Is there still a role for lesioning in functional neurosurgery? Preliminary Italian (and world-first) experience with a trans-cranial MRI-guided focused ultrasound surgery system operating at 1.5 Tesla

Transcranial Magnetic Resonance-Guided Focused Ultrasound Surgery for Brain Tumor Ablation: Are We Ready for This Challenging Treatment?

The treatment of high-grade gliomas (HGGs) remains a challenge for modern therapy. The prognosis for these patients has been poor. The median patient survival after diagnosis has been ∼1 year with surgery and/or radiotherapy and temozolomide.1 The need for a histological diagnosis of tumor tissue in each case and the importance of decompression in symptomatic patients are well established, and extensive surgical resection has been shown to significantly prolong survival. Several factors play a role in the prognosis of patients with HGG, including age, performance status using the Karnofsky performance scale, and the extent of resection.2, 3 At present, the standard therapy for HHG consists …

Magnetic Resonance Imaging-Guided Focused Ultrasound Surgery for the Treatment of Symptomatic Uterine Fibroids

Uterine fibroids, the most common benign tumor in women of childbearing age, may cause symptoms including pelvic pain, menorrhagia, dysmenorrhea, pressure, urinary symptoms, and infertility. Various approaches are available to treat symptomatic uterine fibroids. Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) represents a recently introduced noninvasive safe and effective technique that can be performed without general anesthesia, in an outpatient setting. We review the principles of MRgFUS, describing patient selection criteria for the treatments performed at our center and we present a series of five selected patients with symptomatic uterine fibroids treated with this not y…

Chirurgia trans-cranica mediante ultrasuoni focalizzati ad alta intensità su guida RM: esperienza preliminare a 1,5T

Da qualche anno la chirurgia mediante ultrasuoni focalizzati ad alta intensità guidati da Risonanza Magnetica (Magnetic Resonance guided Focused Ultrasound Surgery, MRgFUS) si sta diffondendo anche in Italia per la palliazione del dolore da metastasi ossee, per il trattamento di tumori ossei primitivi (benigni e non), dei fibromi e dell’adenomiosi uterina; sono già stati inoltre pubblicati i risultati preliminari del trattamento di alcuni tumori epatici, pancreatici, prostatici e della mammella mediante MRgFUS. Questa innovativa tecnica prevede l’utilizzo di un’apparecchiatura di Risonanza Magnetica per il monitoraggio della procedura e sfrutta le caratteristiche fisico- meccaniche degli …

Transcranial magnetic resonance imaging-guided focused ultrasound treatment at 1.5 T: a retrospective study on treatment and patient-related parameters obtained from 52 Procedures

Objective: To present a retrospective analysis of patient- and sonication-related parameters of a group of patients treated with a transcranial magnetic resonance imaging (MRI)-guided focused ultrasound (tcMRgFUS) system integrated with a 1.5-T MRI unit. Methods: The data obtained from 59 patients, who underwent the tcMRgFUS procedure from January 2015 to April 2019, were retrospectively reviewed for this study. The following data, among others, were mainly collected: skull density ratio (SDR), skull area (SA), number of available transducer elements (Tx), and estimated focal power at target (FP). For each of the four different treatment stages, we calculated the number of sonication proces…

Preoperative imaging findings in patients undergoing transcranial magnetic resonance imaging-guided focused ultrasound thalamotomy

AbstractThe prevalence and impact of imaging findings detected during screening procedures in patients undergoing transcranial MR-guided Focused Ultrasound (tcMRgFUS) thalamotomy for functional neurological disorders has not been assessed yet. This study included 90 patients who fully completed clinical and neuroradiological screenings for tcMRgFUS in a single-center. The presence and location of preoperative imaging findings that could impact the treatment were recorded and classified in three different groups according to their relevance for the eligibility and treatment planning. Furthermore, tcMRgFUS treatments were reviewed to evaluate the number of transducer elements turned off after…

Studio preliminare di parcellizzazione talamica per l’identificazione del target di trattamento applicato alle talamotomie trans-craniche mediante ultrasuoni focalizzati guidati da Risonanza Magnetica (tcMRgFUS) [Thalamic parcelization for target identification in trans-cranial MR-guided Focused UltraSound (tcMRgFUS) thalamotomies: a preliminary study]

Introduzione La tcMRgFUS consente di effettuare una vera e propria esplorazione neurofunzionale per confermare ed ottimizzare il target lesionale prima di indurre una lesione cerebrale permanete. La scelta del target di trattamento si basa tuttavia su coordinate stereotassiche che non tengono conto delle diversità anatomiche di ciascun individuo. L'ottimizzazione del target di trattamento viene effettuata sulla base del feedback del paziente durante la procedura stessa. Materiali e metodi È’ stato utilizzato uno scanner RM da 1.5T per acquisire sequenze morfologiche 3D e ultrastrutturali (DTI) in pazienti successivamente sottoposti a tcMRgFUS. È stata effettuata una segmentazione delle aree…

Transcranial magnetic resonance-guided focused ultrasound surgery at 1.5T: a technical note.

Magnetic resonance-guided focused ultrasound is one of the emerging non-invasive technologies offering both image guidance and thermal monitoring. In recent years transcranial application of this technology is starting to impact heavily the neuroscience field. We present here the imaging protocol and the technological methods successfully used with a transcranial magnetic resonance-guided focused ultrasound system certified for clinical treatments of functional neurological disorders, integrated for the first time with a 1.5T magnetic resonance scanner. Compared to the body radiofrequency coil (the one commonly used with transcranial magnetic resonance-guided focused ultrasound system integ…

Chirurgia trans-cranica mediante ultrasuoni focalizzati ad alta intensità su guida RM (trans-cranial MRI-guided Focused Ultrasound Surgery, tcMRgFUS): esperienza preliminare a 1,5T

Scopo del Lavoro Presentiamo i risultati preliminari ottenuti con la prima istallazione italiana di un’apparecchiatura tcMRgFUS (prima ed unica apparecchiatura al mondo installata su uno scanner RM da 1,5T) per trattamenti di neurochirurgia funzionale in pazienti con tremore essenziale, Parkinson idiopatico unilaterale prevalentemente tremorigeno e dolore neuropatico. Materiali e Metodi Sono stati arruolati pazienti con disordini neurologici resistenti a terapia medica. I pazienti eleggibili sono stati sottoposti ad esame TC ed RM di screening per escludere controindicazioni al trattamento. I trattamenti tcMRgFUS sono stati eseguiti da un gruppo multidisciplinare ottimizzando i parametri di…

Italian multicenter, prospective study to evaluate the negative predictive value of 16- and 64-slice MDCT imaging in patients scheduled for coronary angiography (NIMISCAD-Non Invasive Multicenter Italian Study for Coronary Artery Disease)

This was a prospective, multicenter study designed to evaluate the utility of MDCT in the diagnosis of coronary artery disease (CAD) in patients scheduled for elective coronary angiography (CA) using different MDCT systems from different manufacturers. Twenty national sites prospectively enrolled 367 patients between July 2004 and June 2006. Computed tomography (CT) was performed using a standardized/optimized scan protocol for each type of MDCT system (> or =16 slices) and compared with quantitative CA performed within 2 weeks of MDCT. A total of 284 patients (81%) were studied by 16-slice MDCT systems, while 66 patients (19%) by 64-slice MDCT scanners. The primary analysis was on-site/off…

Preliminary experience with a transcranial magnetic resonance-guided focused ultrasound surgery system integrated with a 1.5-T MRI unit in a series of patients with essential tremor and Parkinson's disease.

OBJECTIVETranscranial magnetic resonance–guided focused ultrasound surgery (tcMRgFUS) is one of the emerging noninvasive technologies for the treatment of neurological disorders such as essential tremor (ET), idiopathic asymmetrical tremor-dominant Parkinson’s disease (PD), and neuropathic pain. In this clinical series the authors present the preliminary results achieved with the world’s first tcMRgFUS system integrated with a 1.5-T MRI unit.METHODSThe authors describe the results of tcMRgFUS in a sample of patients with ET and with PD who underwent the procedure during the period from January 2015 to September 2017. A monolateral ventralis intermedius nucleus (VIM) thalamic ablation was pe…

Restoring Neurological Physiology: The Innovative Role of High-Energy MR-Guided Focused Ultrasound (HIMRgFUS). Preliminary Data from a New Method of Lesioning Surgery

Background Tremor is a disabling condition, common to several neurodegenerative diseases. Lesioning procedures and deep brain stimulation, respectively, of the ventralis intermedius nucleus for intentional tremor, and of the subthalamic nucleus for parkinsonian resting tremor, have been introduced in clinical practice for patients refractory to medical treatment. The combination of high-energy focused ultra-sound (HIFUS) with sophisticated magnetic resonance (MR) instrumentation, together with accurate knowledge of the stereotactic brain coordinates, represents a revolution in neuromodulation. Methods At the Neurosurgical Clinic and the Radiology Department of the University of Palermo,, tw…

Is trans-cranial MR-guided Focused UltraSound a repeatable treatment option? Report of a successfully re-treated patient

Background: In recent years, transcranial Magnetic Resonance-guided Focused UltraSounds (tcMRgFUS) treatments for functional neurological disorders are giving a new thrust to the field of therapeutic brain lesioning. This technique has been proven safe and effective in selected patients. Here we present the case of a patient affected by tremor combined with parkinsonism who underwent a second tcMRgFUS thalamotomy because of relapsing tremor after a few months from the first tcMRgFUS treatment. Materials and Methods: A 72-year-old, right-handed man, who came to our observation because of a disabling tremor affecting mainly his upper right limb and refusing any invasive surgical procedure. Hi…

TRANS-CRANIAL MRI-GUIDED FOCUSED ULTRASOUND SURGERY (TCMRGFUS): ITALIAN AND WORLD-FIRST EXPERIENCE AT 1.5 TESLA

Introduction: Transcranial magnetic resonance-guided focused ultrasound surgery (tcMRgFUS) is a promising new technology for the noninvasive treatment of various brain disorders. Here, we present our preliminary results achieved with the first Italian installation of a transcranial MRI-guided focused ultrasound surgery (tcMRgFUS) certified system for functional neurosurgery. Technical issues faced to achieve a safe and effective treatment will be discussed focusing on MR high-resolution live imaging and thermometry sequences optimization. Materials and Methods: Patient enrollment was based on indication for functional neurosurgery and evidence of medication-refractory disease; a detailed me…

Hepatocellular Carcinoma Presenting at Contrast-Enhanced Multi–Detector-Row Computed Tomography or Gadolinium-Enhanced Magnetic Resonance Imaging as a Small (≤2 cm), Indeterminate Nodule

OBJECTIVE: The objective of the study was to measure growth rate and to determine the optimal interval time for imaging follow-up of hepatocellular carcinomas (HCCs) presenting at multi-detector-row computed tomography (MDCT) or magnetic resonance imaging (MRI) as small, indeterminate lesions. METHODS: We included patients with cirrhosis with HCC initially presenting as indeterminate lesion of 2 cm or less at MDCT or MRI August 2005 to August 2009 and with available imaging follow-up. Measures of tumor growth included tumor volume doubling time (TVDT), tumor percentual diameter increase, and tumor percentual volume increase. RESULTS: We examined 48 patients (mean age, 64 years) with 69 HCCs…

246. Analysis of signal-to-noise ratio for a 2-channels coil developed to enable transcranial Magnetic Resonance-guided Focused Ultrasound Surgery (tcMRgFUS) with 1.5 T MRI scanners

Abstract Purpose In recent years trans-cranial Magnetic Resonance-guided Focused Ultrasound Surgery (tcMRgFUS) treatments have aroused large scientific and medical interest [1] . Usually, tcMRgFUS systems are integrated with 3 T systems which allow the use of the body RF coil for both real time imaging and MR-thermometry. At University Hospital of Palermo there is the world-first installation of a tcMRgFUS system integrated with a 1.5 T scanner. Here we present the characterization in terms of signal-to-noise ratio (SNR) of a dedicated RF coils suitably developed (by InSightec) to enable tcMRgFUS treatments with 1.5 T MR units. Methods and materials The focused ultrasound equipment (ExAblat…

Intraoperative imaging findings in transcranial MR imaging-guided focused ultrasound treatment at 1.5T may accurately detect typical lesional findings correlated with sonication parameters

To assess the intraoperative neuroimaging findings in patients treated with transcranial MR-guided focused ultrasound (tcMRgFUS) thalamotomy using 1.5T equipment in comparison with the 48-h follow-up.Fifty prospectively enrolled patients undergoing unilateral tcMRgFUS thalamotomy for either medication-refractory essential tremor (n = 39) or Parkinson tremor (n = 11) were included. Two radiologists evaluated the presence and size of concentric lesional zones (zone I, zone II, and zone III) on 2D T2-weighted sequences acquired intraoperatively after the last high-energy sonication and at 48 h. Sonication parameters including number of sonications, delivered energy, and treatment temperatures …

HIFU for Bone Metastases and other Musculoskeletal Applications

AbstractHigh-intensity focused ultrasound (HIFU) is a totally noninvasive procedure that has shown promising results in the management of numerous malignant and nonmalignant conditions. Under magnetic resonance or ultrasound guidance, high-intensity ultrasound waves are focused on a small, well-defined target region, inducing biologic tissue heating and coagulative necrosis, thus resulting in a precise and localized ablation. This treatment has shown both great safety and efficacy profiles, and may offer a multimodal approach to different diseases, providing pain palliation, potential local tumor control, and, in some cases, remineralization of trabecular bone. In musculoskeletal field, HIF…

Focal nodular hyperplasia: typical and atypical MRI findings with emphasis on the use of contrast media

Focal nodular hyperplasia is a benign hypervascular hepatic tumour, frequently detected in asymptomatic patients undergoing imaging studies for unrelated reasons. Magnetic resonance imaging (MRI) generally allows a confident differential diagnosis with other hypervascular liver lesions, either benign or malignant. In addition, due to the recent development of hepatospecific MRI contrast agents, MRI concomitantly enables functional and morphological information to be obtained, thus providing important clues for the detection and characterization of focal nodular hyperplasia lesions.

Quadruple-Phase MDCT of the Liver in Patients with Suspected Hepatocellular Carcinoma: Effect of Contrast Material Flow Rate

The purposes of this study were to evaluate the effect of contrast material flow rate (3 mL/sec vs 5 mL/sec) on the detection and visualization of hepatocellular carcinoma (HCC) with MDCT and the safety profile of iodixanol at different injection rates.In a prospective, randomized multicenter trial, 97 patients (83 men and 14 women, with a mean age of 64 years) suspected of having HCC underwent quadruple-phase (double arterial, portal venous, delayed phase) 4-16-MDCT. Patients were randomized to receive iodixanol, 320 mg I/mL (1.5 mL/kg body weight), at a flow rate of 3 mL/sec (48 patients) or 5 mL/sec (49 patients). Qualitative (lesion detection, image quality) and quantitative (liver and …