Patent Grant
7819842
The present invention relates to a chronically implantable guide tube. More particularly, the present invention discloses a chronically implantable guide tube designed to provide recurrent controlled delivery of a chemical or pharmaceutical substance without the need for repeated stereotactic neurosurgery or additional stereotactic apparatuses.
Generally, to administer certain types of pharmaceutical therapies to a neurological site, surgeons must perform repeated neurosurgeries. Specifically, the neurosurgeon must repeatedly localize the desired target site in the brain using stereotactic procedures. Stereotactic surgery is achieved by attaching a light weight metal superstructure to the patient's head to provide a fixed frame of reference for insertion of electrodes, probes, instruments or other medical devices into the brain. The apparatus provides multiple degrees of freedom in space for adjusting the positioning of the medical device to be inserted into the brain. Therefore as the patient's head moves in space the metal superstructure also moves in a one to one correspondence. However, the electrode, probe or device to be inserted into the patient's brain is immobilized with respect to the superstructure and therefore always remains in the same position relative to the head or brain. Hence, the stereotactic frame serves as a platform whereby an instrument is guided to a desired brain target site using stereotactic coordinates. That is, pre-mapped brain coordinates are used that are set on the superstructure. The positioning of the target site with respect to the metal frame is verified with imaging techniques, such as CT or MRI images. From this known relationship, the stereotactic coordinates are determined for positioning the probe in the target site. In addition, other techniques are also used to verify the target site area, such as using stimulation or recording electrodes. For example, the target site or nearby adjacent areas can be stimulated with a stimulation electrode for determining appropriate neurophysiological responses. In other situations, a recording electrode can be used to sample neuronal activity to confirm target site location. Once the instrument is guided to the desired target, treatment can begin, such as the administration of a biologic, chemical or pharmaceutical substance to the target site.
The above techniques and procedures are used for each surgical operation. However, repeated intermittent application of pharmaceutical agents to the same target site over time (such as days, weeks, months, etc.) would require many neurosurgical operations. Besides the known risks of multiple repeated operations, there are a number of other difficulties and risks to the patient. Repeated neurosurgical procedures can result in sub-optimal placement of the instrument with respect to the target site that may lead to significant morbidities or failure of the treatment. Sub-optimal placement may result from brain shifts during the operative procedure, changes in tissue pressure or consistency with repeated penetrations of the instrument, deflection of the instrument as it passes through previously penetrated brain tissue to the desired target or may result from miscalculation of stereotactic coordinates.
Additionally, repeated stereotactic neurosurgery may result in damage to the target site. Damage to a target site or region of interest is harmful to the patient's brain tissue and may necessitate a relocation of the target point. Hence, delivery of a biologic, chemical, or pharmaceutical without the need for repeated stereotactic neurosurgery or additional stereotactic apparatuses is greatly desired for such therapies.
Another problem associated with current devices is the delivery of pharmaceuticals to patients that may over-extend the target area. Over-extension and into and beyond the target site may cause damage to the patient's surrounding brain tissue and potentially cause a corresponding functional loss. Therefore, a delivery system that precisely targets the area of interest without over-extending the delivery site is important for patient safety.
Several prior art apparatuses allow for the introduction of drugs or therapeutic agents to selected brain tissue sites. U.S. Patent Application Publication No. 2004/0215164 A1 discloses a catheter assembly for intracranial treatments. This device is not chronically implantable, nor does this device prevent over-extension into the delivery site. Tissue or fluid accumulation at the target area can interfere with precise delivery of pre-determined amounts of substances. Another prior art device is described in U.S. Pat. No. 5,800,390. This patent discloses an intracranial tube for delivery of a pharmaceutical. Similarly, this device also does not prevent overshooting or over-extension into the delivery site.
Another prior art device is described in U.S. Patent Application Publication No. 2004/0186422. This application discloses an apparatus for delivering therapeutic or diagnostic agents to a target site within tissue. However, this device is also not chronically implantable, nor does this device prevent over-extension into the delivery site.
It is therefore desirable to provide a therapy delivery system that is chronically implantable to prevent damage to the target site for intermittent repeated surgeries, and which also prevents overshooting or over-extension into the delivery site.
The present invention relates to a chronically implantable guide tube for use in neurosurgery. The device is particularly useful in delivering a pharmaceutical to a stereotactically targeted surgical site for the treatment of abnormalities of brain function. These abnormalities may include movement disorders such as Parkinson's disease, chorea, tremor, multiple sclerosis, and cerebral palsy. Treatment for abnormalities of the mind may include depression, obsessive compulsive states, Alzheimer's disease, chronic pain syndromes and epilepsy. The device can also be used in the targeted treatment of brain tumors. In general the invention can be used to treat multiple neurological disorders or diseases, including enzyme deficiencies (e.g., lysosomal storage disorders), and stroke. Specifically, this device can be used to administer viral vectors and vectorless nucleic acid sequences for gene therapy and for protein suppression therapies.
The invention is particularly useful for the delivery of biologic, chemical, or pharmaceutical materials to a targeted area with an intermittent release protocol. The invention supports treatment protocols with variant dosing intervals, such as hours, days, weeks, months or variations thereof.
One aspect of the invention discloses a chronically implantable guide tube to provide delivery of a pharmaceutical without the need for repeated stereotactic neurosurgery. The chronically implantable guide tube includes a guide cannula, an access port mounted on a proximal end of the guide cannula, and a first stop disposed near the distal end of the guide cannula. When inserted into the guide tube, the relative positions of the first stop on the guide cannula, and a second stop on a delivery cannula prevent the delivery cannula from extending beyond a predetermined distance from the distal end of the guide tube. The first stop can also be disposed on a distal region of the guide tube, that is, the lower half or lower third regions. With the second stop appropriately positioned, the delivery cannula would then be advanced at a predetermined distance. However, the preferred embodiment is to dispose the first stop at the distal end of the guide tube with the appropriate positioning of the second stop on the delivery cannula.
In one embodiment, a tissue-piercing tip is attached to the distal end of the delivery cannula that is to be guided down the guide tube into a target site in the patient. The tissue-piercing tip can be used to penetrate any tissue plug or clot at the distal end of the chronically implantable guide tube that may otherwise block the flow of a substance or pharmaceutical from the delivery cannula into the tissue.
In certain embodiments, a stylet is inserted in the lumen of the chronically implantable guide tube to plug the distal region of the guide tube. The stylet may plug the chronically implantable guide tube during chronic periods between deliveries of various biologics, chemicals or pharmaceuticals during different therapies. In certain embodiments, the stylet may include a pharmaceutical or other substance to maintain patency.
The drawings illustrate the design and utility of preferred embodiments of the present invention. In order to better appreciate how the advantages and objects of the present inventions are obtained, a more particular description of the present inventions in reference to specific embodiments are illustrated in the accompanying drawings. With the understanding that these drawings depict only typical embodiments of the invention and are not intended to limit its scope, the invention will be described and explained with additional specificity and detail through the use of the accompanying drawings.
A first embodiment of the chronically implantable guide tube is depicted in
The chronically implantable guide tube 2 depicted in
In certain embodiments, the chronically implantable guide tube comprises a first radiopaque marker selected for high visibility during fluoroscopy. In this embodiment, the radiopaque marker is positioned around the distal end of the guide tube 2. The radiopaque marker allows imaging of the distal end of the guide tube 2 during surgery to assess the positioning of the distal end 2 with respect to the intended target site 12. Radiopaque markers may also be used along the length of the guide tube for fluoroscopic or x-ray confirmation of the trajectory of the tube within the patient's brain.
The first stop 3 in the chronically implanted guide tube is a flange that prevents a delivery cannula, depicted in
One embodiment of the guide tube is depicted in
Any of the materials discussed previously with reference to the chronically implantable guide tube may also be suitable for the construction of the delivery cannula. A highly flexible delivery cannula is desirable, as it cannot then be forced past the first stop in the guide cannula. The delivery cannula may be a single use cannula to reduce the risk of infections, and may utilize radiopaque materials or markers for fluoroscopic control of its trajectory inside the guide tube.
In other embodiments, the delivery cannula comprises a second radiopaque marker for fluoroscopic or x-ray visualization of the tip of the cannula. Multiple radiopaque markers may also be used on the length of the delivery cannula for confirmation of its trajectory relative to the patient's neural tissue.
It is understood by those skilled in the art that the flexibility or stiffness of the invention may be varied by using different materials or combination of materials for the chronically implantable guide tube and the delivery cannula.
Yet another embodiment of the chronically implantable guide tube is depicted in
Still another embodiment of the chronically implantable guide tube is depicted in
The stylet is inserted into the access port 1 of the guide tube 2 and is slidable. Because the stylet 7 mechanically interacts with the first stop of the guide tube 3, the stylet cannot extend past the distal end of the guide tube. The stylet may be inserted into the guide tube to prevent tissue in-growth and fluid accumulation between therapeutic administrations. Further, it reduces the risks of potential infections to the patient and maintains an unobstructed pathway for the insertion of the delivery cannula.
The therapy delivery system of the instant invention may further comprise anchoring means to keep the stylet from moving in and out of the guide cannula between treatments. A person of the ordinary skill in the art will appreciate that a variety of ways exist to achieve this objective. In one embodiment, the stylet and the guide cannula may be in a threaded arrangement, so the stylet is screwed into the guide cannula. In another embodiment, there may be a notch in the stylet or the guide cannula, and a corresponding groove in the guide cannula or the stylet. The groove may further comprise a change in geometry so that the stylet cannot be removed with a single longitudinal movement (e.g., without twisting the stylet in the guide cannula. In yet another embodiment, the access port may comprise a lid or a cap which would prevent the stylet from sliding in and out of the guide cannula. The combination of these arrangements is also envisioned.
Depicted in
In yet another embodiment, the delivery cannula interfaces with a microsyringe comprising a catheter for insertion into the guide tube, a flow regulator through which the biologic, chemical or pharmaceutical agent is release at a predetermined rate, a delivery chamber containing a predetermined amount of fluid volume and biologic, chemical or pharmaceutical agent to be injected into the brain tissue, and a second chamber (separate from the first chamber) containing a septum that acts as a piston or plunger to deliver the material through the catheter. The second chamber may be filled with hydraulic fluid, oil, gas, air or other suitable substance to provide controlled pressures for releasing the biologic, chemical or pharmaceutical agent into the brain tissue. A non-limiting example of a suitable microsyringe has been disclosed, for example, in a co-pending application Ser. No. 11/562,282, (Kaemmerer) filed Nov. 21, 2006.
Still yet another embodiment of the invention, the guide tube may also be implanted in the cerebral ventricles for therapeutic delivery of the substance into the cerebral spinal fluid of the patient. Intermittent, acute and invasive delivery of a slurry of small solids, for example, polymer and drug pellets, can be introduced into the cerebral spinal fluid of the cerebral ventricles. The invention may also be used for the intermittent delivery of biologic, enzyme, chemical or pharmaceutical materials in cardiac infarct sites, pancreas or other tissues. The invention can provide a system for intermittent acute delivery of materials for the transplant of islet cells in the pancreas. In another embodiment, the invention provides a system for delivery of cardiomyocytes to the infarcted areas of myocardium.
The invention includes a therapy delivery method comprising (a) implanting a guide tube within a patient, a distal section of the guide tube comprising a first stop; (b) inserting into a proximal end of the guide tube a first delivery cannula, the first delivery cannula having a second stop; (c) feeding the first delivery cannula into the guide tube until the first stop contacts the second stop; (d) delivering a first pharmaceutical into the first delivery cannula; and (e) extracting the first delivery cannula. For example, a first delivery of a first pharmaceutical to a patient using the subject invention could consist of delivering through the guide tube into the brain tissue of the patient a dose of adeno-associated viral (AAV) vector containing approximately 150×109 viral particles in a volume of 50 to 150 microliters of fluid, where the AAV vector contains DNA encoding for a therapeutic gene product. The DNA encoding for the therapeutic gene product may incorporate DNA sequences designed to be recognized by a DNA recombinase such that future contacting of the brain tissue treated with the AAV-delivered DNA by the DNA recombinase would silence the expression of the therapeutic gene product. Thus, using the subject invention, the gene therapy delivered to the patient at one point in time could optionally be reversed at a future point in time if necessary, with the chronically implanted guide tube of the subject invention ensuring that the DNA recombinase needed to reverse the gene therapy is delivered to the same tissue location as that to which the gene therapy was delivered at the first point in time.
In certain embodiments of the therapy delivery method the stylet is (a) extracted from the guide tube; (b) a second delivery cannula, having a third stop, is inserted into the proximal end of the guide tube; (c) the second delivery cannula is fed into the guide tube until the first stop contacts the third stop; (d) a second pharmaceutical, that may be the same as the first pharmaceutical, is delivered; and (e) the second delivery cannula is extracted. For example, a first delivery of a first pharmaceutical to a patient using the subject invention could consist of delivering through the guide tube into the brain tissue of the patient a dose of adeno-associated viral (AAV) vector containing approximately 150×10 viral particles in a volume of 50 to 150 microliters of fluid, where the AAV vector contains DNA encoding for a therapeutic gene product and the AAV serotype is serotype 1. Next, at a later point in time if additional gene therapy is required for the patient, a second delivery of a second pharmaceutical to the patient using the subject invention could consist of delivering through the guide tube into the brain tissue of the patient a dose of adeno-associated viral (AAV) vector containing approximately 150×109 viral particles in a volume of 50 to 150 microliters of fluid, where the AAV vector contains DNA encoding for a therapeutic gene product and the AAV serotype is serotype 1, or optionally, a different serotype than serotype 1. The use of a different serotype than serotype 1 for the second administration of the therapy to the patient may be beneficial in terms of maximizing the therapeutic efficacy of the second administration if the patient's immune system has developed neutralizing antibodies to the proteins of AAV serotype 1.
In some applications of the method of the instant invention, a precise placement of the guide cannula is crucial. A non-limiting example of such application is the use of the method for treating disorders of the brain. Thus, the practitioner (e.g., a person who uses the system and the method of the instant invention) should select the suitable mapping means. Suitable mapping means are known in the art. Such mapping means include, without limitation, Positron Emission Tomography and Single Photon Emission Computed Tomography (PET and SPECT, respectively), pharmacological Magnetic Resonance Imaging (phMRI), functional MRI (fMRI), and contrast-enhanced computerized tomography (CT) scan.
Further, computer-aided atlas-based functional neurosurgery methodology can be used to accurately and precisely place the guide cannula of the present invention. Such methodologies permit three-dimensional display and real-time manipulation of cerebral structures. Neurosurgical planning with mutually preregistered multiple brain atlases in all three orthogonal orientations is therefore possible and permits increased accuracy of target definition for treatment injection or implantation, reduced time of the surgical procedure by decreasing the number of tracts, and facilitates planning of more sophisticated trajectories. See e.g. Nowinski W. L. et al., Computer-Aided Stereotactic Functional Neurosurgery Enhanced by the Use of the Multiple Brain Atlas Database, IEEE Trans Med Imaging 19(1); 62-69:2000.
For example, Serra et al. (the teachings of which are incorporated herein by reference in its entirety) describe technological improvements for surgery in human brains, comprising the use of ST and MR imaging, and the incorporation of detailed stereotactic atlases compiled over the years into their system of hardware and software for planning and carrying out neurosurgery. For example, Serra et al. describe an “electronic brain atlas” for identifying brain targets. Serra et al. describe the use of their system to target brain structures with almost any art-recognized surgical instrument, including probes and delivery devices. Further, Serra et al. provide a detailed blueprint and disclose devices and software, and refer to several print publications, describing, teaching, and showing the use of stereotactic atlases to identify and locate virtually any target in the human brain.
One of skill interested in particular region of the human brain, may, in addition to referring to Serra et al., use the teachings of Morel et al., among others, who disclose a detailed atlas of human thalamus. Morel et al. discuss that computer tomography and magnetic resonance imaging-guided stereotaxy and preoperative microelectrode recordings for localization of targets has aided stereotactic neurosurgery.
Further, in 2001, Medtronic introduced a “mapping means” device termed the Medtronic NT StealthStation® Treon™ into the marketplace. This medical system further refines the computerized technologies of multi-dimensional imaging and navigation to enable neurosurgeons to precisely plan, re-plan and visualize a procedure as it proceeds deep within the brain for treating neurological disorders in a living human patient.
Although the invention herein has been described with reference to particular embodiments, it is to be understood that these embodiments are merely illustrative of the principles and applications of the present invention. It is therefore to be understood that numerous modifications may be made to the illustrative embodiments and that other arrangements may be devised without departing from the spirit and scope of the present invention as defined by the following claims.
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