Robert C. Susil

Design of a novel MRI compatible manipulator for image guided prostate interventions

This paper reports a novel remotely actuated manipulator for access to prostate tissue under magnetic resonance imaging guidance (APT-MRI) device, designed for use in a standard high-field MRI scanner. The device provides three-dimensional MRI guided needle placement with millimeter accuracy under physician control. Procedures enabled by this device include MRI guided needle biopsy, fiducial marker placements, and therapy delivery. Its compact size allows for use in both standard cylindrical and open configuration MRI scanners. Preliminary in vivo canine experiments and first clinical trials are reported.

Feasibility of Real-Time Magnetic Resonance Imaging for Catheter Guidance in Electrophysiology Studies

Background— Compared with fluoroscopy, the current imaging standard of care for guidance of electrophysiology procedures, magnetic resonance imaging (MRI) provides improved soft-tissue resolution and eliminates radiation exposure. However, because of inherent magnetic forces and electromagnetic interference, the MRI environment poses challenges for electrophysiology procedures. In this study, we sought to test the feasibility of performing electrophysiology studies with real-time MRI guidance. Methods and Results— An MRI-compatible electrophysiology system was developed. Catheters were targeted to the right atrium, His bundle, and right ventricle of 10 mongrel dogs (23 to 32 kg) via a 1.5-T MRI system using rapidly acquired fast gradient-echo images (≈5 frames per second). Catheters were successfully positioned at the right atrial, His bundle, and right ventricular target sites of all animals. Comprehensive electrophysiology studies with recording of intracardiac electrograms and atrial and ventricular pacing were performed. Postprocedural pathological evaluation revealed no evidence of thermal injury to the myocardium. After proof of safety in animal studies, limited real-time MRI-guided catheter mapping studies were performed in 2 patients. Adequate target catheter localization was confirmed via recording of intracardiac electrograms in both patients. Conclusions— To the best of our knowledge, this is the first study to report the feasibility of real-time MRI-guided electrophysiology procedures. This technique may eliminate patient and staff radiation exposure and improve real-time soft tissue resolution for procedural guidance.

RF safety of wires in interventional MRI: using a safety index.

With the rapid growth of interventional MRI, radiofrequency (RF) heating at the tips of guidewires, catheters, and other wire‐shaped devices has become an important safety issue. Previous studies have identified some of the variables that affect the relative magnitude of this heating but none could predict the absolute amount of heating to formulate safety margins. This study presents the first theoretical model of wire tip heating that can accurately predict its absolute value, assuming a straight wire, a homogeneous RF coil, and a wire that does not extend out of the tissue. The local specific absorption rate (SAR) amplification from induced currents on insulated and bare wires was calculated using the method of moments. This SAR gain was combined with a semianalytic solution to the bioheat transfer equation to generate a safety index. The safety index (°C/(W/kg)) is a measure of the in vivo temperature change that can occur with the wire in place, normalized to the SAR of the pulse sequence. This index can be used to set limits on the spatial peak SAR of pulse sequences that are used with the interventional wire. For the case of a straight resonant wire in a tissue with very low perfusion, only about 100 mW/kg/°C spatial peak SAR may be used at 1.5 T. But for ≤10‐cm wires with an insulation thickness ≥30% of the wire radius that are placed in well‐perfused tissues, normal operating conditions of 4 W/kg spatial peak SAR are possible at 1.5 T. Further model development to include the influence of inhomogeneous RF, curved wires, and wires that extend out of the sample are required to generate safety indices that are applicable to common clinical situations. We propose a simple way to ensure safety when using an interventional wire: set a limit on the SAR of allowable pulse sequences that is a factor of a safety index below the tolerable temperature increase. Magn Reson Med 47:187–193, 2002.

System for prostate brachytherapy and biopsy in a standard 1.5 T MRI scanner

A technique for transperineal high‐dose‐rate (HDR) prostate brachytherapy and needle biopsy in a standard 1.5 T MRI scanner is demonstrated. In each of eight procedures (in four patients with intermediate to high risk localized prostate cancer), four MRI‐guided transperineal prostate biopsies were obtained followed by placement of 14–15 hollow transperineal catheters for HDR brachytherapy. Mean needle‐placement accuracy was 2.1 mm, 95% of needle‐placement errors were less than 4.0 mm, and the maximum needle‐placement error was 4.4 mm. In addition to guiding the placement of biopsy needles and brachytherapy catheters, MR images were also used for brachytherapy treatment planning and optimization. Because 1.5 T MR images are directly acquired during the interventional procedure, dependence on deformable registration is reduced and online image quality is maximized. Magn Reson Med 52:683–687, 2004. Published 2004 Wiley‐Liss, Inc.

Multifunctional interventional devices for MRI: a combined electrophysiology/MRI catheter.

The design and application of a two‐wire electrophysiology (EP) catheter that simultaneously records the intracardiac electrogram and receives the MR signal for active catheter tracking is described. The catheter acts as a long loop receiver, allowing for visualization of the entire catheter length while simultaneously behaving as a traditional two‐wire EP catheter, allowing for intracardiac electrogram recording and ablation. The application of the device is demonstrated by simultaneously tracking the catheter and recording the intracardiac electrogram in canine models using 7 and 10 frame/sec real‐time imaging sequences. Using solely MR imaging, the entire catheter was visualized and guided from the jugular vein into the cardiac chambers, where the intracardiac electrogram was recorded. By combining several functions in a single, simple structure, the excellent tissue contrast and functional imaging capabilities of MR can be used to improve the efficacy of EP interventions. This catheter will facilitate MR‐guided interventions and demonstrates the design of multifunctional interventional devices for use in MRI. Magn Reson Med 47:594–600, 2002.

Electric Field-Induced Transmembrane Potential Depends on Cell Density and Organizatio

Electrochemotherapy is a novel technique to enhance the delivery of chemotherapeutic drugs into tumor cells. In this procedure, electric pulses are delivered to cancerous cells, which induce membrane permeabilization, to facilitate the passage of cytotoxic drugs through the cell membrane. This study examines how electric fields interact with and polarize a system of cells. Specifically, we consider how cell density and organization impact on induced cell transmembrane potential due to an external electric field. First, in an infinite volume of spherical cells, we examined how cell packing density impacts on induced transmembrane potential. With high cell density, we found that maximum induced transmembrane potential is suppressed and that the transmembrane potential distribution is altered. Second, we considered how orientation of cell sheets and strands, relative to the applied field, affects induced transmembrane potential. Cells that are parallel to the field direction suppress induced transmembrane po...

RF Heating Due to Conductive Wires During MRI Depends on the Phase Distribution of the Transmit Field

In many studies concerning wire heating during MR imaging, a “resonant wire length” that maximizes RF heating is determined. This may lead to the nonintuitive conclusion that adding more wire, so as to avoid this resonant length, will actually improve heating safety. Through a theoretical analysis using the method of moments, we show that this behavior depends on the phase distribution of the RF transmit field. If the RF transmit field has linear phase, with slope equal to the real part of the wavenumber in the tissue, long wires always heat more than short wires. In order to characterize the intrinsic safety of a device without reference to a specific body coil design, this maximum‐tip heating phase distribution must be considered. Finally, adjusting the phase distribution of the electric field generated by an RF transmit coil may lead to an “implant‐friendly” coil design. Magn Reson Med 48:1096–1098, 2002.

Effects of Prostate-Rectum Separation on Rectal Dose From External Beam Radiotherapy

PURPOSE In radiotherapy for prostate cancer, the rectum is the major dose-limiting structure. Physically separating the rectum from the prostate (e.g., by injecting a spacer) can reduce the rectal radiation dose. Despite pilot clinical studies, no careful analysis has been done of the risks, benefits, and dosimetric effects of this practice. METHODS AND MATERIALS Using cadaveric specimens, 20 mL of a hydrogel was injected between the prostate and rectum using a transperineal approach. Imaging was performed before and after spacer placement, and the cadavers were subsequently dissected. Ten intensity-modulated radiotherapy plans were generated (five before and five after separation), allowing for characterization of the rectal dose reduction. To quantify the amount of prostate-rectum separation needed for effective rectal dose reduction, simulations were performed using nine clinically generated intensity-modulated radiotherapy plans. RESULTS In the cadaveric studies, an average of 12.5 mm of prostate-rectum separation was generated with the 20-mL hydrogel injections (the seminal vesicles were also separated from the rectum). The average rectal volume receiving 70 Gy decreased from 19.9% to 4.5% (p < .05). In the simulation studies, a prostate-rectum separation of 10 mm was sufficient to reduce the mean rectal volume receiving 70 Gy by 83.1% (p <.05). No additional reduction in the average rectal volume receiving 70 Gy was noted after 15 mm of separation. In addition, spacer placement allowed for increased planning target volume margins without exceeding the rectal dose tolerance. CONCLUSION Prostate-rectum spacers can allow for reduced rectal toxicity rates, treatment intensification, and/or reduced dependence on complex planning and treatment delivery techniques.

A Single Image Registration Method for CT Guided Interventions

Minimally invasive image guided interventions are an attractive option for localized therapy delivery and diagnostic biopsy. We have developed a method for CT guided needle placement, based upon the Brown-Roberts-Wells frame, which requires no immobilization or fiducial implantation. A localization module, placed on a needle holding robotic end effector, allows for localization of the effector in the image space using a single CT image. In a theoretical analysis, we show that this registration method has attractive sensitivity and error attenuation properties. Experimentally, the average error in needle tip location over 63 trials was 470μm; 95% of the errors were below 1.0 mm. This method is a fast, accurate, and easily implemented registration method for cross sectional image guided stereotaxis.

Transrectal Prostate Biopsy and Fiducial Marker Placement in a Standard 1.5T Magnetic Resonance Imaging Scanner

PURPOSE We investigated the accuracy and feasibility of a system that provides transrectal needle access to the prostate concurrent with 1.5 Tesla MRI which previously has not been possible. MATERIALS AND METHODS In 5 patients with previously diagnosed prostate cancer, MRI guided intraprostatic placement of gold fiducial markers (4 procedures) and/or prostate biopsy (3 procedures) was performed using local anesthesia. RESULTS Mean procedure duration was 76 minutes and all patients tolerated the intervention well. Procedure related adverse events included self-limited hematuria and hematochezia following 3 of 8 procedures (all resolved in less than 1 week). Mean needle placement accuracy was 1.9 mm for the fiducial marker placement studies and 1.8 mm for the biopsy procedures. Mean fiducial marker placement accuracy was 4.8 mm and the mean fiducial marker placement accuracy transverse to the needle direction was 2.6 mm. All patients who underwent the procedure were able to complete their course of radiotherapy without delay or complication. CONCLUSIONS While studies of clinical usefulness are warranted, transrectal 1.5 T MRI guided prostate biopsy and fiducial marker placement is feasible using this system, providing new opportunities for image guided diagnostic and therapeutic prostate interventions.