Classifications

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  • A61B17/22004—Implements for squeezing-off ulcers or the like on inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; for invasive removal or destruction of calculus using mechanical vibrations; for removing obstructions in blood vessels, not otherwise provided for using mechanical vibrations, e.g. ultrasonic shock waves
  • A61B17/22012—Implements for squeezing-off ulcers or the like on inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; for invasive removal or destruction of calculus using mechanical vibrations; for removing obstructions in blood vessels, not otherwise provided for using mechanical vibrations, e.g. ultrasonic shock waves in direct contact with, or very close to, the obstruction or concrement
  • A61B17/2202—Implements for squeezing-off ulcers or the like on inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; for invasive removal or destruction of calculus using mechanical vibrations; for removing obstructions in blood vessels, not otherwise provided for using mechanical vibrations, e.g. ultrasonic shock waves in direct contact with, or very close to, the obstruction or concrement the ultrasound transducer being inside patient's body at the distal end of the catheter
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  • A61B2017/22082—Implements for squeezing-off ulcers or the like on inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; for invasive removal or destruction of calculus using mechanical vibrations; for removing obstructions in blood vessels, not otherwise provided for after introduction of a substance
  • A61B2017/22084—Implements for squeezing-off ulcers or the like on inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; for invasive removal or destruction of calculus using mechanical vibrations; for removing obstructions in blood vessels, not otherwise provided for after introduction of a substance stone- or thrombus-dissolving
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  • A61B2017/22082—Implements for squeezing-off ulcers or the like on inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; for invasive removal or destruction of calculus using mechanical vibrations; for removing obstructions in blood vessels, not otherwise provided for after introduction of a substance
  • A61B2017/22088—Implements for squeezing-off ulcers or the like on inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; for invasive removal or destruction of calculus using mechanical vibrations; for removing obstructions in blood vessels, not otherwise provided for after introduction of a substance ultrasound absorbing, drug activated by ultrasound
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Definitions

• the present invention concerns a device for ultrasonic-accelerated hematoma lysis or thrombolysis of intracerebral or intraventricular hemorrhages or hematomas and the use of such a device for the treatment of intraventricular hemorrhages or hematomas.
• the medical device according to the present invention is suitable for the treatment of brain hemorrhages.
• Background Art :
• Intracerebral hemorrhage counts for 8 to 13 % of all strokes world-wide and results for a wide spectrum of disorders. Intracerebral hemorrhage is more likely to result in death or major disability than ischemic stroke or subarachnoid hemorrhage.
• Intracerebral hemorrhage usually results from bleeding associated with amyloid angiopathy, tumors, hemorrhagic conversion of ischemic stroke, dural venous sinus thrombosis, vasculitis and vascular malformations such as cavernous angiomas, arteriovenous fistulae, arteriovenous malformations, venous angiomas, and aneurysms (Qureshi et al., Spontaneous intracerebral hemorrhage. N Engl J Med. 2001 b; 344:1450-60; Ruiz-Sanoval et al., Intracerebral hemorrhage in young people: analysis of risk factors, location, causes, and prognosis.
• rtPA recombinant tissue plasminogen activator
• Non-traumatic, spontaneous ICH is also associated with intraventricular hemorrhages (IVH) in 40 to 50 % of all cases. IVH is associated with mortality rates of 30 to 80 %, compared to 5 to 29 % for ICH without IVH (Hanley DF. Intraventricular hemorrhage: severity factor and treatment target in spontaneous intracerebral hemorrhage. Stroke. 2009; 40:1533-8). IVH can result in acute hydrocephalus by obstruction of the ventricular system or extraventricular compression from ICH (Lodhia et al. Hydrocephalus in a rat model of intraventricular hemorrhage. Acta neurochirurgica Supplement. 2006; 96:207-1 1 ; Zazulia AR.
• Intraventricular and intracerebral clots have been treated with rtPA (recombinant tissue plasminogen activator) by catheter-directed thrombolysis using ultrasound treatment (Newell et al., Minimally invasive evacuation of spontaneous intracerebral hemorrhage using sonothrombolysis. Journal of neurosurgery. 2001 ; 1 15:592-601 ).
• rtPA tissue plasminogen activator
• Ultrasound-accelerated thrombolysis involves the breaking down or "melting" of blood clots that can form in arteries or veins.
• the methodology applies ultrasound energy along with
• thrombolytics e.g. tPA
• Acoustic energy creates a pressure wave that results in a disruption of fibrin and other components
• ultrasound energy also helps to create a way for the thrombolytic compound to get into the clot by loosening up the fibrin cross-links by 'acoustic streaming'.
• Ultrasound energy therefore alters the shape of the fibrin network, thereby dissociating the clot directly.
• CLOTBUST Design of a Randomized Trial of Ultrasound-Enhanced Thrombolysis for Acute Ischemic Stroke, Journal of Neuroimaging, Volume 14, Issue 2, pages 108-1 12, April 2004
• CLOTBUST Design of a Randomized Trial of Ultrasound-Enhanced Thrombolysis for Acute Ischemic Stroke. Journal of Neuroimaging, 14: 108-1 12).
• Image-guidance was used in order to improve catheter accuracy compared with a standard technique (Levitt et al., 2012; Image- guided cerebrospinal fluid shunting in children: catheter accuracy and shunt survival, J
• WO 2016/007553 A describes an instrument that is specifically configured for image guided or stereotactic evacuation of intracerebral hemorrhage or other lesions.
• the apparatus comprises a cannula having a central channel terminating at an opening at a distal end of the cannula.
• the cannula is configured to be delivered through an aperture in a patient's skull for delivery to a treatment region within the cranium of the patient.
• a suction port is located at a proximal location of the cannula and is in fluid communication with the central channel for evacuating fluid and/or debris from the target treatment region.
• An irrigation port is disposed at a proximal location of the cannula, the irrigation port is in fluid communication with the distal end of the cannula for delivering fluid to the target treatment region.
• US 2012/0265123 A1 describes an apparatus and a method to deliver ultrasound energy through the drain to dissolve hemorrhages and debris occluding the drain lumen and ports.
• CT computed tomography
• CN201379823 Y describes a device for draining a hematoma of hypertensive cerebral hemorrhage (HCH) which uses two rows of drainage holes that are in fluid communication with an intracerebral hematoma drainage silicone tube.
• a metal lead pin is used to be inserted into the intracerebral hematoma drainage silicone tube.
• JP2006043200 A describes a support system that is equipped with an image acquiring device for acquiring a brain image of a patient, a cerebral region detection part for determining a cerebral region from the brain image and a wrinkle range detection part for detecting a region of the brain wrinkle and an uneven region of the brain by determining the difference between a convex closure in the cerebral region and the brain region for the treatment of ICH.
• a blood vessel removing part is used for removing a blood vessel region from the wrinkle region.
• US 2008/319376 A1 describes an ultrasound catheter with fluid delivery lumens, fluid evacuation lumens and a light source used for the treatment of intracerebral hemorrhages.
• the lumens can be used to deliver a fluid to a treatment site and/or to evacuate a fluid from around the treatment site.
• US 5,318,518 describes an irrigating catheter for eliminating solids from body organs and hollow body organs or cavities of man and animals.
• the catheter consists of a catheter body having at least a first lumen and a second lumen, wherein the first lumen transports fluid to the organs and the second lumen discharges irrigating fluid from the organs.
• the device of the present invention combines an ultrasonic-mediated imaging system, pressure sensoring means in the application of ultrasonic in the treatment of intracerebral or
• the device comprises a body that accommodates a number of separated compartments or lumens consisting of a flushing catheter for flushing fluid and/or pharmaceutically active substances into the intracerebral or intraventricular hemorrhages or hematomas, a drainage catheter for draining fluid from the intracerebral or intraventricular hemorrhages or hematomas, an ultrasonic probe duct and a pressure sensor duct.
• the ultrasonic probe duct can contain an ultrasonic probe or a stiletto (or stylet), and the pressure sensor duct integrates a pressure sensor to promote treatment of ICH and IVH.
• the stylet enables quick freehand navigated placements of the ventricular
• the device according to the present invention allows efficient drainage of fluid and debris from the ICH or IVH site and a site-directed application of thrombolytics such as rtPA over the lumen of the flushing catheter.
• the pressure sensor arranged in the present sensor duct allows monitoring of the intracranial pressure during flushing and lysis.
• an endosonographic probe preferably a 10F endosonographic probe, is integrated for B-scan imaging, Doppler and duplex measurements.
• the endosonographic probe provides high-definition imaging of intracranial structures and allows guiding of the device to the ICH- or IVH-sites.
• Ultrasonic-guided imaging allows analysis of blood flow and the lysis of hematomas in intracerebral and intracranial vessels.
• the endosonographic probe thus allows imaging to monitor evolution of ICH and eventually a resulting brain edema in real time.
• the endosonographic probe is thus used both for imaging and treatment of ICH and IVH and allows monitoring of the progress of hematoma lysis.
• Endosonography using the ultrasonic probe of the invention further allows the identification of bleedings, the presence of edemas and eventual side effects on surrounding brain components including, but not limited to compression of cerebral ventricles or a displacement of the cerebral midline.
• Ultrasonic imaging also replaces parts of CCT (Cranial Computed Tomography) diagnostics and can be applied to all sites of intracerebral or intraventricular hemorrhages or hematomas over a prolonged period of time (e.g. up to 2 - 3 weeks). This significantly reduces CCT-dependent radiation impact on the patient.
• CCT Ceranial Computed Tomography
• the outer wall of the ultrasonic probe duct in the lower distal part portion of the body further comprises a membrane, which is permeable for ultrasound.
• the membrane can be integrated fully or partially in the catheter wall to emit ultrasonic energy.
• the endosonographic probe is rotatable within the ultrasonic probe duct. If the ultrasonic-permeable membrane is integrated only partially in the ultrasonic duct, it may be preferable to rotate the whole catheter in order to achieve an unidirectional emission of ultrasonic energy.
• the lumen of the ultrasonic probe duct not only allows integration of the endosonographic imaging and treatment probe, but also of a stiletto that can be interchangeably guided within the ultrasonic probe duct.
• the stiletto or stylet is preferably inserted at the time of implantation of the device of the invention.
• the stiletto provides a higher stiffness for puncture through the cerebral tissue and the hematoma and therefore helps in guiding the device for neuronavigation for an image-guided placement of the catheter system to the center of ICH or IVH, at the same time conserving surrounding cerebral tissue.
• the stiletto is replaced by an ultrasonic probe.
• the outside part of the body of the device of the present invention comprises a connector for cranial fixation, which is adapted to allow angular adjustment of the body both in longitudinal and/or transverse direction.
• the connector is preferably provided as a connector block that integrates the body with
• the connector allows a free movement at different angles, an adjustment of the catheter trajectory within the port system and an entanglement of the body relative to the port. After adjustment of the catheter, the connector can be locked into position.
• the endosonographic probe further allows variation of the ultrasonic frequency in order to limit depth of penetration and fast tissue exposition for ultrasonic energy.
• a minimization of penetration depth to the target sites of ICH and IVH reduces complications and side effects such as bleedings.
• the knowledge about the exact position and the provision of coordinates provide valuable information on the form and volume of bleedings.
• Ultrasonic ICH or IVH can be adjusted in order to influence sonographic peak pressure and penetration depth of sonic energy. All these measures contribute to a minimization of focus energy specifically to the location of the intracerebral or intraventricular hemorrhages or hematomas and a protection of surrounding healthy tissues.
• hematoma lysis is carried out at ultrasonic frequencies between 5,5 to 10 MHz.
• a preferred frequency of 10 MHz showed the safest modalities (Ml (mechanical index) of 0.55) and the best imaging.
• Ultrasonic treatment and the additional provision of pharmaceutically active substances such as rtPA via the flushing catheter into the intracerebral or intraventricular hemorrhages or hematomas are preferred in order to dissociate associated clots.
• the device of the present invention allows high-detailed multimodular intracranial endosonographic imaging in real time and simultaneous flushing of pharmaceutically active substances into the ICH or IVH over prolonged periods of time, wherein at the same intracerebral or intraventricular fluid from the hemorrhages or hematomas is drained by the lumen of a separate drainage catheter which is part of the body.
• Intracerebral or intraventricular pressure is measured during the procedure by a pressure sensor that is integrated within a pressure sensor duct, and which is also part of the body of the device of the present invention.
• the flushing catheter, the drainage catheter, the ultrasonic probe duct and the pressure sensor duct of the device of the present invention are essential parts of the basic body and thus, these elements are integrated in a single unit that allows better handling of the device during surgery and treatment.
• the flushing catheter, the drainage catheter, the ultrasonic probe duct and/or the pressure sensor duct are arranged in proximity to each other and all compartments or lumens are at least sectionally isolated by fluid-tight catheter walls.
• the ultrasonic probe duct is configured to integrate the endosonographic probe or, if required, the stiletto for implantation.
• the upper proximal part of the flushing catheter and/or drainage catheter preferably laterally projects from the body in bended form.
• the lower distal part of the flushing catheter preferably disembogues into the drainage catheter in that the foot end of the catheter is permeably connected by means of one or more penetrations.
• the drainage catheter at the lower distal part of the catheter comprises apertures at the outer wall that allow uptake of the fluid and debris from the hematoma into the catheter lumen for subsequent transport to a collecting container.
• the surrounding catheter wall of the drainage is fully closed and does not contain apertures to allow drainage of fluid or debris to the outlet of the drainage catheter.
• the pressure sensor is preferably arranged opposite to the flushing catheter within the body of the device.
• the pressure sensor duct is arranged in the outer diameter of the body.
• the ultrasonic probe duct is arranged oppositely to the drainage catheter, wherein at least a section of the flushing catheter is arranged between the drainage catheter and the ultrasonic probe duct.
• the optional stiletto (stylet) that is guided during implantation of the device within the ultrasonic probe duct is preferably equipped with a marker of neuro navigation.
• Preferred markers of neuro navigations are disposable marker spheres, preferably coated with IR-light, retro-reflective foil, passive markers, or multi-modality fiducial markers.
• the neuro navigation markers are passive marker plates incorporated in the stylet.
• the marker geometry is automatically recognized by a navigation camera for quick calibration.
• Preferred reflective markers are plastic spheres with a glass-grain coating to reflect infrared light emitted by one or more cameras. The reflection is detected by detectors arranged around the cameras.
• the pressure sensor is part of a pole with a diameter which allows guidance of the pole within the pressure probe duct.
• the pressure sensor is arranged at the cone end of the pole, i.e. at the lower part of the body.
• the present invention also concerns a method for treatment of intracerebral or intraventricular hemorrhages or hematomas (ICH or IVH) via ultrasound-accelerated hematoma lysis thrombolysis by applying a device (catheter system) of the invention that comprises a body, which accommodates a number of separate compartments or lumens.
• the invention also concerns the use of such a device for treatment of intracerebral or intraventricular hemorrhages or hematomas, wherein the application of a device comprises the following steps:
• flushing catheter which forms an integral part of the body of the catheter system into the intracerebral or intraventricular hemorrhages or hematomas;
• the pharmaceutically active substances are thrombolytics such as recombinant tissue plasminogen activator (rtPA), streptokinase, p-anisoylated lys-plasminogen- streptokinase activator complex, urokinase, and prourokinase.
• tissue plasminogen activator compounds include Alteplase (tPA), Reteplase (sometimes called rPA), and Tenecteplase.
• tPA tissue plasminogen activator
• rPA Reteplase
• Tenecteplase Tenecteplase.
• the endosonographic probe is used both for ultrasonic lysis and real time imaging of the ICH or IVH.
• the device and the methods of the present invention allow a more efficient ultrasonic-mediated ICH or IVH lysis, thereby protecting surrounding tissue.
• Hematoma drainage, catheter flushing and rtPA application are carried out via different separate catheter lumens within the body of the device, wherein a separate pressure sensor duct bears a pressure sensor in the lower part of the body in order to monitor intracranial pressure during flushing and lysis.
• One advantage of the device of the present invention is that it can be left in the cerebrum following lysis therapy to monitor intracranial pressure and for drainage fluid from the ICH or IVH site over the drainage catheter as integral part of the device of the invention.
• Ultrasonic- mediated imaging and ultrasonic-accelerated hematoma lysis or thrombolysis allow a real-time imaging and monitoring of the hematoma lysis process.
• the combination of navigation-mediated and angle-controlled integration of the device into the ICH or IVH and the implementation of a removable stiletto are required for accurate placing of the catheter system in the center of the ICH or IVH.
• An additional connector allows an angular adjustment of the body in longitudinal and/or transverse direction; the device thereby can be placed in optimal orientation relative to the hematoma. This allows an efficient draining of the trajectory and simultaneous protection of important tissues and brain areas.
• Fig. 1 shows an embodiment of the sonothrombolytic catheter system according to the present invention.
• the device is comprised of a body 20 that accommodates different compartments or lumens that are arranged in proximity to each other and are separated from each other by respective walls.
• the device of the invention contains several catheters forming a catheter system that includes different functions.
• the first compartment or lumen is part of a flushing catheter 1 for flushing fluid and/or pharmaceutically active substances into the intracerebral or intraventricular hemorrhages or hematomas.
• rtPA or other thrombolytic substances are applied to the site of ICH or IVH by means of the flushing catheter 1 .
• the body 20 further accommodates a compartment or lumen of a drainage catheter 2 for draining fluid from the ICH or IVH.
• the body 20 also comprises a compartment or lumen of an ultrasonic probe duct 3 and a separate pressure sensor duct 5.
• the lumen of the pressure sensor duct 5 integrates a pressure sensor 6, preferably at the cone end of a pole 15 for measurement and analysis of intracranial pressures during implantation and treatment of ICH or IVH.
• the ultrasonic probe duct 3 both comprises either an endosonographic probe 4 (Fig. 1 ) or a stiletto 13 (Fig. 2) that can be interchangeably guided within the ultrasonic probe duct 3.
• the upper proximal portion 1 .1 of the flushing catheter 1 and/or the upper proximal portion 2.1 of the drainage catheter 2 laterally project from the body 20 in bended form.
• the lower distal portion 1 .2 of the flushing catheter 1 and/or the lower distal portion 2.2 of the drainage catheter 2 are provided in straight form.
• the outer wall of the drainage catheter 2 comprises one or more apertures 8. Fluid or debris is flushed from the site of ICH or IVH through the catheter lumen to the upper end of the drainage catheter 2.
• the upper proximal portion 1 .1 of the flushing catheter 1 and/or the upper proximal portion 2.1 of the drainage catheter 2 is equipped with adapters 1 1 or ports 12, respectively.
• the lumen of the flushing catheter 1 is penetrated such that flushing fluid from the flushing catheter 1 flows into the lower distal part portion 2.2 of the drainage catheter 2 through one or more penetrations 7.
• the body 20 also comprises a connector 9 for cranial fixation, which is adapted to allow an angular adjustment of the body 20 in longitudinal and/or transverse direction.
• the connector 9 is integrated into a hole of a skull 10.
• the circular lateral wall of the ultrasonic probe duct 3 further comprises a membrane 16, which is permeable for ultrasound. Furthermore, it is preferred that the endosonographic probe 4 is rotatable within the ultrasonic probe duct 3.
• Fig. 2 shows a replacement of the endosonographic probe 4 by a stiletto 13 which is required for implantation into the ICH or IVH.
• the stiletto 13 provides stiffness for the implantation of the catheter system and also may comprise additional markers of neuronavigation 14 at the upper end, such as reflective marker spheres.

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