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Therapeutic Applications of Ultrasound in Neurological Diseases

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Therapeutic Applications of Ultrasound in Neurological Diseases REVIEW ARTICLE pISSN 2635-425X eISSN 2635-4357 JNN https://doi.org/10.31728/jnn.2019.00046 Therapeutic Applications of Ultrasound in Neurological Diseases Kang-Ho Choi*,1, Ja-Hae Kim†,1 Department of Neurology, Chonnam National University Hospital, Chonnam National University College of Medicine*, Gwangju; Molecular Imaging Center, Department of Nuclear Medicine, Chonnam National University Hospital†, Gwangju, Korea Ultrasonography is well recognized as an imaging tool. Recent research in the Received: April 30, 2019 therapeutic applications of ultrasound has made great progress. Ultrasound can Revised: May 31, 2019 be widely used in ablative or nondestructive therapies, depending on the level of Accepted: June 11, 2019 energy provided. In some neurological diseases, ultrasound has been used for Address for correspondence: therapeutic purposes in clinical practice and has proven effective. The use of Kang-Ho Choi ultrasound energy for therapy continues to expand; therapeutic ultrasound for Department of Neurology, the treatment of essential tremor has been approved by the United States. Thera- Chonnam National University peutic ultrasound has also been approved in many countries for the treatment of Hospital, 42 Jebong-ro, Dong- Parkinson’s disease, neuropathic pain, and neuropsychiatric conditions, such as gu, Gwangju 61469, Korea major depression and obsessive-compulsive disorder. This modality has the po- Tel: +82-62-220-6137 Fax: +82-62-228-3461 tential to treat many more neurological diseases than are currently being treated E-mail: ckhchoikang@han- in clinical practice. Therapeutic ultrasound can be used for functional ablation mail.net, ckhchoikang@chon- of specific brain lesions, tumor ablation, neuromodulation, immunomodulation, nam.ac.kr sonothrombolysis, angiogenesis, and soft tissue healing. In addition, the effects of 1 transient blood-brain barrier opening for the delivery of therapeutic agents and These authors contributed the subsequent use of sonodynamic therapy could revolutionize the treatment of equally to the manuscript. neurological diseases in the future. Therapeutic applications of ultrasound have great potential to change treatment paradigms in various neurological diseases. In this review, we discuss the current clinical applications of therapeutic ultra- sound, as well as the fields in which this promising technology is expected to be useful. J Neurosonol Neuroimag 2019;11(1):62-72 Key Words: Ultrasonic; Therapy; Blood-brain barrier; Neurosurgery; Stroke INTRODUCTION to increase dramatically, as the potential of this method becomes more widely recognized. Ultrasound, comprising sound waves with a frequen- Therapeutic ultrasound is now approved by the Food cy above 20 kHz that humans cannot hear, is used in a and Drug Administration (FDA) for use in the United wide range of diagnostic imaging applications.1 How- States and in many countries outside of the United ever, ultrasound also has great potential for therapeu- States for treatment of certain neurological diseases. tic applications at a higher power and is an emerging However, its therapeutic applications are rapidly ex- treatment applied in a range of clinical fields.2,3 Ultra- panding for several neurological indications in hu- sound can be widely used in ablative or nondestructive mans. Not all clinical applications have reached the therapies, depending on the level of ultrasound energy level of routine application in clinical practice. How- provided.4 The number of possible therapeutic applica- ever, as transducer and computer control technologies tions of ultrasound in neurological diseases continues have rapidly developed in recent years, the therapeutic Copyright © 2019 The Korean Society of Neurosonology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Vol. 11 / No. 1 / June 2019 Journal of Neurosonology and Neuroimaging applications of ultrasound are quite promising. Ultra- single point. Ultrasonic frequencies in the range of 20 sonic technology has shown very encouraging results kHz to about 3 MHz are utilized in therapeutic ultra- for therapeutic application, and is at a highly advanced sound, whereas frequencies beyond these are used in stage of research. In this review, we discuss the current diagnostic ultrasound.1 clinical applications of therapeutic ultrasound, as well In therapy, ultrasound can induce effects not only as the fields in which this promising technology is ex- through focal heating but also through non-thermal pected to be useful. or mechanical effects, including cavitation, acoustic streaming, radiation forced tissue displacement, me- chanical stress, or other undetermined non-thermal BIOLOGICAL MECHANISM processes.2,3 Continuous ultrasound waves with high intensity can induce tissue ablation or hyperthermia, Ultrasound, under appropriate exposure conditions, whereas non-thermal, pulsed ultrasound waves can in- can produce a wide range of biological effects in thera- duce neuromodulation, microbubble-mediated open- peutic application (Fig. 1). Individual ultrasound beams ing of the blood-brain barrier (BBB) to facilitate drug do not affect tissues as they pass through. However, delivery to the brain, tissue healing, and immunomod- the convergence of ultrasonic energy at a single point ulation.4 Several different mechanisms may contribute results in many important biological effects, depending concurrently to the total biological effects of therapeu- on the tissue characteristics and ultrasound parame- tic ultrasound.2,3 ters.4 Focused ultrasound (FUS) uses concentrated ul- trasound energy, where multiple beams intersect on a Fig. 1. Neurological diseases that can be treated in clinical practice, according to the biological mechanism of therapeutic ultrasound. Ultrasound can be widely used in ablative or nondestructive therapies, depending on the level of ultrasound energy provided. Therapeutic ultrasound has been approved in many countries, for the treatment of essential tremor, Parkinson’s disease, neuropathic pain, depression, and obsessive-compul- sive disorder (*). The use of therapeutic ultrasound for the treatment of essential tremor has been approved by the United States Food and Drug Administration (†). The number of possible therapeutic applications of ultrasound in neurological diseases continues to grow dramatically, as the potential of this method becomes more widely recognized. Therapeutic applications of ultrasound have the potential to significantly change treat- ment paradigms in neurological diseases. ds; disease. *Approved by countries outside the United States. †Approved by the United States Food and Drug Administration. J Neurosonol Neuroimag 2019;11(1):62-72 http://www.j-nn.org 63 Kang-Ho Choi, et al. Therapeutic Applications of Ultrasound NEUROSURGERY tremor. In two pilot studies, essential tremor improved in patients treated with MRgFUS thalamotomy target- 1. Brain tumor ablation and functional brain ablation ing the ventral intermediate nucleus (Vim) of the thala- mus.10,11 A subsequent multicenter randomized control Thermal ablation, which is the most direct mecha- trial (RCT) in patients with medically refractory essen- nism of FUS, can be used to treat brain tumors. How- tial tremor showed that MRgFUS thalamotomy signifi- ever, this has been limited to small case series because cantly improved tremor and disability scores compared of concern that FUS, which is strong enough to induce to those of the placebo group.12 Adverse events in the thermal necrosis, carries an increased risk of intracra- MRgFUS treatment group included gait disturbance in nial hemorrhage (ICH), intracranial hypertension, and 36%, and sensory disturbances in 38%, of patients. cerebral edema.5,6 Furthermore, power limitations, and Adverse events, and the effectiveness of MRgFUS for restriction of the target area by the surrounding sensi- essential tremor treatment, could be highly dependent tive brain tissue, prevent sufficient heating for tumor on the location and size of thalamotomy lesions. The ablation.7,8 For these reasons, clinical trials using FUS area of optimal tremor response after MRgFUS thala- for thermal ablation, focused on sites near the center of motomy was identified at the posterior portion of the the brain, have not shown satisfactory results. Conse- Vim, whereas lesions extending beyond the posterior quently, in contrast to tumor ablation, much research region of the Vim and lateral or inferolateral to the has been directed at neurosurgery using FUS for func- thalamus were associated with an increased risk for tional brain ablation, and there have been dramatic de- various acute adverse effects.13 Therefore, recent stud- velopments worldwide (Fig. 1). ies have explored the possibility of refining current Early exploration of FUS for clinical use was limited MRgFUS treatment planning and targeting, thereby re- by beam distortion and energy absorption, because of ducing side effects and improving clinical outcomes in the skull. However, advances in technology have al- patients with essential tremor, using various imaging lowed safety monitoring and confirmation of the ener- technologies, such as diffusion tractography.14 gy being applied at the acoustic focus.2 More recently, FUS treatment has been monitored in real-time with 3. Parkinson’s
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