Device and Method to Cool the Brain Through the Cisterna Magna and to Diagnose and Treat Glioblastoma

Abstract

A method and apparatus used to prevent brain death by use of rapid and safe cooling of the brain is disclosed. The cisterna magna is accessed through a patient's neck and cooled artificial cerebrospinal fluid (aCSF) is circulated about spaces within the brain and in a subarachnoid space surrounding the brain by entering the cisterna magna with an entry through the neck of the patient with a specially designed needle/cannula which allows the flow of cooled aCSF about the brain. aCSF exits from an opening in the skull where a temperature/pressure sensor is placed. Data is sent to a computer-controlled motorized system that pumps cooled aCSF to the needle/cannula placed in the cisterna magna. The pumping of aCSF is controlled to maintain a predetermined temperature and/or pressure of the exiting aCSF.

Claims

1. A method of preventing brain death and ischemic injury by the rapid and safe cooling of the brain accessible through a basal cisterna and sub-arachnoid space in an one-man field or hospital operation comprising: inserting a specially designed needle/cannula into the basal cisterna and sub-arachnoid space under ultrasound control in the one-man field or hospital operation; providing a computer-controlled motorized system that pumps cooled artificial cerebrospinal fluid (aCSF) into the needle/cannula placed in the cisterna magna; circulating cooled aCSF through the basal cisterna and sub-arachnoid space to cool the subarachnoid vessels and brain cortex, monitoring brain parenchymal temperature and pressure through convexity burrholes that drain perfusate from the convexity sub-arachnoid space; and maintaining a predetermined parenchymal temperature and pressure.

2. The method of claim 1 further comprises collection of the exiting aCSF in a sterile container below the patient without recycling.

3. The method of claim 1 further comprising recycling exiting aCSF through a closed filtering and cooling system with the aCSF recycled by the computer-controlled motorized system into the cisterna magna.

4. A method for rapid and safe cooling of a spinal cord of a patient to protect the spinal cord from trauma or ischemia including cases of spinal cord stroke or surgical replacement of a dissecting aortic aneurysm, comprising: providing a source of cooled and pressurized artificial cerebrospinal final (aCSF); perfusing cooled aCSF into through a lumbar sac or cisterna magna with a specially designed needle/cannula; and exiting aCSF through burrholes or through the lumbar sac.

5. A method for rapid and safe cooling of a spinal cord of a patient to protect the spinal cord from trauma or ischemia comprising: providing a source of cooled and pressurized artificial cerebrospinal final fluid (aCSF); inserting cooled aCSF through a lumbar puncture needle; flowing the cooled pressurized aCSF into a lumbar sac; and exiting the aCSF from the cisterna magna at the base of a patient's brain with an exit through the neck of the patient with a specially designed needle/cannula.

6. The method of claim 1 further comprising performing procedures in neurological surgery, radiation therapy, stereotactic surgery, vascular surgery, ultrasound intervention, high energy proton-beam therapy, or other invasive or non-invasive therapy

7. The method of claim 1 further comprising inserting sensors in a sub-arachnoid space of the brain and monitoring brain chemistry using the sensors inserted in the sub-arachnoid space.

8. The method of claim 1 further comprising positioning aCSF drainage burrholes toward the forehead of the skull and facilitating to facilitate aCSF flow through the subarachnoid space by establishing convection cooling with the patient supine, facing upward to cause a differential between cooler fluid in the occipital area brain closer to the cisterna magna and the warmer fluid rising toward the forehead, resulting in a more efficient and rapid flow of aCSF out of the skull and a more rapid cooling effect.

9. An apparatus comprising: a needle having a tip for puncture through a patient's skin; and a phased array of ultrasound elements for generating an ultrasound image, the phased array being disposed in the tip of the needle, or being disposed externally to the tip of the needle to generate one or multiple planes of spatial viewing.

10. The apparatus of claim 9 to prevent injury to the brain by movement of the sharp needle tip, where the tip of the needle has a sharp cutting shape for entry into a patient's cisterna magna and where the tip of the needle is composed of a shape-shifting alloy to respond to a change in temperature when cooled aCSF enters the needle resulting in a change of shape to a dull edge and blunt tip to avoid injuring brain tissue proximate to the cisterna magna.

11. The apparatus of claim 10 to prevent brain injury by the high flow of aCSF where the tip of the needle has a sharp cutting shape and where the tip of the needle is composed of a shape-shifting alloy to respond to a change in temperature when cooled aCSF enters the needle resulting in a change of shape to a shape that allows for a gentle dispersion of the aCSF instead of a forcefully directed flow of fluid which may injure the cisterna magna and the proximate brain tissue.

12. The apparatus of claim 9 to simplify rapid insertion by a single person further comprising: a semi-autonomous unit with a micro-controller with artificial intelligence; an ultrasound imaging system in a lightweight hand-held monitor with audio capabilities communicated to the phased array in the tip of the needle to generate an image of all tissues from a skin surface down to a target tissue; and a servo-controlled motorized inserter controlled by the ultrasound imaging system to guide the needle into the cisterna magna using the ultrasound image data.

13. The apparatus of claim 9 further comprising: a cannula disposed in the needle tip, and an ultrasound imaging system in a lightweight hand-held monitor with audio capabilities communicated to the phased array in the tip of the needle to generate an image of all tissues from a skin surface down to a target tissue; and where the phased array of ultrasound elements is disposed in the cannula, and further comprising a semi-autonomous or robotic unit communicated with the ultrasound imaging system to direct the phased array cannula into arterial circulation of an exsanguinated patient's femoral artery for rapid and accurate placement into a femoral artery where the cannula assists in selective balloon tamponade of aortic circulation or its branches.

14. An apparatus comprising a trephine unit with a hollow screw acting as a conduit from outside a patient's head to the subarachnoid space within the skull, the screw including a central trocar with a cutting tip that, when removed, defines a cone-shaped space within the hollow screw.

15. The apparatus of claim 14 to give stability and a fixation platform where the screw is fixed to a stationary position relative to the patient's head thereby precisely and stably fixing the relative position of an axis of the conduit.

16. The apparatus of claim 14 employed to provide stability and fixation for the cisterna magna perfusion by providing multiple fixation points as well as the external auditory canals, further comprising a band at the back of a patient's head, and a plurality of screws, where the screws are points of immobilization of the front of the band providing further stability to a cannula when within the patient's cisterna magna.

17. The apparatus of claim 14 to achieve rapid and safe entry and re-entry in the case of stereotactic surgery, further comprising an ultrasound guided semi-autonomous or robotic trephine unit combined with the ultrasound imaging system and used to allow the needle to enter the skull and safely and rapidly enter a patient's subarachnoid space through an incision in a patient's skin and a burr hole penetrating in the skull.

18. The apparatus of claim 9 with the phased array of ultrasound elements within the needle tip, to locate, biopsy and treat glioblastoma or other brain systemic tumors, where the phased array of ultrasound elements generates energy for therapeutic mediation of tissue and where the ultrasound imaging system identifies specific tissue characteristics of solid tumors in contrast to normal tissue located in the brain or elsewhere in a patient's body.

19. The apparatus of claim 9 to localize, diagnose, and treat tumors elsewhere in the body including breast, liver, pancreas, and other tumors, further comprising an exoskeleton disposable on an operating location of a patient's body and an ultrasound guided semi-autonomous trephine and/or unit used to allow the needle to be precisely and stably fixed relative to the exoskeleton at the operating location, when guiding the needle's entry.

20. The apparatus of claim 19 where the shape of the exoskeleton is defined using three-dimensional surface scanning of the operating location so that the exoskeleton firmly and precisely fits the operating location with minimal movement relative to the operating location for precise and stable fixation of the trephine unit and/or the needle unit to enable precise targeting and entry of a tumor to within 1 mm proximity, to diagnose and treat the tumor with ultrasound energy, to administer therapeutic medication to the tumor, and/or to monitor any effect of the medication on the tumor and on surrounding normal tissue.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

[0018] FIG. 1 is a simplified side cross sectional diagram of a human head showing the elements of the cooling system with a pump and cooler administering artificial CSF (aCSF) through a fixated needle in the cisterna magna, circulating the cooled aCSF through the basal cisterns, through the subarachnoid space about the cranium, and drainage to a sterile container.

[0019] FIG. 2 is a simplified side cross sectional diagram of a human head showing recycling of aCSF from the exit port in the skull to a pump, filter, and cooling system, and then re-entering the subarachnoid space through the fixated needle in the cisterna magna.

[0020] FIG. 3 is a simplified side cross sectional diagram of a human head showing the specially designed unit, a semi-autonomous trephine, placed into the skull and into the subarachnoid space, for the purpose of exiting aCSF after it has circulated throughout the subarachnoid space. It also includes a temperature sensor and a pressure monitor.

[0021] FIG. 4 is a diagram of the prosthesis used in prior art surgical repair of a dissecting aortic aneurysm in Marfan's Syndrome with current technology that requires the use of deep hypothermia to prevent brain death, demonstrating that “suspended animation” by cooling the brain has been successfully used since 1975 throughout the world.

[0022] FIG. 5 is a simplified side cross sectional diagram of a human head that illustrates a new technique used to enter the cisterna magna from a lateral approach, which was first reported in 2018 using a different approach, which new technique has the advantage of being adjacent to the mastoid bone for locating and fixating the needle to a bony anatomical location.

[0023] FIG. 6 is a simplified side cross sectional diagram of a human body showing an approach to cool the spinal cord by inserting needles into the cisterna magna and into the subarachnoid space of the spinal canal through a lumbar puncture. By circulating cooled aCSF into the cisternal magna and directing it out the lumbar puncture, a pump/cooling system will direct flow of aCSF down the spinal canal. Depending on the situation, cooled aCSF can be directed into the lumbar puncture needle and exit from the cisterna magna needle.

[0024] FIG. 7 is a simplified side cross sectional diagram of a human body illustrating a method to cool both the brain and the spinal cord by using the entry point of cooled aCSF in the cisterna magna and directing flow out both the exit port in the skull and the lumbar puncture below.

[0025] FIG. 8 is a simplified side cross sectional diagram of a human head illustrating the advantage of using convection cooling to more rapidly cool the brain when the patient is lying supine with cool CSF below and warmer CSF above resulting in an additional “motor” effect causing the brain to cool even faster.

[0026] FIG. 9 is a diagram of the components of a phased array ultrasound device within a 2 mm diameter cannula (within a 17-gauge needle) comprised of the needle, an electronic interface unit, and a portable handheld monitor.

[0027] FIG. 10 is a diagram of the transmitting and receiving end of the ultrasound device of FIG. 9 illustrating the use of 64 or more elements in the phased array imaging, a field of view of up to 30 degrees or more, and penetration of up to 2.5 cm.

[0028] FIG. 11 is a perspective view of the terminal end of the ultrasound needle at different times, illustrating the concept of using temperature sensitive alloys such as Nitinol. After penetration by the needle into the cisterna magna, the cooled aCSF entering the needle will cause it to change its shape making the cutting edge dull with blunting of the pointed tip. In addition, the temperature sensitive alloy can reshape the tip to allow flow of aCSF to create less turbulence and direct streaming on neurological tissue.

[0029] FIG. 12 is a simplified side cross sectional diagram of a human head illustrating a “skull cap” which will fit like an exoskeleton to give fixation and stability to the ultrasound needle unit.

[0030] FIG. 13 is a simplified side cross sectional diagram of a human head illustrating the use of a band from the forehead to the upper cervical spine which provides a semi-rigid unit to give support and fixation to the needle. It will be sturdy enough to allow attachment to a servomotor system described in FIG. 14. The fixation anteriorly provided by the screw in the trephine is fixated in the frontal bone. The fixation point posteriorly acts a firmly fitting exoskeleton like a “skull cap” or similar device over the head and upper neck to give stability and precision to the ultrasound needle to enter the neck and into the cisterna magna.

[0031] FIG. 14 is a diagram of a system that semi-autonomously or robotically can insert the phased array ultrasound needle into the cisterna magna or femoral artery described in FIG. 15. Once the needle is put into proper position, the information from the phased array ultrasound needle is sent to the microprocessor/artificial intelligence unit and then to the servomotors which control the insertion of the needle to the target site. This requires a fixation unit that is sturdy and stable as shown in FIG. 13.

[0032] FIG. 15 is a simplified front cross sectional diagram of the femoral artery target site and the associated anatomy for localization of the needle entry.

[0033] FIG. 16 is a diagram of the aorta showing the trajectory of a phased array ultrasound cannula as it enters the aorta from the femoral artery. With a 30 degrees range of view and a penetration of up to 2.5 cm, a balloon tamponade of the aorta is made more precise and performed quickly.

[0034] FIG. 17 is a series of side plan view, and two side cross sectional views of a hollow trephine screw with a central trocar, which when removed will leave a cone-shaped tunnel for exact placement of the ultrasound probe into the subarachnoid space safely, precisely, and with good fixation. Once in place, this trephine screw allows for removal of cerebrospinal fluid from the subarachnoid space.

[0035] FIG. 18 is an enlarged view illustrating the trephine device unit that houses four or more transducers to give ultrasound information to the microcontroller that semi-autonomously controls the servomotor to direct the screw through the skull to fixate it firmly to the bone and to stop it once it enters the subarachnoid space.

[0036] FIG. 19 is a simplified side cross sectional diagram of a human head which illustrate the device of FIG. 10, namely an ultrasound needle including a 2 mm inside diameter needle with 64 or more elements which can characterize the tissue characteristics of a tumor in contrast to normal tissue. The instrumented ultrasound needle gives information to image, to direct the semi-autonomous or robotic insertion of the needle, and to treat a glioblastoma tumor. The ultrasound transducers generate energy at the tip of the needle in proximity of the tumor. After pretreatment of the tumor, the same needle allows for the administration of microliters of various treatment modalities. Following administration of medication, the ultrasound needle tip images the tissue to determine the location of the treatment effect in relation to normal brain tissue.

[0037] FIG. 20 is a side cross sectional view of an insertion site in the human skull illustrating a combination of the devices of FIGS. 14 and 18 which includes the trephine unit with the ultrasound needle unit to carefully direct the needle into the subarachnoid space and fixate it in position for tissue diagnosis, to map the brain tissue, and to develop a trajectory of the ultrasound needle into the brain.

[0038] FIG. 21 is a side cross sectional diagram of an ultrasound needle having a diameter of 2 mm and fitting within a 3 to 4 mm hollow cone space within the surrounding screw, providing sufficient freedom to precisely place the ultrasound needle using the semi-autonomous or robotic system with high precision.

[0039] FIG. 22 is a diagram of a perspective view of a human body illustrating how an exoskeleton can be used to treat solid tumors elsewhere in the body. From laser scanning data or from other imaging data such as MRI or CT scanning, a 3-dimensional printing of an exoskeleton can be expeditiously produced to fit firmly and precisely with minimal movement. This will give solid infrastructure for fixation of the trephine and/or the ultrasound needle unit to precisely enter the body and target a tumor to within 1 mm proximity to the tumor to diagnose and treat with ultrasound energy and to administer therapeutic medication to the tumor with great precision and monitoring of the effect on the tumor and the surrounding normal tissue.

[0040] FIG. 23 is a diagram of a side cross sectional view of the use of the exoskeleton on a human breast to give stability and precision to the semi-autonomous or robotic unit to direct the ultrasound needle to within 1 mm of the tumor of the breast, where it can diagnose, delineate, and treat the tumor with minimal injury to the normal tissue.

[0041] FIG. 24 is a sagittal view of the decapitated head and neck of a pig used in an animal study. This CT scan confirms the location of the cisterna magna needle and the location of the thermistors denoted by the white arrows.

[0042] FIG. 25 is a graph of the measured temperature verses time in the porcine experiment depicted in FIG. 24.

[0043] The disclosure and its various embodiments can now be better understood by turning to the following detailed description of the preferred embodiments which are presented as illustrated examples of the embodiments defined in the claims. It is expressly understood that the embodiments as defined by the claims may be broader than the illustrated embodiments described below.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0044] Animal Studies:

[0045] The cisterna magna, located at the base of the brain, was chosen to be the entry point for the cooling devices duc to ineffective previous attempts to cool the brain via a lumbar puncture. Entering through the spinal canal resulted in a rise in temperature of the aCSF due to the warmth of the circulating vessels in the spinal canal. By entering the largest cistern, the cisterna magna, a 17-gauge needle can be placed into the subarachnoid space and used to circulate cooled saline out through a vent in the forehead. Using this methodology, initial work on more than 50 recently deceased pigs provided promising results and encouraged testing in vivo.

[0046] To test in vivo, our approach was combined with thermistors, placed at various depths (5 mm increments) in the brain to monitor the temperature of the tissue and therefore the effects of the circulating cooled aCSF as depicted in the CT scan in FIG. 24. Brain temperature collected during the in vivo experiment demonstrated that cooling the brain can be accomplished within a large animal model under general anesthesia with warm blood flowing into the brain. Furthermore, once the specimen was terminated with euthasol at 15:35, the brain temperature was monitored with no blood flow. The graph of FIG. 25 demonstrates that termination of inflow of warm blood from the heart results in additional cooling of the brain. These results are consistent with our hypothesis that it is imperative to consider the warm gradient of incoming blood when attempting to cool the brain with cooled aCSF. FIG. 25 is a graph of data collected from four implanted thermistors monitoring the brain temperature of a porcine model under general anesthesia and our proposed methodology of inducing hypothermia. Each thermistor is placed within the cortex at four different depths of the brain from the surface at 5 mm increments. The horizontal bars indicate the pump speed in mL/min. Within the first 10 minutes, the temperature drops to 15° C. After terminating the specimen at 15:35, the temperature continued to decrease until the experiment was concluded.

[0047] Contrarily, this radical system is designed for extreme cases of emergency, specifically targeting patients who are experiencing shock or have little to no blood flow to the brain. These cases would be more advantageous as there would be minimal heat from the circulating blood making cooling the brain even easier and therefore maximize the time for intervention.

[0048] Results from our in vivo studies give support to our approach of cooling the brain by cooling the CSF directly and allow convection cooling to increase the cooling effect in the subarachnoid space adjacent to the cortex where the neurons are located. Moreover, since the CSF flow from the cisterna magna starts at the base of the brain, cooling of the memory circuitry is cooled early. Since the vertebrobasilar circulation is adjacent to the cisterna magna, there will be cooling of the circulating blood without cannulating any blood vessel, resulting in additional cooling of deep structures.

[0049] We have demonstrated in our live animal studies the efficacy of the cooling system as shown ill FIG. 1. The most important caveat is that once the needle is inserted, it must be immobilized immediately in order to prevent repositioning of the ultrasound needle 3 outside of the cisterna magna 1. The aCSF is refrigerated in the cooler 7 to a temperature in the range of 1 to 10° C., carried by the pump 8, through a filter 9 and into the needle 3 in the cisterna magna 1. The flow of cooled aCSF throughout the subarachnoid space 2 is very effective in cooling the brain at several levels, especially at the cortical surface where the more vulnerable neurons of the gray matter reside. In older adult patients, the subarachnoid space 2 is more capacious for there is natural shrinkage of the brain with age, resulting in more rapid exposure of the brain to the cooling effect with a larger volume of aCSF in circulation. The cooled aCSF in the cisterna magna 1 is near the basilar artery and the circulation of the Circle of Willis, which will have an additional cooling effect upon central structures, especially to areas of the brain that subserve memory. Note that the cooling system may initially be chemical cooling, which is a more simplified and effective method in emergency situations. Moreover, if the treatment is not necessarily to cool the brain but to change the temperature to a warmer state, a cooler and/or a warmer may be utilized in a similar system to result in the proper temperature for the irrigant. Thermistors are provided to monitor temperature within the subarachnoid space 2 at the exit of aCSF 5 in the frontal skull through the trephine 4 and at the entrance into the cisterna magna 1. An intracranial pressure manometer monitors intracranial pressure.

[0050] The disclosed apparatus and method provide a successful and safe way to rapidly cool the brain to prevent brain death by using deep hypothermia. A needle 3 is placed into the cisterna magna 1 safely, rapidly, and accurately to circulate cold artificial cerebrospinal fluid (or other isotonic solution) into the intracranial and subarachnoid space 2. By lowering the temperature of the artificial cerebrospinal fluid (aCSF) and circulating it around the blood vessels of the basal cisterns, the circulation of the brain will be cooled. Once the cooled aCSF reaches the subarachnoid space 2 especially in the back of the brain by a computer-controlled peristaltic pump, convection cooling will begin, for an exit will be made through the frontal bone for egress of the warmer fluid. The exiting aCSF will then be sterilely collected as illustrated in FIG. 1.

[0051] Alternatively, it will be cooled and filtered outside the body and recirculated as shown in FIG. 2 back into the inserted needle 3 which will be securely placed into the cisterna magna 1. In FIG. 2 recycling of aCSF 10 from the exit port in the skull to a pump requires a filtering system 9 to remove infectious agents and debris from the aCSF before it re-enters the cisterna magna 1. Recycling aCSF 10 in a sterile environment has many advantages: it is easier to maintain a sterile environment; cooling is more efficacious; less aCSF is necessary to carry in an emergency; efficiency of space and of supplies may result. The inserted needle 3 will be fixated to a stable structure as described in FIGS. 12 and 13 of the head and neck to prevent movement of the needle tip within the cisterna magna 1.

[0052] FIG. 12 illustrates one configuration of a method to fixate the needle tip after entry into the cisterna magna 1 including the use of an exoskeleton 24 placed over the posterior head and neck to give fixation, stability, and precision to the proper insertion of the ultrasound needle into the cisterna magna 1. The mastoid bones and/or the external auditory canals will be the posterior points of fixation while the trephine screw in the frontal bone will be the anterior point of fixation. A “skull cap” will fit like an exoskeleton 24 to give fixation and stability to the ultrasound needle.

[0053] FIG. 13 represents a second embodiment to fixate the needle after entry into the cisterna magna 1. It includes the use of a firm band placed around the forehead at the trephine which is firmly screwed into the frontal bone 25 and going around the upper cervical spine without causing compression injury to the ears. The external auditory canals will serve as reference points for locating the band in the proper plane. It gives stable fixation to the needle as it enters the cisterna magna 1. Moreover, if a servomotor system is used to semi-autonomously or robotically direct and move the needle into the cisterna magna 1, it will require a stable and fixed base from which it will direct the needle such as the “skull cap” exoskeleton 24 as described in FIG. 12.

[0054] This circulation of cooled aCSF in the subarachnoid space rapidly cools the entire brain including the structures at the base of the brain as well as the grey matter on the outer surface of the brain.

[0055] In FIG. 3 a single opening in the skull is planned in order to exit circulating aCSF from the subarachnoid space 2, and if the patient is lying supine it is best to place that opening toward the frontal lobe in order to take advantage of convection cooling as shown in FIG. 8. A semi-autonomous or robotic trephine 4 with a hollow screw serves to evacuate the fluid in FIG. 18. Through the same opening a temperature sensor 11 gives feedback about depth of cooling, efficacy of cooling, and rate of cooling. A pressure sensor (not shown) will also be necessary to prevent brain damage with too high a pressure during administration of aCSF. Knowing the temperature of fluid entering the cisterna magna 1 and leaving the exit point 4 as well as flow rate will give rate of cooling as well as efficacy of cooling. FIG. 8 explains the additive effect of convection cooling 13 to the pumping action on aCSF after it enters the cisterna magna 1 and settles in the occipital region of the head with the patient lying supine. With cool CSF in the occipital region below and relatively warmer CSF toward the frontal lobe above, convection cooling will occur with the warmer fluid being evacuated to drainage.

[0056] Thus, the disclosed apparatus and method successfully produce deep hypothermia of the brain safely and rapidly. In addition, this method will also be effective in cooling the spinal cord as described in FIG. 6 rapidly and safely to prevent swelling of the spinal cord after trauma or to protect the cord against ischemic injury: redirecting the flow of cooled aCSF from the cisterna magna 1 down to the lumbar area by venting through a lumbar puncture needle 14 results in cooling of the spinal cord.

[0057] Cardiac arrest, stroke, and exsanguination can result in brain death in five minutes unless the brain can be placed into suspended animation rapidly, giving the treating physician up to one hour or longer to save the life of the patient, which is provided by the apparatus and method of the disclosure.

[0058] The disclosed apparatus includes an ultrasound guided needle 3 as described in FIGS. 9 and 10 with multiple elements configured to give a 3-dimensional ultrasound image in front of the entering needle. The image and ultrasound feedback are displayed on a video monitor similar in size to a cell phone, making it possible for a paramedic to enter the cisterna magna 1 of the brain rapidly and safely. In addition, the tip of needle 3 includes a temperature sensitive alloy as shown in FIG. 11 to reshape it to prevent cutting brain tissue and to facilitate gentle flow of aCSF through the needle 3. A similarly designed needle 3 facilitates entry semi-autonomously into arteries and other vessels in the body, such as the femoral artery when rapid and safe entry is needed in an emergency.

[0059] To rapidly cool the brain to prevent brain death by using deep hypothermia, it is crucial that a needle 3 be designed to be placed into the cisterna magna 1 safely, rapidly, and accurately to circulate cooled artificial cerebrospinal fluid or other isotonic solution into the intracranial and subarachnoid space 2.

[0060] FIG. 5 illustrates a new approach from the lateral side of the neck just below the mastoid bone 12. Gong et al. (J Neurosurg 129: 146-152, 2018) describe a Lateral Atlanto-occipital Space Puncture on 1,008 punctures in which 98.3% were successful. This has the advantages of rapid insertion, proximity to the mastoid bone for fixation, and high success rate of insertion. Currently, this procedure is performed by neurological surgeons and neuro-radiologists using fluoroscopy which is not always available in the field, the emergency room, or the operating room. Moreover, mistakes can occur under the stress of emergency situations, and the sharp needle tip poses a hazard to the brain while in the cisterna magna for a prolonged period. Therefore, there is obvious need for new technology to enter the cisterna magna 1. This is addressed in this disclosure.

[0061] The lateral neck below the mastoid bone may be easier for the paramedic or nurse to locate and access. It is easily identified as the bony prominence behind the ear as shown in FIG. 5, it usually does not have to be shaved of hair, it is a stationary point of fixation, and immobilization of the needle 3 can be done quickly and easily. Insertion of the ultrasound guided needle 3 gives directional images on the handheld unit like a cellphone with visual and audio information displayed in real time as shown in FIG. 9. Semi-autonomous or robotic insertion is also described. The data obtained from the tip of the ultrasound needle 3 directs the tip of the unit to its trajectory.

[0062] Spinal Cooling

[0063] FIG. 6 shows a new approach to treating and/or preserving the spinal cord when subjected to direct trauma, blunt trauma, concussive injuries, ischemic trauma, explosive exposure, and surgical intervention that may jeopardize the circulation to the spinal cord. Sending cooled aCSF into the cisterna magna 1 and directing the flow 15 of aCSF down the spinal canal results in venting through a lumbar puncture needle 14. Similar to cooling the brain, cooling the spinal cord can be done by pumping aCSF into the cisterna magna 1 and venting to a drainage bottle. Recycling the aCSF from the lumbar puncture needle 14 back to the cisterna magna 1 by using a pump, filter, and cooler in series emulates the technique for brain cooling. Depending on fluid dynamics and location on the spinal cord that needs to be cooled, cooling can be initiated through the lumbar puncture needle 14 and vented above through the cisterna magna 1.

[0064] FIG. 7 relates to situations when both the brain and spinal cord needs to be cooled simultaneously. Such cases may include extensive dissecting of aortic aneurysms, explosive and concussive trauma, and other exposure to trauma such as radiation exposure. By cooling from the cisterna magna 1, both the brain and spinal cord can be cooled at the same time by draining cooled aCSF from vents in the head and the lumbar puncture sites.

[0065] Prevention of the Sharp Needle Tip from Cutting the Brain

[0066] To prevent the sharp tip of the needle 3 from puncturing or lacerating the cisterna magna 1 or other neurological tissues in the brainstem, spinal cord, and brain, the tip of needle 3 is made of a shape-memory alloy that changes it shape when the temperature changes to a predetermined range as shown in FIG. 11. In addition to removing the sharpness of the needle tip, the outlet can be reshaped to maximize the outflow of the cooled aCSF while ameliorating flow patterns that may injure the adjoining neurological tissue. Nitinol is one shape-shifting alloy that was developed by the U.S. Navy and stands for nickel titanium alloy, and it has thermal memory.

[0067] FIG. 11 illustrates the concept of using temperature sensitive alloys such as Nitinol at the cutting tip of the needle. After penetration oldie sharp pointed needle 21 into the cisterna magna 1, the shaft of the needle must be securely fixated at that determined location. The cannula is removed and cooled aCSF is administered through the needle shaft, causing the cutting tip to reshape into a blunted tip 22 with no sharp edges. If the pump is raised to a higher volume given rapidly, it is important to design a new shape for the end of the needle shaft to create gentle dispersion of the aCSF as it enters the cisterna magna 1. It may require a flared tip 23 or other shape as determined by computer simulation and modeling.

[0068] In the case of using a similarly designed needle 3 for rapid entry into a large vessel such as the femoral artery, the phased array cannula 19 within the tip of needle 3 delineates the various tissues until the needle 3 enters the artery, while the paramedic uses the handheld video and audio unit as depicted in FIG. 9 to rapidly guide the tip and the needle 3 into the vessel. FIG. 15 illustrates the femoral artery 28 target site and the various tissues and vessels that may cause confusion on insertion. The semi-autonomous unit 26 is fixated to anatomic structures that will give stability and fixation for insertion of the needle into the femoral artery 28. If there is confusion regarding differentiating the artery from the vein, a Doppler signal tells the difference. Once the needle tip 3 is in the artery, if it needs to be there for any extended time, the temperature-sensitive alloy tip 3 changes shape at a higher temperature of arterial blood to blunt any sharp surfaces to prevent damage to the artery as suggested by FIG. 1I. The phased array cannula 16 is extended up the aorta to identify the circulation of the surrounding abdominal tissue as well as the vessels to structures such as the kidney, spleen, pancreas, liver, heart, and other organs as depicted by FIG. 16. The phased array elements have a field of view of 30 degrees, can penetrate forward for up to 2.5 cm, and have real time 3-D imaging as shown in FIG. 10. FIG. 16 shows the trajectory of a phased array ultrasound cannula as it enters the aorta from the femoral artery 28. The cannula has a 30 degree of range of view as well as penetration up to 2.5 cm, giving it a 3-dimensional real-time image of the vascular branches off the aorta. If there is life threatening exsanguination, balloon tamponade 29 of the aorta will be more precise and more quickly performed.

[0069] FIG. 10 demonstrates the effective 3-dimensional space in front of the 64-or-greater elements within a 2 mm inside diameter cannula configured to do phase array imaging. Ultrasound data can cover a field of view of 30 degrees and a depth of penetration of up to 2.5 cm 20. The use of phased array using multiple ultrasound elements is utilized throughout the medical industry. Volcano Corporation Systems images with a catheter ultrasound system has the Angio+™ Quantitative Coronary Analysis which automatically calculates lumen dimensions and stenosis in real time. Interson Corporation has commercially produced a small transducer system with commercially available hardware, using its own built-in electronics to apply to cardiac disease.

[0070] Motorized Insertion of Needle

[0071] Semi-autonomous or robotic technology has been in general practice for decades and is used in the navigation of self-driving cars, etc. Based on radar, camera data, and GPS information the “self-driving” car uses artificial intelligence to program the car to maneuver its way from home to work safely. Similarly, we utilize 3-dimensional ultrasound information from the tip of the needle to use artificial intelligence to program the servomotors to direct the needle to safely travel through the skin, fat, muscles, tendons, and blood vessels on its way to the cisterna magna. Once in the cisterna magna, the needle automatically locks in place to prevent damage to neurological tissue. This requires expert software development all of which has been done in other industries. The novelty of this invention is the application of a custom developed software to enable semi-autonomous or robotic insertion of the needle with several orders of magnitude greater precision than a self-driving car, in the order of a fraction of an mm within the target site.

[0072] As disclosed in Mathiassen et. al. “Visual Servoing of a Medical Ultrasound Probe for Needle Insertion,” 2016 IEEE International Conference on Robotics and Automation (16-21 May 2016), percutaneous needle insertion guided by ultrasound imaging is routinely performed in hospitals. Automating these procedures increases placement accuracy and lowers time usage of health care personnel to perform these procedures. An important step in the automation is the estimation of the needle orientation and position in the ultrasound image. One approach to estimate the needle orientation and position is to have the needle aligned with the image plane of the ultrasound probe. Aligning the needle with the plane is difficult, even with accurate measurements and calibration of both needle and probe. Visual servoing to move the ultrasound probe is performed using a robot to align the image plane of the probe with the needle, which solves the problem of needle alignment. The method segments the needle and updates a set of visual features based on a model of the needle. A state machine is used to keep track of the alignment process, and different visual features are used to control the probe in the different states.

[0073] The methods, algorithms, and apparatuses of using images collected from cameras to guide the steering, braking, and accelerating a vehicle exist in the field. For example, see “Autonomous Driving Control Device,” U.S. Pat. Appl. 15/413,568 and “Control Arrangement Arranged To Control An Autonomous Vehicle, Autonomous Drive Arrangement, Vehicle And Method” U.S. Pat. No. 9,566,983, both incorporated herein by reference. In our technology, instead of using images from cameras, we use images from our ultrasound probe. Instead of controlling the movement of a car, we control the movement of the probe. Overall, the concept and approach are similar. The algorithms will be different to accommodate the use of a different kind of image and the control of a different kind of actuation mechanisms. The means to make these adjustments are well within the ordinary skill in the art. There have been numerous patents issued on using ultrasound images as feedbacks to control a medical device. In particular, “Feedback in Medical Ultrasound Imaging for High Intensity Focused Ultrasound” U.S. Pat. No. 8,343,050, incorporated herein by reference, describes the use of ultrasound imaging to detect and monitor the small change in tumorous tissues as a result of applying high-intensity focused ultrasound (HIFU) to the tissues. The image is used as a feedback to control the focal point, intensity, and duration of the HIFU. In our case, we are using the same ultrasound imaging technique as a feedback to control the movement of the probe. The algorithm is adapted to control the servo motor instead of the HIFU. The basic principles and approach are the same.

[0074] A motorized inserter for the needle 3 to enter the cisterna magna 1 requires a micro-controller 38 with artificial intelligence to control a servomotor 39. Servomotor 39 is a rotary actuator or linear actuator that allows for precise control of angular or linear position, velocity, and acceleration. It is comprised of a suitable motor coupled to a sensor for position feedback as illustrated in FIG. 14. FIG. 14 depicts a system 26 that semi-autonomously or robotically inserts the needle 3 which is equipped with a phased array ultrasound cannula with an ultrasound data feedback unit 37 to the micro-controller 38 and micro-controller directed servomotor 39. Once the medical specialist sets the trajectory for the needle 3 on its way to the target, the cisterna magna 1, the ultrasound data feedback unit 37 directs the servomotor 39 in real time to insert needle 3. It is firmly attached to a fixation device on a site such as a “skull cap” in the shape of an exoskeleton 24 or similar device as described in FIGS. 12 and 13 and which depends on information from the ultrasound data feedback unit 37 obtained from the phased array ultrasound system 16 as depicted in FIGS. 9 and 10. Rapid, accurate, and safe insertion of the needle 3 into the cisterna magna 1 in an emergency will be facilitated by servomotor inserter 26. FIG. 9 shows the device used to direct the needle through the skin to the cisterna magna 1 by using known technology in a unique adaptation at the tip of a needle. By using a 2 mm diameter cannula within a cutting needle (17-gauge needle) 16, 64 or more ultrasound elements 19 shown in FIG. 10 are used to create a phased array ultrasound imaging field 20. By using raster graphics, a three-dimensional image is presented on a handheld portable monitor 18 in real time. An interface unit 17 converts the ultrasound data into imaging information to be displayed. Both visual and auditory feedback provided by monitor 18 aid in the insertion of the needle into the cisterna magna 1. Moreover, the shape of the cisterna magna 1 can be delineated for greater ease and accuracy of insertion. Once the needle 3 is fixated to a stationary site as described in greater detail below in relation to FIGS. 12 and 13, the cannula 16 is removed from the cisterna magna 1 to allow for administration of cooled aCSF. In the situation of insertion of the phased array needle into the femoral artery, the cannula 16 can be directed into the aorta for visualizing the many vascular branches in the aorta.

[0075] FIG. 22 shows how an exoskeleton 36 can be used to treat solid tumors elsewhere in the body, such as in the breast. From laser scanning data or from other imaging data such as MRI or CT scanning, 3-dimensional printing of a rigid exoskeleton can be expeditiously produced to fit the entry or operating site firmly and precisely with minimal movement. This will give solid structure for fixation of the trephine unit 33 and/or the ultrasound needle 3 to precisely enter the body and target tumor 34 to within 1 mm proximity of the tumor 34 to diagnose and treat with ultrasound energy and to administer therapeutic medication to the tumor 34 with precision and monitoring of its effect on the tumor and the surrounding normal tissue.

[0076] FIG. 23 shows the use of the exoskeleton 36 of FIG. 22 as tightly fixed to the breast to give stability and precision. The ultrasound needle 3 is then accurately directed to the tumor 34 within 1 mm to diagnose the tissue and to give treatment to the tumor 34 precisely without damage to the surrounding normal tissue.

[0077] In the case of insertion of a needle 3 into the femoral artery, a phased array ultrasound system will give anatomic information to facilitate the identification of the femoral artery in distinction to a femoral vein. Moreover, if the pulse of the femoral artery cannot be felt, then the anatomic information from the ultrasound system will better locate the femoral artery. A semi-autonomous ultrasound needle unit 14 to be inserted into the femoral artery also requires fixation of the unit as shown in FIG. 15, in this case to the inguinal ligament and/or bony protuberances in the configuration of an exoskeleton.

[0078] Method and Device to Create a Safe and Rapid Insertion of a Trephine through the Skull:

[0079] In order to create an exit point in the forehead for cooled fluid to leave the subarachnoid space 2 during irrigation of aCSF to cool the brain, trephining of the hone in the skull must be accomplished safely, quickly, bloodlessly, and with precision by a single health care person. The unit must be self-contained including transducers and a semi-autonomous or robotic motorized insertion device as described in “Method of Insertion of the Needle” 26 in a “box” which will be attached to the area of the frontal bone. The “screw” 30 includes a hollow shaft within a 3 to 4 mm inside diameter screw with a trocar 31 which is carefully screwed into the cranial bone. Information received from the transducers within the device 26 control the semi-autonomous or robotic insertion of the screw 30 through the bone and safely into the subarachnoid space 2. FIG. 17 shows a hollow trephine screw 30 with a central trocar 31, which when removed leaves a cone-shaped tunnel 32 for exact placement into the subarachnoid space 2 safely, precisely, and with good fixation. Once in place, this trephine screw 30 allows for removal of cerebrospinal fluid from the subarachnoid space.

[0080] The insertion method for the semi-autonomous trephine unit includes the following: after choosing the point of entry, usually in the upper forehead near the hair line, an incision is made with a scalpel along the line of Kraissl in the natural skin fold from the skin down to the subcutaneous tissues overlying the frontal bone. Sterility is maintained, anesthesia with a vasoconstrictor is injected into the skin, and the length of the incision is between 1.0- and 1.5-mm. Insertion of self-retaining retractors are placed into the wound to give stability and hemostasis. The box unit 26 and the screw 30 are inserted into this opening and fixated to the retractors. The semi-autonomous or robotic insertion is activated and carefully directed through the bone into the subarachnoid space 2. The ultrasound data is obtained from four or more transducers 40 within the trephine “box” attached to the scalp. The micro-controller 38 with artificial intelligence directs the servomotor 39 which in turn screws the trephine into the skull. The final configuration is very stable and mobilized by the screw in the frontal bone as depicted in FIG. 18.

[0081] The screw 30 in the frontal bone is rigidly attached, quite stable, and well fixated. It serves as one point upon which a headband is taken to the back of the head and attached to two or three points posteriorly to give greater stability during insertion of the ultrasound needle into the cistern magna as depicted in FIG. 13.

[0082] At the conclusion of the procedure, removal of the screw 30 can be done with local anesthesia, bone wax, if needed, placed into the small 3 to 4 mm opening, and a single suture placed across the skin. Since the incision is made in the line of Kraissl, there is minimal scarring, with the incision being in the natural skin fold.

[0083] In addition, for its central role in cooling the brain by creating an exit port, the disclosed method and device can be used in other brain operations including surgery for epidural hematoma, surgery for subdural hematoma, and for stereotactic intracranial surgery.

[0084] Hence an approach to the treatment of intracranial brain tumors, especially glioblastoma, is presented here combining the ultrasound needle 3 with the trephine 33. FIG. 18 shows the trephine device unit 33 that houses four or more transducers to give ultrasound information to a semi-autonomous or robotic controlled servomotor to direct the screw through the skull to fixate it firmly to the bone and to stop it once it enters the subarachnoid space 2.

[0085] A Novel Approach to the Diagnosis, Localization, and Management of Glioblastoma:

[0086] Glioblastoma, the most common intrinsic brain cancer, defies early diagnosis and treatment. From diagnosis with conventional imaging and brain biopsy to inevitable death of the patient within 4 to 16 months, these patients frequently undergo neurosurgery, radiation, and chemotherapy with little hope for a cure. We have the technology and expertise to accomplish characterization and diagnosis of disease, perhaps without taking a formal biopsy of the tissue by studying the tissue signature from data using ultrasonography. The disclosed approach is to do minimally invasive insertion of an ultrasound needle into the skull and into the subarachnoid space to scan the brain with a 30-degree field of view and a depth of up to 2.5 cm. Ultrasound data from the needle tip will image the tumor in 3-dimensions, and then be used to semi-autonomously or robotically insert the needle tip to within 1 mm of the target tissue. This requires precision and the development of servo-controlled devices to trephine 33 through the skull and to guide the ultrasound needle 3 to the target tissue.

[0087] The current state of the art for ultrasound imaging of the brain is to use transducers on the scalp and transmit energy through the bony skull. Low frequency transducers have the advantage in transmitting through the tissue of the scalp and bone, but resolution is low. In order to have high resolution imaging at the cellular and/or tissue level, the ultrasound transducer must be closer to the object and have high frequency imaging. This poses a dilemma. Therefore, the ideal ultrasound design would be to have a non-invasive device with penetration to the site of the disease with high frequency transducers. This can be done by making a trephine 33 opening through the bony skull sufficiently small to be minimally invasive, and using an ultrasound unit designed to be placed within the profile of a needle 3. Moreover, the ultrasound needle 3 is inserted into soft tissue of the body using semi-autonomous or robotic motorized systems with precision. Recent basic laboratory research by Sheehan et al. reported positive effects of use of ultrasound radiation to augment the effect of medications on the death of glioblastoma cells in culture (Kimball Sheehan et al. Investigation of tumoricidal effects of sonodynamic therapy in malignant glioblastoma brain tumors. J. Neuro-Oncology. 148, 9-16, 2020).

[0088] What is disclosed above is a use of an ultrasound needle 26 and semi-autonomous or robotic trephine 33 used beyond the initial purpose of cooling the brain in the case of brain death. The basis of this approach is sound, for it utilizes the elements in the tip of the needle 3 used for imaging, to be programmed to generate energy from the same transducers in the tip of the same needle 3. This method for the treatment of glioblastoma of the brain depends on an intimate relationship of the semi-autonomous or robotic ultrasound needle 26 and the semi-autonomous or robotic trephine 33 joining together to form a unique, precision, and stable platform. The design and the characteristics of the ultrasound needle 26 and the trephine 33 have been described above. The application of this technology creates a new approach to the diagnosis, localization, and management of glioblastoma of the brain.

[0089] Moreover, the ultrasound needle includes at least 64 elements within a 2 mm diameter cannula in the tip of the needle has a definition to less than 0.1 mm, with a field of view of 30°, and a depth of up to 2.5 cm. It is capable not only of imaging the shape and size of the tumor, but also is able to render specific tissue characteristics when ultrasound is passed near or within the tumor and through normal tissue. Therefore, tissue diagnosis may be done with ultrasound alone. After the semi-autonomous or robotic insertion of the hollow screw 30 is made down to the level of the subarachnoid space 2, the trocar 31 of the screw 30 is removed and replaced with the ultrasound needle 3 surrounded by its own semi-autonomous or robotic unit 26. These two units act as one and are securely attached, giving extreme accuracy and fixation while the needle 26 is sent deeper within the cranial cavity. FIG. 19 shows the use of the device of FIG. 10, namely an ultrasound needle 3 including a 2 mm inside diameter needle 3 with 64 or more ultrasound elements which characterize the tissue of a tumor in contrast to surrounding normal tissue. The ultrasound elements give information to image, to direct the semi-autonomous or robotic insertion apparatus 26 of the needle 3 through the semi-autonomous or robotic trephine 33, and to treat a glioblastoma tumor 34. The ultrasound transducers generate energy at the tip of the needle 3 in proximity of the tumor 34. After pretreatment of the tumor 34, the same needle 3 will allow for the administration of microliters of various treatment modalities. Following administration of medication, the ultrasound needle 3 can then image the tissue to determine the location of the treatment effect.

[0090] Ultrasound (US) guided biopsy is a medical procedure routinely performed in clinical practice. This task could be performed by robotic systems to improve the precision in the execution and then the safety for the patient. Both robotic and human procedures greatly benefit from real-time localization of the needle in US images. This information guides the robot or the specialists to the correct target point avoiding critical structures. In Mathiassen et. al. “Real Time Biopsy Needle Tip Estimation in 2D Ultrasound Images,” 2013 IEEE International Conference on Robotics and Automation (6-10 May 2013) a needle localization method able to extract the needle orientation and the tip position in real time from B-mode US images is disclosed. The results show an improvement in term of localization accuracy compared to previous works in literature.

[0091] As disclosed in Mathiassen, “Robust Real-Time Needle Tracking in 2-D Ultrasound Images Using Statistical Filtering”, IEEE Transactions on Control Systems Technology, 2017, 25 (3) 966-978, percutaneous image-guided tumor ablation is a minimally invasive surgical procedure for the treatment of malignant tumors using a needle-shaped ablation probe. Automating the insertion of a needle by using a robot increases the accuracy and decreases the execution time of the procedure. Extracting the needle tip position from the ultrasound (US) images verifies that the needle is not approaching any forbidden regions (e.g., major vessels and ribs), and also is used as a direct feedback signal to the robot inserting the needle. A method for estimating the needle tip has previously been developed combining a modified Hough transform, image filters, and machine learning. A method of introducing a dynamic selection of the region of interest in the US images and filtering the tracking results using either a Kalman filter or a particle filter is also known. The results show a significant improvement in precision and more than 85% reduction of 95th percentile of the error compared with the previous automatic approaches. The method runs in real time with a frame rate of 35.4 frames/s. The increased robustness and accuracy make the disclosed algorithm usable in autonomous or robotic surgical systems for needle insertion.

[0092] FIG. 20 is an enlargement of a portion of FIG. 19 showing the insertion site, and illustrates a combination of the devices of FIGS. 17 and 19 including the trephine unit 33 with the ultrasound needle unit 26 to carefully direct the ultrasound needle 3 into the subarachnoid space 2 and fixate it in position for tissue diagnosis, mapping of the brain tissue, and developing a trajectory of the ultrasound needle 3 into the brain.

[0093] FIG. 21 shows how the design allows for precise directional guidance of the ultrasound needle 3 to its target at the glioblastoma tumor 34. Because the ultrasound needle 3 has a diameter of 2 mm and fits within a 3 to 4 mm hollow cone space within the surrounding stabilizing screw 30, precision placement of the ultrasound needle 3 using the semi-autonomous or robotic system 26 is performed with accuracy.

[0094] Since the hollow core within the screw 30 is shaped like a cone, there will be some play of the 2 mm diameter needle within the 3 to 4 mm hollow screw trephine. Therefore, control with the semi-autonomous or robotic motor allows the needle 3 to extend its range to cover a greater area than 30°. Imaging of the tissue immediately in front of the ultrasound needle to a depth of up to 2.5 cm will delineate the shape and size of the tumor. Moreover, because tissue density can be determined with ultrasound it will be possible to diagnose glioblastoma cells from normal tissue. To corroborate the ultrasound diagnosis, it is possible to do a needle biopsy through the needle 3 for confirmation.

[0095] If it is decided to direct the needle 3 deeper into the brain tissue with the semi-autonomous or robotic control and ultrasound information, it can be slowly and precisely placed up to the border of the tumor 34 or even within the tumor 34. The transducers can then be programmed to generate ultrasound energy in front of the needle tip 3 into the tumor 34. The addition of chemotherapeutic agents, immune therapy, or other modality can be given through the needle tip 3 in well-controlled small microliter volumes. The effect of the injection into the tissue can be ascertained by using ultrasound imaging to look for abnormal tissue response. An intracranial pressure gauge (not shown) shows if there is swelling of the tissue causing increased intracranial pressure. If need be, the hypothermia of the brain procedure can then he applied to cool the brain and prevent swelling.

[0096] Semi-Autonomous or Robotic Insertion of the Ultrasound Needle:

[0097] The semi-autonomous or robotic insertion of the needle into the cisterna magna is accomplished by using servo-controlled motors guided by information obtained from the 64 elements within the tip of the needle 3. The information will have a 3-dimensional space with a 30-degree range and a depth of up to 2.5 cm as shown in FIG. 10. Artificial intelligence with self-learning algorithms give machine learning to the micro-controller 38 in the device 26 in FIG. 14. Semi-autonomous or robotic insertion and servo-controlled motors enablement are described under “Motorized Insertion of the Needle.”

[0098] Semi-Autonomous or Robotic Insertion of Screw Trephine:

[0099] The semi-autonomous or robotic insertion of the screw trephine 33 through the skull into the subarachnoid space will use a servo-controlled motor (not shown) guided by information obtained from four or more transducers in the unit 26 placed on the scalp. In FIG. 18, the information includes ultrasound data of the bone thickness and the interfaces of the dura and the arachnoid and the subarachnoid space 2 containing cerebrospinal fluid. Once the controller ascertains the proper interface in relationship to the hollow-bore screw 30 with the trocar 21, the fixation of the screw 30 within the bone will automatically be completed. Semi-autonomous or robotic insertion and servo-controlled motors enablernent are described under “Motorized Insertion of the Needle.”

[0100] Many alterations and modifications may be made by those having ordinary skill in the art without departing from the spirit and scope of the embodiments. Therefore, it must be understood that the illustrated embodiment has been set forth only for the purposes of example and that it should not be taken as limiting the embodiments as defined by the following embodiments and its various embodiments.

[0101] Therefore, it must be understood that the illustrated embodiment has been set forth only for the purposes of example and that it should not be taken as limiting the embodiments as defined by the following claims. For example, notwithstanding the fact that the elements of a claim are set forth below in a certain combination, it must be expressly understood that the embodiments includes other combinations of fewer, more or different elements, which are disclosed in above even when not initially claimed in such combinations. A teaching that two elements are combined in a claimed combination is further to be understood as also allowing for a claimed combination in which the two elements are not combined with each other but may be used alone or combined in other combinations. The excision of any disclosed element of the embodiments is explicitly contemplated as within the scope of the embodiments.

[0102] The words used in this specification to describe the various embodiments are to be understood not only in the sense of their commonly defined meanings, but to include by special definition in this specification structure, material or acts beyond the scope of the commonly defined meanings. Thus, if an element can he understood in the context of this specification as including more than one meaning, then its use in a claim must be understood as being generic to all possible meanings supported by the specification and by the word itself.

[0103] The definitions of the words or elements of the following claims are, therefore, defined in this specification to include not only the combination of elements which are literally set forth, but all equivalent structure, material or acts for performing substantially the same function in substantially the same way to obtain substantially the same result. In this sense it is therefore contemplated that an equivalent substitution of two or more elements may be made for any one of the elements in the claims below or that a single element may be substituted for two or more elements in a claim. Although elements may be described above as acting in certain combinations and even initially claimed as such, it is to be expressly understood that one or more elements from a claimed combination can in some cases be excised from the combination and that the claimed combination may be directed to a sub combination or variation of a sub combination.

[0104] Insubstantial changes from the claimed subject matter as viewed by a person with ordinary skill in the art, now known or later devised, are expressly contemplated as being equivalently within the scope of the claims. Therefore, obvious substitutions now or later known to one with ordinary skill in the art are defined to be within the scope of the defined elements.

[0105] The claims are thus to be understood to include what is specifically illustrated and described above, what is conceptionally equivalent, what can be obviously substituted and also what essentially incorporates the essential idea of the embodiments.