as measured from magnetic resonance imaging (MRI)-compatible optical strain sensors. A biopsy needle with embedded fiber Bragg grating (FBG) sensors to measure surface strains is used to estimate its full 3-D shape and control the imaging plane of an MR scanner in real-time, based on the needle's estimated profile. The needle and scanner coordinate frames are registered to each other via miniature radio-frequency (RF) tracking coils, and the scan planes autonomously track the needle as it is deflected, keeping its tip in view. A 3-D needle annotation is superimposed over MR-images presented in a 3-D environment with the scanner's frame of reference. Scan planes calculated based on the FBG sensors successfully follow the tip of the needle. Experiments using the FBG sensors and RF coils to track the needle shape and location in real-time had an average root mean square error of 4.2 mm when comparing the estimated shape to the needle profile as seen in high resolution MR images. This positional variance is less than the image artifact caused by the needle in high resolution SPGR (spoiled gradient recalled) images. Optical fiber strain sensors can estimate a needle's profile in real-time and be used for MRI scan plane control to potentially enable faster and more accurate physician response.

Reliability of airway obstruction analyses from Sleep MRI sequences.

OBJECTIVE: A real-time MRI "movie" during natural sleep ("Sleep MRI") allows observation of dynamic airway obstructions in obstructive sleep apnea syndrome (OSAS) patients. The purpose of this article was to determine the reliability of assessing these obstructions. STUDY DESIGN: Cross-sectional diagnostic test evaluation. SETTING: Academic referral center. SUBJECTS AND METHODS: A total of 23 Sleep MRI sequences randomly selected from 20 consecutive OSAS patients were analyzed by two experienced sleep surgeons on two separate occasions separated by at least two weeks. Five dimensions were assessed: presence or absence of any obstruction, presence or absence of a retropalatal obstruction, presence or absence of a retroglossal obstruction, presence or absence of a swallow, and duration of an obstructive event. RESULTS: For all dimensions measured, intra-rater reliability coefficients ranged from a low of 0.95 to a high of 1.0 for each rater. Inter-rater reliability coefficients ranged from a low of 0.85 to a high of 1.0. On two separate evaluations separated by at least two weeks, rater 1 identified a retropalatal obstruction in 100 percent of sequences, whereas rater 2 did so in 91 percent and 96 percent of the sequences, respectively. Retroglossal obstruction was identified in 57 percent (rater 1) and 65 percent (rater 2) of sequences. CONCLUSION: Intra-rater and inter-rater reliability coefficients are very high for determination of presence or absence of any obstruction, presence or absence of a retropalatal obstruction, presence or absence of a retroglossal obstruction, presence or absence of a swallow, and duration of obstruction from Sleep MRI sequences in OSAS patients.

MR-guidance of HIFU therapy.

MR guidance of high intensity focused ultrasound is evolving with each new application. In this paper we describe ongoing research in the MR-guidance aspect of MR-guided focused ultrasound. The structure is divided into the pretreatment/setup phase of the procedure, MR thermometry for monitoring the actual treatment, and methods for assessment and follow-up.