Perspectives in Medicine (2012) 1, 1113

Bartels E, Bartels S, Poppert H (Editors):

New Trends in Neurosonology and Cerebral Hemodynamics an Update.
Perspectives in Medicine (2012) 1, 1113

journal homepage: www.elsevier.com/locate/permed

Sonothrombolysis: Current status

Peter D. Schellinger a,, Carlos A. Molina b

a
Departments of Neurology and Geriatry, Johannes Wesling Klinikum Minden, Germany
b
Vall dHebron Stroke Unit, Department of Neurosciences, Hospital Universitari Vall dHebron, Barcelona, Spain

KEYWORDS Summary This contribution summarizes the past and present status of ultrasound-facilitated
thrombolysis (sonolysis) with and without the use of microspheres. Different ultrasound tech-
Sonothrombolysis;
niques are addressed and advantages as well as pitfalls are discussed.
rt-PA;
2012 Elsevier GmbH. Open access under CC BY-NC-ND license.
Microbubbles

Introduction are associated with higher recanalization rates and conse-

Intravenous thrombolysis with rt-PA is the only approved
therapy for treating acute ischemic stroke and needs to
be administered within the rst 4.5 h after symptom onset
[1]. Among other factors, the speed and completeness of
recanalization, and successive reperfusion of ischemic brain
tissue is associated with nal infarct size, restoration of
function, and nally clinical outcome. With i.v. rt-PA only,
there is a rather low percentage of patients achieving early
(3040%) and complete (18%) recanalization [2]. Therefore,
various ways to improve speed and completeness of recanal-
ization have been studied, among others the therapeutic
use of ultrasound, alone or in combination with thrombolyt-
ics. The following brief overview reects the current clinical
status of sonothrombolysis. For an extensive recent review
(and the basis for this chapter) including the experimental
background of sonothrombolysis the reader is referred to
Amaral-Silva et al. [3].
Delivery of tPA to the thrombus is dependent on the resid-
ual ow to and around the arterial obstruction, and better
residual ow signals detected by Transcranial Doppler (TCD)
quently better clinical courser in stroke patients treated
with i.v. tPA [3,4]. Proximal arterial occlusions are a marker
of clot burden and poorer response to thrombolysis in terms
of recanalization [5,6]. Therefore, proximal intracranial
occlusion is a target for more advanced reperfusion strate-
gies, among them ultrasound-enhanced thrombolysis. While
several ultrasound techniques have been applied, the focus
of this contribution shall remain on the techniques that are
also used in standard diagnostic ultrasound, i.e. transcranial
color coded duplex (TCCD) and TCD.
TCD is a non-invasive technique that uses ultrasound to
access regional blood ow by determining ow velocities of
intracranial arteries. TCD is a fast and reliable method of
obtaining real-time information on the presence and loca-
tion of arterial occlusion and recanalization during or shortly
after thrombolysis [3]. The patterns of intracranial arterial
occlusion and recanalization on TCD have been validated
against angiography with high sensitivity and specicity val-
ues resulting in the now widely used derived thrombolysis
in brain ischemia (TIBI) grading system [7].

Clinical studies
Corresponding author at: Department of Neurology, Johannes
Wesling Klinikum Minden, Hans-Nolte-Str. 1, D-32429 Minden,
Germany. Tel.: +49 571 7903501; fax: +49 571 790293500. High frequencies lead to greater attenuation of ultrasound,
E-mail addresses: peter.schellinger@klinikum-minden.de, lower frequencies may be harmful due to tissue heating.
peter.schellinger@muehlenkreiskliniken.de (P.D. Schellinger). There are only very limited data on the effect of ultrasound

2211-968X 2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

doi:10.1016/j.permed.2012.02.023
12
alone (without thrombolytic drugs) to facilitate clot lysis in
acute stroke.
The TRUMBI study, a phase II clinical trial testing
the use of low frequency ultrasound insonation in acute
stroke patients treated with i.v. t-PA, showed a signicant
increase in hemorrhage, both symptomatic and asymp-
tomatic [8]. The trial included i.v. rt-PA patients within
6 h of symptom onset but was closed early because of
signs of ICH in 13/14 patients compared with 5/12 patients
on rt-PA only albeit identical recanalization rates. Since
then, clinical trials restricted the use of ultrasound for
therapeutical purposes to the settings usually used for
diagnostic purposes (12 MHz), which have proved their
safety and efcacy in several experimental and clinical tri-
als.
Alexandrov et al. reported one of the rst clinical reports
on the use of sonothrombolysis in acute stroke patients [9]
and showed with 2 MHz TCD a higher response rate to i.v.
t-PA at 24 h than previously documented (40% of patients
versus 27% in the NINDS trial showed a >10 points improve-
ment in NIHSSS or complete recovery). This pilot trial was
followed by a phase II randomized controlled trial CLOTBUST
(Combined Lysis of Thrombus in Brain Ischemia using Tran-
scranial Ultrasound and Systemic TPA), which demonstrated
that enhancement of the thrombolytic activity of tPA could
be safely achieved by using higher frequency (2 MHz) and
low intensity (<700 mW/cm2 ) single element pulsed-wave
ultrasound [2]. In 126 patients randomized in a 1:1 fashion
acute rt-PA treated stroke patients were either insonated
within a 3-h time window for 2 h or not. rt-PA induced
arterial recanalization was increased by ultrasound (sus-
tained complete recanalization rates at 2 h: 38% versus 13%,
p = 0.002) with a non-signicant trend toward an increased
rate of clinical recovery from stroke, as compared with
placebo and at no increased cost of bleeding complica-
tions (4.8% in both arms). A phase III trial has been planned
for quite some time and protocols have been published
[10]. The problem, however, is still the lack of an inves-
tigator independent device, although this may be solved in
the close future (Andrei Alexandrov, personal communica-
tion).
Transcranial color coded duplex ultrasound (TCCD) has
been used in four smaller trials of ultrasound enhanced
thrombolysis [3]. In general, the results were somewhat bet-
ter than control rt-PA patients with regard to recanalization
and trends for outcome, but again at the cost of higher
bleeding rates fortunately not in the same range as in the
TRUMBI trial.
Microbubble-enhanced sonothrombolysis
Microbubbles (MBs, microspheres), originally developed as
ultrasound contrast agents, have been utilized for increasing
ultrasound performance in neurovascular imaging and sonol-
ysis by enhanced cavitation and microstreaming [11,12].
Derived from experimental studies in the 90s [13], the
approach was consecutively applied to the clinical setting
[12,14]. In a rst study Molina and colleagues used levovist
given at 3 time points in 38 patients compared to 73 patients
treated with either 2 MHz TCD and rt-PA or rt-PA alone
[12]. Complete recanalization rate 2 h after t-PA bolus was
P.D. Schellinger, C.A. Molina
signicantly higher in the tPA/US/MB group (54.5%)
compared with tPA/US (40.8%) and tPA (23.9%) groups
(p = 0.038). No systemic symptoms deriving from MBs use
were documented. Symptomatic ICH rates did not differ. A
French TCCD (plus rt-PA plus MB versus rt-PA alone) study was
terminated prematurely because of safety concerns [15].
Other MBs have been tested but none have emerged so far
as superior to others.
Newer submicron lipid coated perutren MBs
(nanobubbles) were tested in a pilot trial and a
phase IIa study [14,16]. Preliminary data compared to
historic controls from the CLOTBUST trial showed a higher
rate of complete recanalization (50% versus 18%, p = 0.028)
and sustained complete recanalization at 2 h (42% versus
13%, p = 0.003). Interestingly, in a majority of patients
MBs were detected in areas with no pretreatment ow,
indicating permeation beyond intracranial occlusions [17].
The phase IIa TUCSON study [14] aimed to determine
the safety, tolerability, and activity of perutren-lipid
MBs MRX-801 plus TCD insonation in sonothrombolysis.
Thirty-ve patients with pretreatment proximal intracra-
nial occlusions on TCD were randomized (2:1 ratio) to
increasing doses of MRx-801 MBs infusion over 90 min.
The study was terminated prematurely by the sponsor
because of bleeding events in the 2nd dose tier, although
all the 3 bleedings could have been attributed to very
severe strokes and high blood pressures during treatment.
Despite that, a trend toward higher sustained complete
recanalization rates in both MBs dose tiers compared
to control was observed (67% for Cohort 1, 46% for
Cohort 2, and 33% for controls, p = 0.255). To date this
was the last sonothrombolysis study also using MBs, and
the concept remains to be rechallenged in the authors
opinion.
Conclusions
Early and effective reperfusion is the key for early ischemic
tissue rescue and further good clinical outcomes. How-
ever, i.v. tPA alone can only accomplish this goal in less
than 50% of the patients. Ultrasound may be a tool to
enhance clot lysis, albeit the nal verdict has to be spoken.
At the current stage a phase III trial with an investiga-
tor blinded 2 MHz device using the settings of the original
CLOTBUST study is underway, and the protocol has been
nalized. Future research should be dedicated to optimiz-
ing the technical setting of ultrasound, the development
of untargeted and targeted MBs and optimizing the feasi-
bility of this not so novel therapeutic approach to acute
stroke.
Financial disclosures
Peter D Schellinger is Honoraria, Advisory Board, Travel
grants, Speaker Board for Boehringer Ingelheim, Coaxia Inc.,
Photothera, Cerevast, ImARX, Sano, Ferrer, ev3/covidien,
GSK, Haemonetics, Bayer.
Carlos A Molina is Honoraria, Advisory Board, Travel
grants, Speaker Board for Boehringer Ingelheim, Coaxia Inc.,
Cerevast, ImARX, Sano, Ferrer, Haemonetics.
Sonothrombolysis: Current status 13

References dramatic clinical recovery during tPA infusion when continu-

ously monitored with 2-MHz transcranial Doppler monitoring.
Stroke 2000;31(3):6104.
[1] Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti
[10] Saqqur M, Tsivgoulis G, Molina CA, Demchuk AM, Garami Z, Bar-
D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute
reto A, et al. Design of a PROspective multi-national CLOTBUST
ischemic stroke. N Engl J Med 2008;359(13):131729.
collaboration on reperfusion therapies for stroke (CLOTBUST-
[2] Alexandrov AV, Molina CA, Grotta JC, Garami Z, Ford SR,
PRO). Int J Stroke 2008;3(1):6672.
Alvarez-Sabin J, et al. Ultrasound-enhanced systemic throm-
[11] Bogdahn U, Becker G, Schlief R, Reddig J, Hassel W.
bolysis for acute stroke. N Engl J Med 2004;351(21):21708.
Contrast-enhanced transcranial color-coded real-time sonog-
[3] Amaral-Silva A, Pineiro S, Molina CA. Sonothrombolysis for the
raphy. Results of a phase-two study. Stroke 1993;24(5):
treatment of acute stroke: current concepts and future direc-
67684.
tions. Expert Rev Neurother 2011;11(2):26573.
[12] Molina CA, Ribo M, Rubiera M, Montaner J, Santamarina E,
[4] Alexandrov AV, Burgin WS, Demchuk AM, El-Mitwalli A, Grotta
Delgado-Mederos R, et al. Microbubble administration acceler-
JC. Speed of intracranial clot lysis with intravenous tissue
ates clot lysis during continuous 2-MHz ultrasound monitoring
plasminogen activator therapy: sonographic classication and
in stroke patients treated with intravenous tissue plasminogen
short-term improvement. Circulation 2001;103(24):2897902.
activator. Stroke 2006;37(2):4259.
[5] Riedel CH, Jensen U, Rohr A, Tietke M, Alfke K, Ulmer S,
[13] Tachibana K, Tachibana S. Albumin microbubble echo-contrast
et al. Assessment of thrombus in acute middle cerebral artery
material as an enhancer for ultrasound accelerated thrombol-
occlusion using thin-slice nonenhanced computed tomography
ysis. Circulation 1995;92(5):114850.
reconstructions. Stroke 2010;41.
[14] Molina CA, Barreto AD, Tsivgoulis G, Sierzenski P, Malkoff MD,
[6] Riedel CH, Zimmermann P, Jensen-Kondering U, Stingele R,
Rubiera M, et al. Transcranial ultrasound in clinical sonothrom-
Deuschl G, Jansen O. The importance of size: successful
bolysis (TUCSON) trial. Ann Neurol 2009;66(1):2838.
recanalization by intravenous thrombolysis in acute anterior
[15] Tsivgoulis G, Eggers J, Ribo M, Perren F, Saqqur M, Rubiera M,
stroke depends on thrombus length. Stroke 2011;42(6):17757.
et al. Safety and efcacy of ultrasound-enhanced thrombolysis:
[7] Demchuk AM, Burgin WS, Christou I, Felberg RA, Barber PA, Hill
a comprehensive review and meta-analysis of randomized and
MD, et al. Thrombolysis in brain ischemia (TIBI) transcranial
nonrandomized studies. Stroke 2010;41(2):2807.
Doppler ow grades predict clinical severity, early recovery,
[16] Barreto AD, Sharma VK, Lao AY, Schellinger PD, Amarenco P,
and mortality in patients treated with intravenous tissue plas-
Sierzenski P, et al. Safety and dose-escalation study design of
minogen activator. Stroke 2001;32(1):8993.
Transcranial Ultrasound in Clinical SONolysis for acute ischemic
[8] Daffertshofer M, Gass A, Ringleb P, Sitzer M, Sliwka U, Els T,
stroke: the TUCSON Trial. Int J Stroke 2009;4(1):428.
et al. Transcranial low-frequency ultrasound-mediated throm-
[17] Alexandrov AV, Mikulik R, Ribo M, Sharma VK, Lao AY, Tsiv-
bolysis in brain ischemia: increased risk of hemorrhage with
goulis G, et al. A pilot randomized clinical safety study
combined ultrasound and tissue plasminogen activator results
of sonothrombolysis augmentation with ultrasound-activated
of a phase II clinical trial. Stroke 2005;36(7):14416.
perutren-lipid microspheres for acute ischemic stroke. Stroke
[9] Alexandrov AV, Demchuk AM, Felberg RA, Christou I, Barber
2008;39(5):14649.
PA, Burgin WS, et al. High rate of complete recanalization and