Systems, devices, and methods for accessing the subdural space

Abstract

Disclosed herein are systems, devices, and methods for accessing the subdural space. In some embodiments, the apparatus may include a shaft configured to be slidably disposed within a lumen of a catheter. The shaft may be configured to be advanced distally from a distal end of the catheter into a blood vessel of a subject. The shaft may include a perforating tip including an energy element configured to generate radiofrequency energy to form an opening through the wall of the blood vessel and the dura mater and into the extravascular space of the subject. The curved section may be configured to be radially constrained within the lumen of the catheter and, upon exiting the lumen of the catheter, to curve toward the wall of the blood vessel and the dura mater, positioning the energy element to form the opening.

Description

[Technical Field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application is a continuation-in-part of U.S. Patent Application No. PCT / US2021 / 029276, filed April 27, 2021, which claims priority to U.S. Provisional Application No. 63 / 016,613, filed April 28, 2020, which is a continuation-in-part of U.S. Patent Application No. 18 / 469,437, filed September 18, 2023, which is a continuation-in-part of U.S. Patent Application No. 17 / 976,667, filed April 27, 2021, the contents of each of which are incorporated herein by reference in their entirety.

[0002] This application also claims priority to U.S. Patent Application No. 18 / 469,376, filed September 18, 2023, and to its continuation-in-part, U.S. Provisional Application No. 63 / 422,799, filed November 4, 2022, the contents of each of which are incorporated herein by reference in their entireties. U.S. Patent Application No. 18 / 469,376, filed September 18, 2023, also claims priority to U.S. Provisional Application No. 63 / 422,799, filed November 4, 2022.

[0003] The devices, systems, and methods herein relate to minimally invasive procedures for accessing the intracranial extravascular space in a subject, including, but not limited to, treating subdural hematomas. [Background technology]

[0004] Subdural hematomas (SDHs) are collections of blood outside the brain that typically result from head trauma and are commonly associated with anticoagulants. If not surgically evacuated, SDHs can cause increased intracranial pressure, damaging delicate brain tissue and becoming life-threatening. Initially, acute SDHs (aSDHs) typically form as a firm clot, but over the next few days, they can gradually liquefy into viscous subacute SDHs (saSDHs), which tend to persist and expand into chronic SDHs (cSDHs). Chronic subdural hematomas (cSDHs) are collections of blood on the brain surface that typically begin to form and expand several weeks after head trauma, potentially causing brain compression, neurological deficits, and death. cSDH is expected to become the most common neurosurgical diagnosis in the United States by 2030, with a 16.7% in-hospital mortality rate, a 32% 1-year mortality rate, and only 21.1% of hospitalized patients returning home, associated with a significant decrease in patient life expectancy. cSDH is becoming a public health problem in the elderly population because it is associated with brain atrophy in elderly patients and anticoagulation due to the use of anticoagulants. Furthermore, acute-on-chronic SDH (acSDH) occurs in more than 10% of patients with cSDH and can be formed by a contained liquefied hematoma mixed with a solid subdural clot.

[0005] The current standard of care for symptomatic SDH is surgical evacuation. For example, two burr holes are created to drain relatively thin cSDH, and a craniotomy (e.g., a bony "window") is used to drain the viscous fluid and / or blood clots of aSDH and acSDH. While surgical evacuation can be effective initially, it has a failure rate of up to approximately 37%. Even if the initial conventional treatment fails and the patient undergoes a second surgical treatment, further recurrence is common. The recurrence rate for cSDH can be up to approximately 46%. Furthermore, open surgical intervention can pose additional risks to the patient, including the temporary interruption of anticoagulant and antiplatelet medications (e.g., thereby increasing the risk of ischemic complications) and the use of general anesthesia, which can contribute to high morbidity and mortality rates of approximately 25% and 11%, respectively.

[0006] Surgical drainage is commonly combined with the introduction of a drain into the subdural space, which usually remains in place for up to about 3 days. Drains can reduce recurrence and 6-month mortality rates by about 50%, but they can also result in other complications such as brain injury, bleeding from the subdural space, and infection.

[0007] Intravascular middle meningeal artery (MMA) embolization is an endovascular procedure used to reduce postoperative recurrence of SDH and involves the injection of an embolic agent into the MMA, which causes the hematoma to slowly resorb, thus reducing the mass effect on the brain over a period of weeks to months. MMA embolization can be used to treat cSDH and reduce recurrence in high-risk patients with aSDH, saSDH, and acSDH (i.e., those with coagulopathy or requiring anticoagulants).

[0008] Surgical drainage for rapid cerebral decompression has been used with endovascular MMA as a preoperative or postoperative adjunct to treat SDH. However, such a combination entails the aforementioned risks and requires two separate procedures, which can increase hospital stays, recovery time, and medical costs. Therefore, it may be desirable to provide an endovascular procedure with access to the subdural space to facilitate drainage of SDH and embolization of the artery. Summary of the Invention

[0009] Systems, devices, and methods useful for minimally invasive surgical procedures are described herein. These systems, devices, and methods may, for example, access a subject's subdural space (e.g., intradural space) and treat intracranial hematomas. For example, evacuation of one or more of intracranial extravascular fluid, thrombus, and particulate matter (e.g., subdural hematomas) and embolization of the middle meningeal artery in a single intravascular intervention (e.g., approach) are described herein.

[0010] In some embodiments, a device for evacuating a subdural hematoma disposed in a patient's intracranial extravascular space may include an aspiration catheter disposable within the patient's intracranial blood vessel and defining a lumen. A shaft may be configured to be advanced through the lumen of the catheter until a distal tip portion of the shaft is disposed within the intracranial blood vessel. The shaft may include a piercing element configured to cut through the wall of the patient's intracranial blood vessel and the dura mater to create a slit that serves as a passageway from the intracranial blood vessel lumen to the intracranial extravascular space. A distal segment may be coupled to the distal tip portion, the distal segment having a cross-section with a first transverse dimension greater than a second transverse dimension, facilitating bending of the shaft in a first plane and limiting bending in a second plane perpendicular to the first plane. An aspiration catheter may be advanced through the slit to the subdural hematoma and configured to allow fluid or material from the subdural hematoma to be evacuated from the intracranial extravascular space via the lumen of the catheter.

[0011] In some embodiments, the piercing element has a resistance of about 1200 A / m 2 ~About 12000A / m 2 In some embodiments, the piercing element can be configured to deliver a current density of about 10 W to about 100 W. In some embodiments, the piercing element can include a tip bending stiffness of up to about 15 gf. In some embodiments, the shaft has a column strength of up to about 100 gf.

[0012] In some embodiments, the shaft may further include a wider section having a transverse dimension equal to or substantially equal to the inner diameter of the lumen of the aspiration catheter to prevent ovalization of the aspiration catheter when the aspiration catheter is advanced through the longitudinal slit. In some embodiments, the aspiration catheter may include a proximal end configured to be coupled to a suction source, where the suction source can apply suction to the lumen to evacuate fluid or material from the subdural hematoma. In some embodiments, the piercing element may have an atraumatic shape. In some embodiments, the shaft may further include a proximal section having an outer diameter that tapers from a first outer diameter substantially equal to the inner diameter of the aspiration catheter to a second outer diameter, the proximal section configured to limit the length that the shaft can be advanced distally beyond the distal end of the aspiration catheter.

[0013] In some embodiments, the device can further include a sheath defining a sheath lumen configured to receive an aspiration catheter. The aspiration catheter can include a distal segment including a proximal portion having an outer diameter that tapers from a first outer diameter to a second outer diameter substantially equal to an inner diameter of the sheath, the proximal portion configured to limit the length that the distal segment can advance distally beyond the distal end of the sheath.

[0014] In some embodiments, a device for evacuating a subdural hematoma disposed in a patient's intracranial extravascular space may include an aspiration catheter disposable within the patient's intracranial blood vessel and defining a lumen. A shaft may be configured to be advanced through the lumen of the aspiration catheter until a distal tip portion of the shaft is disposed within the intracranial blood vessel, the distal tip portion being coaxial with the shaft. The shaft may include a perforating element disposed at a distal end of the distal tip portion, the perforating element configured to obliquely cut the wall of the patient's intracranial blood vessel and the dura mater to create a passageway from the intracranial blood vessel to the intracranial extravascular space. The aspiration catheter may be configured to be advanced through the passageway to the subdural hematoma and allow fluid or material from the subdural hematoma to be drained from the intracranial extravascular space via the lumen of the catheter.

[0015] In some embodiments, the piercing element has a resistance of about 1,200 A / m 2 ~Approx. 12,000A / m 2 In some embodiments, the piercing element can be configured to deliver a current density of about 10 W to about 100 W. In some embodiments, the piercing element can include a tip bending stiffness of up to about 15 gf. In some embodiments, the shaft can have a column strength of up to about 100 gf.

[0016] In some embodiments, the shaft may further include a wide section having a transverse dimension equal to or substantially equal to the inner diameter of the lumen of the aspiration catheter to prevent ovalization of the aspiration catheter as it is advanced through the longitudinal slit.

[0017] In some embodiments, the suction catheter can include a proximal end configured to be coupled to a suction source, which can apply suction to the lumen to evacuate fluid or material from the subdural hematoma. In some embodiments, the piercing element can have an atraumatic shape. In some embodiments, the shaft can further include a proximal section having an outer diameter that tapers from a first outer diameter to a second outer diameter substantially equal to the inner diameter of the suction catheter, the proximal section configured to limit the length that the shaft can be advanced distally beyond the distal end of the suction catheter.

[0018] In some embodiments, the device can further include a sheath defining a sheath lumen configured to receive an aspiration catheter. The aspiration catheter can include a distal segment including a proximal portion having an outer diameter that tapers from a first outer diameter to a second outer diameter substantially equal to an inner diameter of the sheath, the proximal portion configured to limit the length that the distal segment can advance distally beyond the distal end of the sheath.

[0019] In some embodiments, the method may include positioning a distal end of a catheter disposed within a subject's intracranial blood vessel near a target location; advancing a shaft through a lumen of the catheter; extending a distal tip portion of the shaft coaxially from the distal end of the catheter so as to position a radiofrequency (RF) element of the distal tip portion at an oblique angle to the wall of the blood vessel and to the overlying surface of the dura mater; activating the radiofrequency (RF) element to deliver RF energy to the wall of the blood vessel to create an opening through the wall of the subject's blood vessel and the dura mater into the extravascular intracranial space; advancing the distal end of the shaft substantially parallel to the surface of the dura mater into the extravascular intracranial space; and advancing the catheter on the shaft into the extravascular intracranial space.

[0020] In some embodiments, the method may further include advancing the distal end of the shaft into the subdural hematoma, advancing a catheter over at least a portion of the shaft into the subdural hematoma, and applying suction to the lumen of the catheter to remove fluid from the subdural hematoma after the catheter is positioned within the subdural hematoma. In some embodiments, the method may further include retracting the catheter toward the opening created in the wall of the artery and delivering a hemostatic element or RF device through the lumen of the catheter to close the opening.

[0021] In some embodiments, the device may include a shaft configured to be slidably disposed within a lumen of a catheter. The shaft may be configured to be advanced distally from a distal end of the catheter into a blood vessel of a subject. The shaft may include a perforating tip including an energy element. The energy element may be configured to generate radio frequency (RF) energy to form an opening through the wall and dura of the blood vessel of the subject and into the extravascular space of the subject. The curved section may be configured to be radially constrained within the lumen of the catheter. The curved section may be configured to curve toward the wall and dura of the blood vessel upon exiting the lumen of the catheter, with the energy element positioned to form the opening. A first discontinuity may be disposed between the perforating tip and the curved section. A second discontinuity may be disposed proximal to the curved section. The second discontinuity may be configured to orient the shaft to follow the curvature of the blood vessel as the shaft is advanced within the lumen of the catheter.

[0022] In some embodiments, the first discontinuity comprises a bend in the shaft. In some embodiments, the curved section has a first radius of curvature and the first discontinuity comprises a section of the shaft having a second radius of curvature that is smaller than the first radius of curvature. In some embodiments, the curved section can be configured to transition to the curved configuration when the curved section moves through the opening and into the extravascular space.

[0023] In some embodiments, the curved section can have a cross-section with a first transverse dimension greater than the second transverse dimension. In some embodiments, the second discontinuity can include a bend in the shaft. In some embodiments, the second discontinuity can include a partial spiral or twist in the shaft. In some embodiments, the curved section can have a first curved section including a convex curvature, and the shaft further includes a second curved section proximal to the first curved section, the second curved section including a concave curvature. In some embodiments, the shaft can include a wide section having a transverse dimension equal to or substantially equal to the inner diameter of the catheter lumen, preventing the catheter from ovalizing as the catheter advances through the opening. In some embodiments, the opening has a length equal to or substantially equal to the length of the energy element.

[0024] In some embodiments, the system may include a catheter having a proximal end and a distal end defining a lumen therebetween. The distal end of the catheter may be configured to be disposed within a blood vessel of a subject. A shaft may be slidably disposed within the lumen, the shaft including a perforating tip having an energy element configured to generate RF energy to penetrate the wall and dura of the blood vessel of the subject. The shaft may further include a curved section configured to transition from a radially constrained configuration to a curved configuration. The shaft may be configured to be advanced along the catheter, the curved section curved along the direction of the vessel curvature and oriented to exit the distal end of the catheter. The curved section may be configured to curve toward the wall of the blood vessel, such that the perforating tip is positioned against the wall of the blood vessel and, upon activation of the energy element, can penetrate the wall of the blood vessel and the dura to enter the extravascular space.

[0025] In some embodiments, the distal end of the catheter can include a radiopaque element. In some embodiments, the shaft can include a first radiopaque element disposed at the piercing tip and a second radiopaque element disposed proximal to the curved section. In some embodiments, the catheter can be configured to be advanced into the extravascular space over the shaft. The shaft can further include a widened section disposed proximal to the curved section, the widened section preventing ovalization of the catheter as it is advanced into the extravascular space. In some embodiments, the distal end of the catheter can include a first radiopaque element and the shaft can include a second radiopaque element disposed near the widened section, the widened section being aligned with the distal end of the catheter before advancing the catheter into the extravascular space.

[0026] In some embodiments, the shaft is a first RF device and the system further includes a second RF device including a straight tip configured to penetrate a membrane of a subdural hematoma, hi some embodiments, the second RF device is configured to deliver RF energy to close a vascular lumen of a blood vessel.

[0027] In some embodiments, the method includes positioning a distal end of a catheter disposed within a subject's intracranial blood vessel near a target location; advancing the shaft through a lumen of the catheter such that a curved section of the shaft curves in a direction that follows the curvature of the blood vessel and the curved section is constrained within the lumen of the catheter; extending the curved section of the shaft from the distal end of the catheter so that the curved section curves toward a wall of the blood vessel and positioning an RF element disposed at the distal end of the shaft against the wall of the blood vessel; activating the RF element to deliver RF energy to the wall of the blood vessel and create an opening through the wall of the subject's blood vessel and the dura mater into the extravascular intracranial space; advancing the distal end of the shaft into the extravascular intracranial space until the curved section transitions to an unconstrained configuration within the extravascular intracranial space; and advancing the catheter over the shaft into the extravascular intracranial space.

[0028] In some embodiments, the method further includes advancing the distal end of the shaft into the subdural hematoma, advancing a catheter over at least a portion of the shaft into the subdural hematoma, and applying suction to the lumen of the catheter to remove fluid from the subdural hematoma after the catheter is positioned within the subdural hematoma. In some embodiments, the method further includes retracting the catheter toward the opening created in the wall of the artery and delivering a hemostatic element or RF device through the lumen of the catheter to close the opening. [Brief explanation of the drawings]

[0029] [Figure 1] 1 is a schematic coronal cross-sectional view of a subdural hematoma in a subject, according to an embodiment. [Figure 2] 1 is a schematic perspective view of a subject undergoing surgical drainage, according to an embodiment. FIG. [Figure 3A] 1 is a schematic side view of a subject's head, according to an embodiment. [Figure 3B] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 3C] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 3D] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 4A] 1 is an X-ray image of arterial blood flow in a subject's head, according to an embodiment. [Figure 4B] 1 is an X-ray image of arterial blood flow in a subject's head, according to an embodiment. [Figure 4C] 1 is an X-ray image of a subject's head, according to an embodiment. [Figure 5] FIG. 1 is a schematic block diagram of a system, according to an embodiment. [Figure 6] FIG. 1 is a schematic diagram of a system, according to an embodiment. [Figure 7A] FIG. 2 is a schematic diagram of a shaft, according to an embodiment. [Figure 7B]7A and 7C are detailed schematic diagrams of the shafts shown in FIGS. 7A and 7C, respectively. [Figure 7C] FIG. 2 is a schematic diagram of a shaft, according to an embodiment. [Figure 7D] 7A and 7C are detailed schematic diagrams of the shafts shown in FIGS. 7A and 7C, respectively. [Figure 7E] 7A and 7C are detailed schematic diagrams of the shafts shown in FIGS. 7A and 7C, respectively. [Figure 8A] 1 is an image of a shaft according to an embodiment. [Figure 8B] 1 is an image of a shaft according to an embodiment. [Figure 8C] 1 is an image of a shaft according to an embodiment. [Figure 9] FIG. 2 is a schematic diagram of a shaft, according to an embodiment. [Figure 10] FIG. 1 is a flow diagram of a method for accessing an extravascular space, according to an embodiment. [Figure 11A] 1 is an image of a method of accessing the extravascular intracranial space, according to an embodiment. [Figure 11B] 1 is an image of a method of accessing the extravascular intracranial space, according to an embodiment. [Figure 11C] 1 is an image of a method of accessing the extravascular intracranial space, according to an embodiment. [Figure 11D] 1 is an image of a method of accessing the extravascular intracranial space, according to an embodiment. [Figure 11E] 1 is an image of a method of accessing the extravascular intracranial space, according to an embodiment. [Figure 11F] 1 is an image of a method of accessing the extravascular intracranial space, according to an embodiment. [Figure 11G] 1 is an image of a method of accessing the extravascular intracranial space, according to an embodiment. [Figure 11H] 1 is an image of a method of accessing the extravascular intracranial space, according to an embodiment. [Figure 11I] 1 is an image of a method of accessing the extravascular intracranial space, according to an embodiment. [Figure 11J]1 is an image of a method of accessing the extravascular intracranial space, according to an embodiment. [Figure 11K] 1 is an image of a method of accessing the extravascular intracranial space, according to an embodiment. [Figure 11L] 1 is an image of a method of accessing the extravascular intracranial space, according to an embodiment. [Figure 12A] FIG. 1 is a schematic diagram of tissue impedance, according to an embodiment. [Figure 12B] FIG. 1 is a schematic diagram of tissue impedance, according to an embodiment. [Figure 13A] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 13B] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 13C] 1 is a schematic axial cross-sectional view of a subject's head, according to an embodiment. [Figure 13D] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 13E] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 13F] FIG. 1 illustrates a side view of a subject's head, according to an embodiment. [Figure 13G] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 13H] FIG. 1 illustrates a side view of a subject's head, according to an embodiment. [Figure 13I] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 13J] FIG. 1 illustrates a side view of a subject's head, according to an embodiment. [Figure 14A] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 14B] FIG. 1 illustrates a side view of a subject's head, according to an embodiment. [Figure 14C] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 14D] FIG. 1 illustrates a side view of a subject's head, according to an embodiment. [Figure 14E] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 14F] FIG. 1 illustrates a side view of a subject's head, according to an embodiment. [Figure 15A] 1 is an image of a dissected cadaver head, according to an embodiment. [Figure 15B] 1 is a side view of a 3D computed tomography scan of a subject's head, according to an embodiment. [Figure 16] FIG. 1 is a perspective cutaway view of a subject's head, according to an embodiment. [Figure 17A] 1A-1C are schematic sagittal and axial cross-sectional views of a subject's head, according to an embodiment. [Figure 17B] 1 is a schematic sagittal cross-sectional view of a subject's head, according to an embodiment. [Figure 17C] 1 is a schematic sagittal cross-sectional view of a subject's head, according to an embodiment. [Figure 17D] 1 is a schematic sagittal cross-sectional view of a subject's head, according to an embodiment. [Figure 17E] 1 is a schematic sagittal cross-sectional view of a subject's head, according to an embodiment. [Figure 18] FIG. 10 is a plot of fluid shear rate versus viscosity for chronic and subacute subdural hematomas, according to an embodiment. [Figure 19A] FIG. 10 is a top view of a hematoma heatmap. [Figure 19B] FIG. 10 illustrates an overlay of a hematoma heatmap and a set of arterial perforation trajectories, according to an embodiment. [Figure 19C] FIG. 10 illustrates an overlay of a hematoma heatmap with a set of arterial perforation locations, according to an embodiment. [Figure 19D] FIG. 10 plots the probability that a set of arterial perforation trajectories intersects with a set of arterial perforation locations, according to an embodiment. [Figure 20A] 1 is a three-dimensional image of a set of veins and dural sinuses in a subject's head, according to an embodiment. [Figure 20B] 1 is a coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 21A] 1 is a schematic top view of a subject's head, according to an embodiment. [Figure 21B] 1 is a schematic coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 22] 1A-1C are schematic top and coronal cross-sectional views of a subject's head, according to an embodiment. [Figure 23] 1A-1C are schematic side and cross-sectional views of a shaft, according to an embodiment. [Figure 24] 1A-1C are schematic top and coronal cross-sectional views of a subject's head, according to an embodiment. [Figure 25] 1 is a schematic coronal cross-sectional view of a subject's head, according to an embodiment. [Figure 26] FIG. 10 is a plot of permittivity and frequency for a set of tissue types, according to an embodiment. [Figure 27] FIG. 10 is a plot of the dielectric constant of a set of tissue types against a set of RF frequencies, according to an embodiment. [Figure 28] FIG. 1 is a coronal cross-sectional view of a catheter assembly disposed in the head of a subject, according to an embodiment. DETAILED DESCRIPTION OF THE INVENTION

[0030] Described herein are systems, devices, and methods for use in minimally invasive surgical procedures that enable transvascular neurosurgery without opening the skull. For example, the systems, devices, and methods described herein can improve access to a subject's extravascular spaces (e.g., subdural space, epidural space, subarachnoid space, extravascular spinal space) and extravascular organs (e.g., brain, spinal cord) by performing the procedure under minimal sedation, reducing one or more of procedural complexity, sterile field management, and time, allowing for the continuous use of anticoagulant and antiplatelet medications, providing faster postoperative recovery, shorter hospital stays, and fewer complications compared to traditional open surgical procedures. For example, access to the extravascular space can include navigation within a body compartment without blood extravasation while blood vessels remain patent or tissue damage (e.g., due to perforation) occurs. In some embodiments, access to the subdural space can be used to facilitate evacuation of the dural substratum.

[0031] While conventional solutions require separate procedures to evacuate the subdural hematoma (SDH) and embolize the artery, the systems, devices, and methods disclosed herein can be performed with a single, endovascular approach. For example, the systems, devices, and methods described herein can facilitate immediate cerebral decompression through transvascular drainage of the SDH and prevention of hematoma recurrence through embolization of the MMA within the same procedure, thereby obviating the need for a second, separate, invasive open surgical procedure.

[0032] In some embodiments, the systems and devices may include a first catheter configured to self-orient within a blood vessel to cut the vessel wall and dura mater in a pushless, depth-controlled manner without damaging the brain. The first catheter may then be atraumatically advanced through one or more of the subdural and epidural spaces into the SDH for drainage using a second catheter. Once the viscous fluid in the SDH has been drained, a second or third catheter may be used to occlude the arteriotomy created by the first catheter without bleeding. Some of the surgical systems described herein may be used to perform surgical procedures, including one or more of surgical evacuation, embolization, drug or biologic delivery, device delivery (e.g., including electrodes), tissue sampling, and combinations thereof.

[0033] In some embodiments, the method may include positioning a distal end of a catheter disposed within a subject's intracranial blood vessel near a target location and advancing a shaft through a lumen of the catheter such that the curved section of the shaft curves in a direction that follows the curvature of the blood vessel. For example, the curved section may be constrained within the lumen of the catheter. The curved section of the shaft may extend from the distal end of the catheter, such that the curved section curves toward a wall of the blood vessel and positions an RF element disposed at the distal end of the shaft against the wall of the blood vessel. The RF element may be activated to deliver RF energy to the wall of the blood vessel, creating an opening through the wall of the subject's blood vessel and the dura mater into the extravascular intracranial space. The distal end of the shaft may be advanced into the extravascular intracranial space until the curved section transitions to an unconstrained configuration within the extravascular intracranial space. The catheter may be advanced over the shaft to enter the extravascular intracranial space.

[0034] In some embodiments, the device may include a shaft configured to be slidably disposed within a lumen of a catheter. The shaft may be configured to be advanced distally from a distal end of the catheter into a blood vessel of a subject. In some embodiments, the shaft may include a perforating tip including an energy element configured to generate RF energy to form an opening through the wall and dura of the blood vessel of the subject and into the extravascular space of the subject. A curved section of the shaft may be configured to be radially constrained within the lumen of the catheter. The curved section may be configured to curve toward the wall and dura of the blood vessel upon exiting the lumen of the catheter, with the energy element positioned to form the opening. A first discontinuity may be disposed between the perforating tip and the curved section, and a second discontinuity may be disposed proximal to the curved section. The second discontinuity may be configured to orient the shaft to follow the curvature of the blood vessel as the shaft is advanced within the lumen of the catheter.

[0035] In some embodiments, the system may include a catheter having a proximal end and a distal end and defining a lumen therebetween. The distal end of the catheter may be configured to be disposed within a blood vessel of a subject. The shaft may be slidably disposed within the lumen. The shaft may include a perforating tip having an energy element configured to generate RF energy to penetrate the wall and dura of the blood vessel of the subject. The shaft may further include a curved section configured to transition from a radially constrained configuration to a curved configuration. The shaft may be configured to be advanced along the catheter, with the curved section curved along the direction of the vessel curvature and oriented to exit the distal end of the catheter. The curved section may be configured to curve toward the wall of the blood vessel, such that the perforating tip is positioned against the wall of the blood vessel and, upon activation of the energy element, can penetrate the wall of the blood vessel and the dura to enter the extravascular space. Other suitable embodiments of the systems, devices, and methods are described in International Application No. PCT / US2021 / 029276, filed April 27, 2021, the disclosure of which is incorporated herein by reference in its entirety.

[0036] The systems, devices, and methods described herein can be used to access extravascular spaces in a subject, including, for example, the intradural extravascular space along the spinal cord or within the brain of a subject. Figure 1 shows a schematic coronal cross-section of a subject 100, including a skull 110 encasing a brain 120, a dura mater (dura mater or dura) 130, a superior sagittal sinus (SSS) 140, and a subdural hematoma (SDH) 150. An SDH is a type of hemorrhage commonly associated with traumatic brain injury, in which blood collects between the inner layer of the dura mater and the arachnoid membrane, a meningeal membrane that surrounds the brain. It typically results from a tear in the bridging veins that traverse the subdural space, followed by persistent bleeding from small blood vessels. A subdural hematoma can cause increased intracranial pressure, which in turn can cause compression and damage to delicate brain tissue. The SDH 150 is shown in Figure 1 between the brain 120 and the dura mater 130, typically facing the convexity of the cerebral hemisphere. Although not shown in Figure 1, the SDH may be in close proximity to vascular structures in the dura mater 130, including the middle meningeal artery (MMA), middle meningeal vein (MMV), superior sagittal sinus (SSS) 140, inferior sagittal sinus (ISS), superior petrosal sinus (SPS), and transverse sigmoid or transverse sinus (TS).

[0037] SSS 140 is a valveless midline vein that runs along the falx cerebri from near the crest to the confluence of the sinuses at the back of the skull. SSS 140 faces both cerebral hemispheres and is generally about 31 cm to about 38 cm long, receiving about 12 to about 20 venous tributaries from the left and right cerebral hemispheres. SSS 140 generally has a triangular shape with a width of about 3 mm to about 18 mm and a height of about 3 mm to about 14 mm. The cross-sectional area of ​​SSS 140 is about 15 mm. 2 ~about 90mm 2The angle between the sinus wall and the midline may be about 25° to about 65°. The typical distance between the SSS 140 and the subdural hematoma 150 is usually less than about 35 mm. The SSS 140 is typically surrounded by the dura mater 130 and separated from the brain 120 by the arachnoid mater and the subarachnoid space, which is filled with cerebrospinal fluid. When cerebral atrophy occurs, the space between the SSS 140 and the brain 120 may expand. For example, the space between the surface of the brain 120 and the dura mater 130 may be about 1 mm to about 20 mm (e.g., about 2 mm to about 8 mm) in a subject with chronic SDH.

[0038] It may be further useful at this point to briefly describe a conventional approach to the treatment of subdural hematomas. Figure 2 shows a schematic perspective view 200 of a subject undergoing surgical evacuation of a hematoma. In particular, a first borehole 210 and a second borehole 212 are formed in the subject's skull adjacent to a hematoma 230, which is shown for illustrative purposes in Figure 2 with the overlying portion of the skull removed. A saline solution 220 may be introduced into first borehole 210 such that fluid 232 (including hematoma 230) may flow out of second borehole 212.

[0039] In some embodiments, a single, endovascular approach can be performed to access a subject's extravascular space. For example, FIGS. 3A-3D are side cross-sectional views of a subject's head 300, 302, 304, 306. The head 300 in FIG. 3A shows a skull 310, an internal maxillary artery 340 connected to a middle meningeal artery (MMA) 342, and a subdural hematoma (SDH) 350. In some embodiments, a sheath (e.g., a sleeve, a delivery catheter, a guide catheter, an intermediate catheter) 360 can be advanced through one or more of the internal maxillary artery 340 and the MMA 342. A catheter 362 (e.g., an embolization catheter) can be advanced from the distal end of the sheath 360 to deliver a hemostatic element 370 (e.g., an occlusion element, an embolic material, an embolic fluid, a particulate, a coil) into a set of branches of the MMA 342 to reduce bleeding from one or more branch vessels of the MMA 342. In some embodiments, the sheath 360 can be advanced through any suitable vascular access point (e.g., the peripheral arterial vasculature), such as the femoral artery (e.g., the groin), radial artery (e.g., the wrist), brachial artery, or carotid artery.

[0040] The MMA 342 is generally the third branch of the first portion of the internal maxillary artery 340. Each side of the head can include an MMA 342 that branches off from the internal maxillary artery 340 in the infratemporal fossa and enters the intracranial compartment through the foramen spinosum, where the MMA 342 deflects anteriorly and laterally at an angle of about 60° to about 120° relative to the longitudinal axis of the foramen spinosum.

[0041] As shown in Figures 3B-3D, the MMA 342 is typically located on the dura mater 330, on the epidural side. The MMA 342 generally branches parallel to the dura mater 330. The MMA 342 can supply blood to the dura mater 330, the outer meningeal layer, and the calvaria. The main trunk of the MMA 342 can generally be about 14 mm to about 34 mm. The MMA 342 generally branches into frontal and parietal branches (as well as other minor branches). The average diameter of the main trunk of the MMA 342 can be about 0.6 mm to about 1.2 mm. However, subjects with cSDH may have an average diameter of the main trunk of the MMA 342 of about 1 mm to about 2 mm. The MMA 342 can supply blood to pathological membranes that maintain and / or expand the SDH. Figure 3C shows a catheter 362 and shaft 364 advanced into the MMA 342 between the dura mater 330 and the skull 310. Shaft 364 may be configured to be slidably disposed within the lumen of catheter 362. As described in more detail herein, shaft 364 may be configured to form an opening through the wall of a blood vessel (e.g., MMA 342) and dura mater 330 into the extravascular space of a subject to facilitate access to the intradural space between dura mater 330 and brain 320. Figure 3D shows delivery of hemostatic element 370 into MMA 342 by catheter 362.

[0042] Figures 4A and 4B are x-ray images 400, 402 of arterial blood flow in a subject's head. For example, Figure 4A shows blood flow through a middle meningeal artery (MMA) 410, and Figure 4B shows blood flow through the MMA 410 after occlusion of the MMA 410. Figure 4C is an x-ray image 404 of a subject's head with two borehole locations 420 connected by a craniotomy and a catheter 430 disposed within the MMA 410.

[0043] I. System The systems and devices described herein may be configured to enable transvascular procedures, including, but not limited to, improved access to the extravascular space, treatment of subdural hematomas, delivery of drugs or therapeutic agents, delivery of devices (e.g., sensors, electrodes, biopsy devices, ablation devices, catheters, drainage systems), tissue sampling, device implantation, and the like. FIG. 5 is a schematic block diagram of a system 500 including a catheter assembly 502, a vacuum source 550, a signal generator 560, and a visualization device 570. The catheter assembly 502 may be configured to form an opening between a blood vessel of interest and the extravascular space. In some embodiments, the catheter assembly 502 may include a catheter 510, a shaft 520, a hemostatic device 530, one or more optional sensors 540, and an optional sheath (e.g., a delivery catheter, a guide catheter) (not shown).

[0044] In some embodiments, one or more components of the catheter assembly 502 may comprise one or more of a hypotube, a single solid rod, multiple rods, a bundle, tubing (having one or more lumens), a shaft strand, a cable (two or more wires running side by side, bonded, twisted, or braided), a coil, a braid, combinations thereof, etc. In some embodiments, one or more components of the catheter assembly 502 may comprise one or more of stainless steel, nitinol, silver, titanium, copper, cobalt chromium, nickel chromium, platinum iridium, polymers, nylon, polyamide, fluoropolymers, polyolefins, polytetrafluoroethylene, high density polyethylene, polyurethane and polyimide, ceramics, bioabsorbable or dissolvable materials, combinations thereof, etc.

[0045] In some embodiments, one or more components of the catheter assembly 502 have a resistance of about 0.0002 lb / in 2 ~about 0.15lb / in 2(including all ranges and subvalues ​​therebetween). The components of the catheter assembly 502 may have variable tip bending stiffness along the respective lengths of each component.

[0046] In some embodiments, one or more components of the catheter assembly 502 may include knurling configured to increase flexibility (e.g., to traverse the curve of the foramen barbae). The knurling may include, but is not limited to, a spiral knurling pattern (e.g., continuous, intermittent), a radial knurling pattern, a custom knurling pattern, a radial ring pattern, longitudinal knurling, diagonal knurling, windows, tabs, holes, combinations thereof, and the like.

[0047] In some embodiments, one or more components of the catheter assembly 502 may have a cross-sectional shape that may include, but is not limited to, a circle, an oval, a square, a star, a diamond, a rectangle, a flat shape, combinations thereof, and the like.

[0048] catheter The catheter 510 can be configured to remove fluids from and / or deliver fluids or devices to the extravascular space. In some embodiments, the catheter assembly can be small and flexible enough to navigate intracranially by traversing multiple complex angles and can have high and precise torque capabilities to direct drilling toward the subdural space from an access site more than about 170 cm away. These challenges are compounded by subject variability, including the degree of aortic and meningo-cervical vascular tortuosity, the location of arterial drilling points along the temporal bone valves, fluid viscosity, and the presence of thick membranes and septa.

[0049] In some embodiments, the catheter 510 may be slidably disposed within a lumen of a sheath. For example, the sheath may include one or more of a guide catheter (e.g., a 5F Asahi Fubuki Guide Catheter), an intermediate delivery catheter (e.g., a DAC 044, Stryker), and a microcatheter (e.g., a 0.027 inch Phenome 27 Microcatheter, Medtronic).

[0050] The catheter 510 can be designed to be highly flexible. In some embodiments, the catheter 510 is flexible enough to assume the shape of the shaft 520 slidably disposed therein. However, the shape of the catheter 510 and shaft 520 may be constrained by the shape of the lumen or body cavity (e.g., artery, subdural space) in which the catheter is disposed.

[0051] In some embodiments, the catheter assembly can be configured to prevent herniation of the catheter during advancement, ovalization of the catheter, and snagging of the catheter at the opening. Additionally, the catheter can be configured to not collapse when negative suction is applied through the catheter lumen and to remain patent without kinking when the shaft is withdrawn.

[0052] In some embodiments, the inner diameter of the catheter can be maximized while ensuring guidance of the catheter through the intracranial vessels to the puncture point. For example, with respect to the puncture point within the MMA, the catheter 510 can have a distal inner diameter of about 0.005 inches to about 0.060 inches, and about 0.012 inches to about 0.03 inches, including all ranges and subvalues ​​therebetween.

[0053] In some embodiments, a catheter configured to reach radial and / or femoral access points may have a working length of at least about 120 cm, and between about 140 cm and 160 cm, including all ranges and subvalues ​​therebetween. In some embodiments, the catheter 510 may be configured to advance through a minimum bend angle of 70° without kinking to facilitate advancement through the foramen spinosum into the intracranial compartment.

[0054] In some embodiments, the catheter 510 has sufficient column strength to generate a forward load of greater than about 1 N to perforate the MMA and dura without kinking, ovalizing, or herniating into a vessel (e.g., a branch artery), as well as to accept a negative pressure of greater than about 29 inHg without collapsing for fluid removal.

[0055] The catheter 510 may define a lumen (having a corresponding inner diameter) extending from the proximal end to the distal end of the catheter 510. In some embodiments, the inner and / or outer diameter of the catheter 510 may be tapered. In some embodiments, the inner diameter at the distal end of the catheter 510 may be smaller than the inner diameter at the proximal end of the catheter 510, for example, to facilitate increased fluid flow (e.g., during aspiration).

[0056] In some embodiments, the distal end of the catheter 510 can include a radiopaque element, which can be configured to facilitate alignment between the distal end of the catheter 510 and features of the shaft, such as wider or larger areas of the shaft to prevent ovalization, as described further below.

[0057] In some embodiments, the catheter may include multiple lumens and one or more distal openings. In some embodiments, one or more of the lumens may be configured for aspiration and / or fluid injection. For example, the catheter may be configured to infuse non-ionic dextrose during RF energy delivery to reduce current leakage and increase the efficiency of vaporization of the target tissue.

[0058] In some embodiments, the catheter may be configured to minimize, prevent, and / or address catheter blockage, including the slidable element and the deployable element. For example, the catheter may include two nested hypotubes. The outer catheter (e.g., the proximal hypotube) may have an inner diameter sufficient to accommodate the inner catheter (e.g., the distal hypotube), which is advanced using, for example, a push wire. These inner and outer hypotubes may include one or more tapers to gradually reduce the gap between the inner and outer hypotube outer diameters until no significant gap remains in a given section of the catheter. The given section may be configured to form a seal that maximizes cross-section and suction force and flow. Additionally, a dual hypotube catheter may have the advantage of using the catheter to stop flow within the intraosseous or extracranial MMA while providing a lumen for distal instrumentation within the MMA and through transvascular passageways.

[0059] In some embodiments, the catheter 510 may include a proximal segment coupled to a distal segment defining a lumen and configured for guidance. For example, the proximal segment may be configured to control translation (e.g., bidirectional longitudinal movement, pushing, pulling) of the catheter 510 through a blood vessel. In some embodiments, the proximal segment may lack a lumen to aid pushability. For example, the proximal segment may include one or more of a hypotube, a single solid rod, a wire (e.g., having one or more cross-sectional shapes including round, flat, square, diamond), multiple rods, a bundle, one or more tubes (having one or more lumens), multiple shaft strands, a cable (e.g., two or more wires running side by side, bonded, twisted, or braided), a coil, a braid, a wire (e.g., round, flat, square, diamond), combinations thereof, and the like. The distal segment may include a second catheter defining a lumen configured to receive one or more of the shaft 520, a negative pressure, an SDH, a hemostatic device 530, and the like. The proximal segment may have a smaller diameter than the distal segment, hi some embodiments, the distal segment of catheter 510 may have a length of about 7 cm to about 20 cm.

[0060] In some embodiments, the proximal portion of the distal segment can have an outer diameter that substantially matches the inner diameter of the distal portion of the sheath so that the distal segment can be coupled to the sheath via a friction fit. In some embodiments, the distal segment includes a proximal portion having an outer diameter that tapers from a first outer diameter substantially equal to the inner diameter of the sheath to a second outer diameter, the proximal portion configured to limit the length that the distal segment can advance distally beyond the distal end of the sheath. In some embodiments, the inner diameter of the distal end of the sheath can decrease or narrow gradually and / or in step increments. Thus, the catheter 510 can be advanced through the sheath until the proximal portion of the distal segment of the catheter 510 abuts the distal portion of the sheath at a “seal region” where the inner diameter of the sheath substantially matches the outer diameter of the catheter 510.

[0061] 28 shows a coronal cross-sectional view 2800 of a catheter assembly disposed within a MMA 2810 of a subject's head. The catheter assembly may include a sheath 2820 and a catheter 2830 disposed within a lumen of the sheath 2820. The catheter 2830 may include a proximal segment 2840 (e.g., a push wire) coupled to a distal segment 2850 that defines a lumen. A proximal portion 2852 of the distal segment 2850 may have an outer diameter that substantially matches the inner diameter of the distal portion of the sheath 2820 such that the distal segment 2850 may be coupled to the inner diameter of the sheath 2820 via a friction fit. In some embodiments, the distal segment 2850 includes a proximal portion 2852 having an outer diameter that tapers from a first outer diameter substantially equal to the inner diameter of the sheath to a second outer diameter, the proximal portion 2852 configured to limit the length that the distal segment 2850 can advance distally beyond the distal end of the sheath 2820. The proximal segment 2840 can be coupled to the inner diameter of the proximal portion 2852 of the distal segment 2850.

[0062] In some embodiments, the outer diameter of the proximal portion 2852 of the distal segment 2850 of the catheter 2830 can be about 0.001 inch to about 0.005 inch smaller than the inner diameter of the distal end of the sheath 2820 to form an airtight seal. When the distal segment 2850 and the sheath 2820 are coupled via a friction fit, negative pressure applied through the sheath 2820 can propagate through the catheter 510 and facilitate evacuation of the SDH. Furthermore, the inner diameter of the distal segment 2850 can be smaller than the inner diameter of the sheath 2820 to facilitate a higher flow rate through the catheter assembly when negative pressure is applied through the sheath (e.g., based on the Hagen-Poiseuille equation).

[0063] shaft The shafts described herein can be configured to meet a complex array of requirements. In some embodiments, a catheter assembly can be guided intracranially through the MMA and have a shaft configured to self-orient within the MMA to form an opening in the MMA and dura in the correct direction (e.g., away from the skull), and can indicate to the operator when the shaft has completed self-orientation. For example, for middle meningeal artery transvascular access, a combination of opposing curves (e.g., proximal curve, distal curve) along different segments of the shaft can be configured to induce shaft rotation (e.g., self-orientation) to align the proximal curve of the shaft with the curvature of the foramen spinosum and middle cranial fossa (e.g., lateral concavity) and the distal curve of the shaft with the curvature of the fossa and calvaria (e.g., medial concavity).

[0064] The shaft can be configured to form a transvascular opening having a length, width, and / or diameter sufficient for passage of a catheter, such as, for example, the catheter 510 described above (e.g., a suction catheter, a 0.027 inch microcatheter). The opening can be circular, oval, or elongated (e.g., a slit).

[0065] In some embodiments, the shaft 520 can be coupled to the signal generator 560. As described in more detail herein, the shaft 520 can include a distal tip portion 522 having a piercing element 524 configured to create (e.g., form) an opening in the wall of a blood vessel and the dura of a target. For example, the shaft can be configured to form a transvascular passageway within the subdural space using electrocautery. In some embodiments, the shaft 520 can further include an offset 526 (e.g., a discontinuity, a bend) configured to orient a predetermined portion of the shaft 520 in a predetermined direction as the shaft 520 is advanced within the lumen of the catheter 510 and the blood vessel. The shaft 520 can include multiple portions having one or more different diameters, shapes, durometers, etc. For example, a multi-durometer shaft 520 can be formed by combining a proximal stainless steel core wire having a first stiffness with a distal nitinol wire having a second stiffness less than the first stiffness. Additionally or alternatively, the nitinol wire may be tapered to provide a proximal stiffness with a gradually decreasing distal stiffness.

[0066] In some embodiments, the shaft may be configured to prevent ovalization of the catheter to prevent it from getting caught in the opening formed by the shaft. For example, a space (e.g., a difference, a shelf) between the inner diameter of the catheter and the outer diameter of the shaft may cause the catheter to compress into an oval shape, which may increase the likelihood of the catheter getting caught on the edge of the tissue opening (e.g., a slit) and thus prevent the catheter from advancing out of the MMA and into the subdural space. In some embodiments, the shaft may be configured such that a given portion of the shaft has an outer diameter similar (e.g., substantially equal) to the inner diameter of the given portion of the catheter, allowing the shelf between the shaft and the catheter to be negligible, thereby allowing the catheter to maintain a circular (e.g., non-oval) cross-sectional shape along a given length to facilitate passage through the formed tissue opening. For example, the outer diameter or maximum transverse dimension of the shaft may be increased at the location of a reference point or radiopaque marker. The radiopaque marker on the shaft may be aligned with the radiopaque marker on the distal end of the catheter, as described above, before advancing the catheter with the shaft through the vessel wall or dural opening. The larger dimension of the shaft at this location can prevent the catheter from ovalizing as it is advanced through the opening, while having a minimal impact on the overall increase in friction resulting from negligible shear between the shaft and catheter along the longer segments. The relatively high overall friction between the shaft and catheter can prevent rotation (e.g., self-orientation) of the shaft as described herein for directional penetration into the subdural space.

[0067] In some embodiments, the shaft can be configured to prevent fluid extravasation. For example, the shaft can include one or more of a taper, a focal expansion of the outer diameter, a surface modification, an expandable element, etc.

[0068] In some embodiments, the shaft 520 can have a predetermined shape at predetermined portions (e.g., spiral points along its length) configured to steer the advancement catheter away from the dural margin at the arteriotomy / dural incision site. In some embodiments, the predetermined shape can include one or more of a J-shape, a U-shape, a C-shape, a V-shape, an M-shape, an S-shape, a spiral, and combinations thereof. For example, the shape can form a mountain-like shape configured to force apart or lift the dura.

[0069] In some embodiments, the shaft 520 can include a shape memory material (e.g., nitinol) wire with a polymer jacket. As described in more detail herein (e.g., FIGS. 6 and 8), the shaft can include a flat (e.g., pinched) portion configured to self-orient within the intracranial MMA. As described in more detail herein, different shapes and configurations of the shaft (e.g., J-curves, curves and inverse curves, bends, offsets, diameter changes) can improve flexibility, pushability, and support.

[0070] In some embodiments, the shaft can be formed with a set of distal and proximal segments of constant diameter, with the distal and proximal segments having different diameters between about 0.014 inches and 0.027 inches (including all ranges and subvalues ​​therebetween).

[0071] In some embodiments, the shape memory material of the shaft can have a proximal diameter of about 0.010 inches to about 0.025 inches, including all ranges and subvalues ​​therebetween. In some embodiments, the shape memory material of the shaft can have a tapered distal diameter of about 0.0060 inches to about 0.014 inches, including all ranges and subvalues ​​therebetween.

[0072] In some embodiments, the distal segment of shape memory material can be flattened to a width of about 0.008 inches to about 0.018 inches, including all ranges and subvalues ​​therebetween. In some embodiments, the distal segment of shape memory material can have a thickness of about 0.003 inches to about 0.008 inches, including all ranges and subvalues ​​therebetween.

[0073] In some embodiments, the shaft may be configured to be slidably disposed within the lumen of the catheter. The shaft may be configured to be advanced distally from the distal end of the catheter into a blood vessel (e.g., the MMA) of the subject. The shaft may include a perforating tip including an energy element. The energy element may be configured to generate RF energy to form an opening through the wall and dura of the blood vessel of the subject and into the extravascular space of the subject. The curved section may be configured to be radially constrained within the lumen of the catheter. The curved section may be configured to curve toward the wall and dura of the blood vessel upon exiting the lumen of the catheter, with the energy element positioned to form the opening. A first discontinuity may be disposed between the perforating tip and the curved section. A second discontinuity may be disposed proximal to the curved section. The second discontinuity may be configured to orient the curve of the shaft to follow the curvature of the blood vessel as the shaft is advanced within the lumen of the catheter.

[0074] In some embodiments, the first discontinuity can include a bend in the shaft. In some embodiments, the curved section can have a first radius of curvature, and the first discontinuity includes a section of the shaft having a second radius of curvature that is smaller than the first radius of curvature. In some embodiments, the curved section can be configured to transition to the curved configuration when the curved section moves through the opening and into the extravascular space.

[0075] In some embodiments, the curved section can have a cross-section with a first transverse dimension greater than the second transverse dimension. In some embodiments, the second discontinuity can include a bend in the shaft. In some embodiments, the second discontinuity can include a partial spiral or twist in the shaft. In some embodiments, the curved section can have a first curved section including a convex curvature, and the shaft can further include a second curved section proximal to the first curved section. The second curved section can include a concave curvature. In some embodiments, the shaft can include a wide section having a transverse dimension equal to or substantially equal to the inner diameter of the catheter lumen, which can prevent the catheter from ovalizing as the catheter advances through the opening. In some embodiments, the opening has a length equal to or substantially equal to the length of the energy element.

[0076] In some embodiments, the shaft can include a first radiopaque element disposed at the piercing tip and a second radiopaque element disposed proximal to the curved section. The shaft can further include a wide section disposed proximal to the curved section. For example, as described above, the wide section can be configured to prevent ovalization of the catheter as it is advanced into the extravascular space. The distal end of the catheter can include a first radiopaque element, and the shaft can include a second radiopaque element disposed near the wide section, and the wide section can be aligned with the distal end of the catheter before advancing the catheter into the extravascular space.

[0077] In some embodiments, the shaft may include one or more lumens with one or more openings. The one or more lumens may be configured for one or more of fluid infusion and suction (e.g., for coupling). For example, infusion of non-ionic dextrose through a first lumen during RF energy delivery may reduce or eliminate alternative current pathways, resulting in more efficient vaporization of target tissue. The second lumen may be configured to provide suction (e.g., suction) to improve wall apposition to the RF electrode and / or to collapse arterial vessels during RF-mediated arterial occlusion. In some embodiments, the proximal end of the shaft may be coupled to a signal generator (e.g., an RF generator) via a push-button electrosurgical pencil.

[0078] Distal tip In some embodiments, the piercing element 524 of the shaft 520 can include an electrode (e.g., an RF ablation tip). Delivery of RF energy using the electrode can rapidly increase tissue temperature and convert fluid to vapor (e.g., evaporation), resulting in localized tissue destruction and voiding. The evaporation can result in a fenestration from the intravascular lumen (and through the dura) to the intradural compartment.

[0079] In some embodiments, penetration of the dura is achieved using a mechanical (e.g., cutting) element. A needle penetration force of 0.29 to 1.29 N (0.68 ± 0.24 N) may be required to penetrate the dura, a highly resistant tissue that requires both high sharpness and high penetration force. However, a sharp needle tip can result in catheter skiving or scratching along the curvature and unintentional brain perforation. Furthermore, high penetration force requires high catheter column strength and pushability, which can be achieved by using rigid materials and structures that counter the strength and pushability requirements for guiding the catheter through tortuous vascular geometries. In some embodiments, the distal tip portion 522 of the shaft 520 can have a tip bending stiffness of about 0.5 gf to about 15 gf (including all ranges and subvalues ​​therebetween) (e.g., when the distal end of the shaft 520 is attached about 5 mm, about 10 mm, and about 20 mm from the distal end of the distal tip portion 522).

[0080] RF tissue ablation without mechanical cutting may allow the shaft 520 to have reduced column strength compared to mechanical cutters, such as needles, which require high pushability. Additionally, a non-invasive piercing element may be less likely to damage the catheter 510 compared to a shaft with a needle tip. Ablation resulting in voided tissue may also reduce snagging at the edges as the catheter 510 is advanced through a tissue opening. In some embodiments, the distal portion of the shaft 520 (e.g., up to about 300 mm from the distal tip portion 522) may have a column strength of up to about 50 gf, between about 10 gf and about 50 gf, or between about 50 gf and about 100 gf (including all ranges and subvalues ​​therebetween).

[0081] In some embodiments, RF energy may be used to facilitate penetration into a hematoma through one or more of the surrounding membranes, perforation of septa associated with mixed senile SDH and chronic SDH, and catheter unclogging. Additionally, RF energy may be used to coagulate tissue to facilitate one or more of the formation and closure of a tissue opening.

[0082] In some embodiments, the piercing element 524 may include two or more electrodes. For example, the piercing element 524 may include two or more tubular elements. In some embodiments, multiple electrodes may be individually connected in parallel to the signal generator 560 in a monopolar configuration and share the same ground pad. In another embodiment, a first electrode may be connected to the signal generator 560 and a second electrode may be connected to ground in a bipolar configuration. In a bipolar configuration, the current may be concentrated between the first and second electrodes.

[0083] In some embodiments, in a bipolar configuration, the piercing element 524 can include a first electrode and the catheter 510 can include a second electrode. In this configuration, the piercing element 524 and the catheter 510 can be advanced simultaneously to maintain current delivered to the tissue, or the piercing element 524 can be advanced relative to the catheter 510 to reduce current delivery as the tissue is destroyed, reducing the possibility of brain damage.

[0084] In some embodiments, the piercing element 524 may comprise platinum-iridium, stainless steel, copper, titanium, and nickel-titanium alloy and may be configured as a fluoroscopic marker and an RF electrode. The piercing element 524 may have an atraumatic shape (e.g., tubular, blunt, rounded distal end). For example, the piercing element 524 may have a shape including one or more of a bullet, cone, frustum, cylinder, sphere, dome, ring, semi-ring, ellipse, bevel, and arrowhead. In some embodiments, the electrodes of the piercing element 524 may be uninsulated or partially insulated and may be made of and / or coated with a conductive and biocompatible material with high radiopacity, such as stainless steel, silver, gold, platinum, or combinations thereof. In such embodiments, the shaft may be coated with an insulating material along its length, and the electrodes at its distal end are uninsulated or coated with a conductive material. In some embodiments, the uninsulated portion of the piercing element 524 is approximately 16 mm 2 Less than 1mm 2 ~about 5mm 2 (including all ranges and subvalues ​​therebetween). In some embodiments, the energy-delivery portion of the piercing element 524 may have a length of about 1.3 mm to about 1.7 mm (including all ranges and subvalues ​​therebetween). In some embodiments, the piercing element 524 may be configured to deliver a power of about 10 W to about 100 W (including all ranges and subvalues ​​therebetween). In some embodiments, the piercing element 524 may have a power of about 1,200 A / m 2 ~Approx. 12,000A / m 2 , approx. 2,000A / m 2 ~Approx. 10,000A / m2 , approx. 2,000A / m 2 ~Approx. 5,000A / m 2 , approx. 5,000A / m 2 ~Approx. 10,000A / m 2 , approx. 1,200A / m 2 ~Approx. 6,000A / m 2 , about 8,000A / m 2 ~Approx. 12,000A / m 2 (including all ranges and subvalues ​​therebetween). In some embodiments, the piercing element 524 can be configured to deliver a power of about 10 W to about 100 W, about 20 W to about 75 W, including all ranges and subvalues ​​therebetween. In some embodiments, the distal end of the piercing element 524 can be open or closed. In some embodiments, the piercing element can be tapered.

[0085] hemostatic device In some embodiments, hemostatic device 530 includes a hemostatic element or RF device configured to close the opening formed by piercing element 524 of shaft 520. Hemostatic device 530 may optionally be coupled to signal generator 560. In some embodiments, catheter 510 may be configured to deliver hemostatic device 530 through the wall of a blood vessel and / or the dura to the location of the opening (e.g., to seal the opening).

[0086] Linear RF Devices In some embodiments, a shaft assembly, such as shaft 520 and shaft assembly 900, including a straight-tip RF device (e.g., shaft 920), is configured to create an opening in a blood vessel wall and / or dura, for example, to access the epidural and / or subdural space. The straight-tip RF device can have a shaft and a distal tip portion coupled to the shaft, where the longitudinal axis of the shaft is parallel to the longitudinal axis of the distal tip portion. That is, the distal tip portion may not form an angle or curve with respect to the shaft. The straight-tip RF device can be advanced epidurally a predetermined length to facilitate distal access to the subdural space and underlying tissue. The straight-tip RF device can be configured to deliver one or more of energy and / or mechanical force between bone and tissue (e.g., blood vessel wall, dura) to create an opening between the blood vessel or epidural space and the subdural space. For example, the energy can include one or more of RF energy, pulsed field ablation, microwave, diathermy, laser, electrocautery, and cryoenergy. In some embodiments, the mechanical force may include one or more of cutting, tension, compression, bending, torsion, and shear.

[0087] In some embodiments, one or more portions of the shaft can have a cross-section with a first transverse dimension that is greater than a second transverse dimension. In some embodiments, the shaft can include a wide section having a transverse dimension equal to or substantially equal to the inner diameter of the catheter lumen to prevent ovalization of the catheter as it advances through the opening, facilitate bending of the shaft in a first plane, and limit bending in a second plane perpendicular to the first plane.

[0088] In some variations, the straight-tip RF device may have a diameter similar to the diameter of the blood vessel to be punctured. In some embodiments, the straight-tip RF device may be advanced into the subdural space in a trajectory substantially parallel to the surface of the dura mater and / or the brain surface to prevent brain perforation during advancement into the extravascular subdural space. The straight-tip RF device may have a shape that allows it to be easily advanced through a sheath and penetrate the membrane of a subdural hematoma. This may facilitate the entry and exit of a catheter (e.g., an aspiration catheter) into the SDH. For example, the straight-tip RF device may include an RF electrode configured to operate in a monopolar configuration. In some embodiments, the second RF device may be configured to deliver RF energy to close the vascular lumen of the blood vessel. For example, when the catheter is withdrawn from the extravascular space into a blood vessel (e.g., the MMA), the second RF device may be used to seal the opening formed in the MMA. This second RF device may therefore function as a hemostatic device.

[0089] In some embodiments, the linear RF device may be configured in a monopolar or bipolar configuration, single or multiple bipolar configurations. In some embodiments, the linear RF device may have a shape corresponding to a ring or coiled configuration for circumferential thermal ablation. In some embodiments, the coiled configuration may be disposed at the distal end of the linear RF device and may have a length of about 3 mm to about 30 mm and a diameter of about 0.01 inches to about 0.05 inches, including all ranges and subvalues ​​therebetween. In some embodiments, the diameter may be continuous or tapered.

[0090] In some embodiments, the linear RF device may include a temperature sensor such as a thermistor or thermocouple, hi some embodiments, the temperature sensor may be thermally isolated from the RF electrode.

[0091] Sensor In some embodiments, one or more sensors 540 may be coupled to one or more of the catheter 510, the shaft 520, and the hemostasis device 530. The sensor 540 may be configured to measure one or more parameters, including, but not limited to, pressure and impedance. The sensor measurements may be used by one or more of the operator and the signal generator during the procedure. For example, a pressure measurement may indicate to the operator the position and / or orientation of the shaft 520 of the catheter assembly 502, and RF energy may be delivered to the piercing element 524 only when the measured impedance is within a predetermined range to prevent damage to brain tissue.

[0092] In some embodiments, the pressure sensor may include one or more of a potentiometric pressure sensor, an inductive pressure sensor, a capacitive pressure sensor, a strain gauge pressure sensor, a fiber optic pressure sensor, a variable reluctance pressure sensor, a microelectromechanical system pressure sensor, and a piezoelectric pressure sensor. For example, the piezoelectric pressure sensor may include a piezoelectric film disposed along the outer diameter of the piercing element proximate the distal end. The measured signal may include a peak pressure value associated with penetrating the MMA wall and a subsequent pressure drop associated with accessing the subdural space. In some embodiments, the pressure sensor may be configured to measure a pressure waveform (e.g., an arterial, intracranial, or venous piercing waveform) upon penetration from the vascular lumen to the intracranial compartment. In some embodiments, tissue spectroscopy may be measured to monitor piercing and access into the subdural space.

[0093] In some embodiments, the first pressure sensor may be disposed at or adjacent to the distal end of the piercing element and configured to measure pressure on tissue and / or fluid. The second pressure sensor may be disposed proximal to the first pressure sensor (e.g., about 0.2 mm and about 2 mm from the first pressure sensor). The first pressure sensor measurement and the second pressure sensor measurement as the piercing element is advanced through the blood vessel correspond to a nominal blood pressure. When the piercing element contacts the wall of the blood vessel, the first pressure sensor measurement corresponding to the wall of the blood vessel may be higher than the second pressure measurement corresponding to the blood pressure. During tissue piercing, the first pressure sensor measurement may be lower than the second pressure measurement. After forming an opening in the wall of the blood vessel, the first pressure measurement and the second pressure measurement may correspond to fluid pressure in the subdural space.

[0094] In some embodiments, the impedance sensor can be configured to measure tissue and fluid impedance, permittivity, and / or conductivity to monitor perforation and access into the subdural space. Changes in impedance (or other dielectric properties) between the artery, dura, fluid (e.g., contrast agent, cerebrospinal fluid, subdural hematoma), intradural space, and brain can indicate the location of the perforating element throughout the procedure. Impedance measurements can be used to control energy delivery by the signal generator. For example, energy delivery can be modified to optimize ablation or stopped based on the measured impedance.

[0095] In some embodiments, a temperature sensor can be configured to measure tissue and fluid temperatures. For example, the temperature sensor can include a thermocouple disposed at or adjacent to the distal end of the piercing element. The measured temperature can be used to control waveform delivery (e.g., impedance, voltage, duty cycle, pulse width) by the signal generator. For example, energy delivery can be optimized and cut off and stopped if the measured temperature exceeds a predetermined threshold to prevent unintended tissue damage.

[0096] In some embodiments, the piercing element 524 (e.g., an electrode) can be configured to measure electroencephalographic (EEG) signals disposed within about 20 mm of the distal end of the piercing element 524. The piercing element 524 can be configured to alternately deliver RF energy and measure EEG signals, impedance signals, etc.

[0097] In some embodiments, a force sensor disposed on or adjacent to the piercing element can be configured to measure the force associated with penetration of the shaft through the MMA and dura mater. For example, pressure can be measured using a pressure transducer disposed outside the subject.

[0098] vacuum source In some embodiments, a vacuum source 550 may be coupled to the catheter 510. The vacuum source 550 may be configured to provide negative pressure (e.g., suction) to a lumen of the catheter 510. The suction force generated by the vacuum source 550 may be configured to remove fluids and matter (e.g., from a subdural hematoma) through the lumen of the catheter 510. In some embodiments, the vacuum source may include one or more of a pump and a syringe. The vacuum source 550 may be configured to operate in one or more modes, including continuous, dynamic, cyclic, pulsed, low frequency, high frequency, combinations thereof, etc.

[0099] signal generator Generally, the signal generators described herein can be configured to provide energy (e.g., energy waveforms) to the piercing elements to form openings in tissue. In some embodiments, signal generator 560 can be coupled to one or more of shaft 520 and hemostatic device 530. In particular, signal generator 560 can be configured to generate energy for delivery using piercing elements 524 of distal tip portion 522. Signal generator 560 can include a processor 562, a memory 564, and an input / output device 566 configured to control signal generator 560, provide appropriate energy waveforms for tissue ablation, and ensure patient safety. In some embodiments, the signal generator can be configured to control waveform generation and delivery in response to received sensor data. For example, energy delivery can be prevented unless impedance sensor measurements confirm the tissue type to be ablated.

[0100] The signal generator may generate and deliver several types of signals, including, but not limited to, RF, pulsed field ablation, microwave, diathermy, laser, and electrocautery. For example, diathermy, laser, and electrocautery waveforms may be used to cut and / or coagulate membranes surrounding a subdural hematoma, septa within the hematoma, or any source of bleeding. Diathermy, laser, and electrocautery waveforms may also be used to close vascular lumens, such as transvascular passageways and MMAs. In some embodiments, the monopolar or bipolar cautery may be separate from or integrated with the catheter and / or shaft. In some embodiments, one or more of the shaft and catheter may be coupled with thermal ablation. For example, the signal generator may generate monophasic (DC) pulses and biphasic (DC and AC) pulses. The signal generator may comprise a processor, a memory, an energy source, and a user interface. The processor may incorporate data received from one or more of the memory, the energy source, the user interface, and the catheter assembly. The memory can further store instructions that cause the processor to execute modules, processes, and / or functions associated with the system, such as waveform generation and delivery. For example, the memory can be configured to store patient data, clinical data, treatment data, etc. In some embodiments, the signal generator can be configured to generate a waveform within the ranges of about 250 kHz to about 750 kHz and about 120 V to about 400 V, including all ranges and subvalues ​​therebetween. In some embodiments, the signal generator can be configured to generate an ablation waveform (e.g., cutting waveform) within the range of about 1 W to about 300 W, including all ranges and subvalues ​​therebetween. For example, a transvascular opening between the lumen of the MMA and the subdural space can be formed by the signal generator generating an ablation waveform including a power of about 15 W to about 60 W, a duty cycle of at least about 300 ms, and a duration of less than about 5 seconds, including all ranges and subvalues ​​therebetween. For example, the ablation waveform can be generated for less than about 2 seconds.

[0101] Generally, a processor (e.g., a CPU) described herein can process data and / or other signals to control one or more components of a system. The processor can be configured to receive, process, compile, calculate, store, access, read, write, and / or transmit data and / or other signals. In some embodiments, the processor can be configured to access or receive data and / or other signals from one or more of a sensor (e.g., impedance sensor, pressure sensor) and a storage medium (e.g., memory, flash drive, memory card). In some embodiments, a processor may be any suitable processing device configured to operate and / or execute a set of instructions or code, and may include one or more data processors, image processors, graphics processing units (GPUs), physical processing units, digital signal processors (DSPs), analog signal processors, mixed-signal processors, machine learning processors, deep learning processors, finite state machines (FSMs), compression processors (e.g., data compression to reduce data rates and / or memory requirements), encryption processors (e.g., for secure wireless data and / or power transfer), and / or central processing units (CPUs). A processor may be, for example, a general-purpose processor, a field programmable gate array (FPGA), an application specific integrated circuit (ASIC), a processor board, etc. The processor may be configured to operate and / or execute application processes and / or other modules, processes and / or functions associated with the system.The underlying device technology can be provided in a variety of component types (e.g., metal-oxide semiconductor field-effect transistor (MOSFET) technologies such as complementary metal-oxide semiconductor (CMOS), bipolar technologies such as emitter-coupled logic (ECL), polymer technologies (e.g., silicone-conjugated polymers and metal-conjugated polymer-metal structures), mixed analog and digital technologies, etc.

[0102] The systems, devices, and / or methods described herein may be implemented by software (executed on hardware), hardware, or a combination thereof. Hardware modules may include, for example, general-purpose processors (or microprocessors or microcontrollers), field-programmable gate arrays (FPGAs), and / or application-specific integrated circuits (ASICs). Software modules (executed on hardware) may be expressed in various software languages ​​(e.g., computer code), including C, C++, Java, Python, Ruby, Visual Basic, and / or other object-oriented, procedural, or other programming languages ​​and development tools. Examples of computer code include, but are not limited to, microcode or microinstructions, machine instructions such as those produced by a compiler, code used to create web services, and files containing high-level instructions executed by a computer using an interpreter. Additional examples of computer code include, but are not limited to, control signals, encryption code, and compression code.

[0103] Generally, ablation devices described herein may comprise a memory configured to store data and / or information. In some embodiments, the memory may include one or more of random access memory (RAM), static RAM (SRAM), dynamic RAM (DRAM), memory buffer, erasable programmable read-only memory (EPROM), electrically erasable read-only memory (EEPROM), read-only memory (ROM), flash memory, volatile memory, non-volatile memory, combinations thereof, etc. In some embodiments, the memory may store instructions that cause a processor to perform modules, processes, and / or functions, such as signal waveform generation, system control, data and / or signal transmission, data and / or signal reception, and / or communications. Some embodiments described herein may relate to computer storage products with a non-transitory computer-readable medium (which may also be referred to as a non-transitory processor-readable medium) having instructions or computer code for performing various computer-implemented operations. The computer-readable medium (or processor-readable medium) is non-transitory in the sense that it does not include transient, propagating signals (e.g., propagating electromagnetic waves that carry information over a transmission medium such as space or a cable) themselves. The medium and computer code (which may also be called code or algorithms) may be designed and constructed for one or more specific purposes.

[0104] In some embodiments, the system may further include a communications device configured to enable an operator to control the system. The communications device may include a network interface configured to connect the system to another system (e.g., the Internet, a remote server, a database) via a wired or wireless connection. In some embodiments, the system may communicate with other devices (e.g., a mobile phone, a tablet, a computer, a smartwatch, etc.) via one or more wired and / or wireless networks. In some embodiments, the network interface may include one or more of an RF receiver / transmitter, an optical (e.g., infrared) receiver / transmitter, etc. configured to communicate with one or more devices and / or networks. The network interface may communicate with one or more of the system, the network, the database, and the server via a wired and / or wireless connection.

[0105] The network interface may include RF circuitry configured to receive and / or transmit RF signals. This RF circuitry can convert electrical signals to and from electromagnetic signals and communicate with communication networks and other communication devices via electromagnetic signals. The RF circuitry can include known circuits for performing these functions, including, but not limited to, an antenna system, an RF transceiver, one or more amplifiers, a tuner, one or more oscillators, a mixer, a digital signal processor, a CODEC chipset, a subscriber identity module (SIM) card, memory, etc.

[0106] Wireless communication through any of the devices may use any of a number of communications standards, protocols, and technologies, including Global System for Mobile Communications (GSM), Enhanced Data GSM Environment (EDGE), high-speed downlink packet access (HSDPA), high-speed uplink packet access (HSUPA), Evolution, Data-Only (EV-DO), HSPA, HSPA+, Dual-Cell HSPA (DC-HSPA), long term evolution (LTE), near field communication (NFC), wideband code division multiple access (W-CDMA), code division multiple access (CDMA), time division multiple access (TDMA), Bluetooth, Wireless Fidelity (WFI), and the like. Fidelity, WiFi) (e.g., IEEE802.11a, IEEE802.11b, IEEE802.11g, IEEE802.11n, etc.), voice over Internet Protocol (VoIP), Wi-MAX, protocols for email (e.g., Internet message access protocol (IMAP) and / or post office protocol (POP)), instant messaging (e.g., extensible messaging and presence protocol (XMPP), Session Initiation Protocol for Instant Messaging and Presence Leveraging Extension (SIMPLE), Instant Messaging and Presence Service (IMPS)), and / or Short Message Service (SMS), or any other suitable communication protocol. In some embodiments, devices herein can communicate directly with each other without transmitting data over a network (e.g., via NFC, Bluetooth, WiFi, RFID, etc.).

[0107] In some embodiments, the input devices (e.g., keyboards, buttons, touchscreens) and output devices (e.g., display devices) may be configured to receive input data from one or more of a system, a network, a database, and a server. For example, operator control of the input devices (e.g., keyboards, buttons, touchscreens) may be received by the input / output devices and then processed by a processor and memory for the user interface to output control signals to the system. Some embodiments of the input devices may include at least one switch configured to generate a control signal. For example, the input device may include a touch surface for an operator to provide input (e.g., a finger touch on the touch surface) corresponding to the control signal. Input devices with touch surfaces may be configured to detect contact and movement on the touch surface using any of a number of touch sensitivity technologies, including capacitive, resistive, infrared, optical imaging, dispersive signal, acoustic pulse recognition, and surface acoustic wave technologies. In embodiments of input devices that include at least one switch, the switch may include, for example, at least one of a button (e.g., hard key, soft key), a touch surface, a keyboard, an analog stick (e.g., a joystick), a directional pad, a mouse, a trackball, a jog dial, a step switch, a rocker switch, a pointer device (e.g., a stylus), a motion sensor, an image sensor, and a microphone. The motion sensor may receive operator movement data from an optical sensor and classify the operator's gestures as control signals. The microphone may receive audio data and recognize the operator's voice as a control signal.

[0108] A haptic device can be incorporated into one or more of the input and output devices to provide additional sensory output (e.g., force feedback) to the operator. For example, a haptic device may generate a haptic response (e.g., vibration) to confirm an operator input on an input device (e.g., a touch surface). As another example, haptic feedback may signal that an operator input is overridden by the system.

[0109] Visualization Device In some embodiments, the visualization device 570 can be configured to visualize (e.g., generate one or more images) corresponding to one or more components of the catheter assembly 502 disposed within a subject (e.g., the catheter 510, the shaft 520, the hemostasis device 530). As described in more detail herein, the visualization device 570 can facilitate positioning of the catheter assembly 502 within the intravascular and extravascular spaces of a subject (e.g., the orientation and placement of the distal tip portion 522 and the piercing element 524 relative to the blood vessel).

[0110] In some embodiments described herein, one or more elements of the catheter assembly 502 (e.g., catheter 510, shaft 520, hemostasis device 530) may include a set of fiducials (e.g., radiopaque elements) spaced along the length of the catheter assembly 502 (e.g., catheter 510, shaft 520) and configured to be imaged by a visualization device. For example, the set of fiducials may include radiopaque fluoroscopic markers (FMs).

[0111] In some embodiments, the radiopaque element may include one or more of gold, platinum, platinum-iridium, tantalum, bismuth, tungsten-filled polymers, combinations thereof, etc. In some embodiments, a reference point may be disposed at the proximal end of the piercing element 524 to indicate the relative position of the distal end of the piercing element 524. In some embodiments, the reference point may be configured to indicate a rotational orientation.

[0112] For example, visualization may include one or more of optical coherence tomography (OCT) and intravascular ultrasound (IVUS). With IVUS, the dura mater, dural appendages, cerebrospinal fluid, superficial pia mater, cortical gray matter, and white matter are hyperechoic. The subarachnoid space contains numerous blood vessels that can be seen in Doppler ultrasound. The subdural collection may have a hyperechoic membrane, which may be hyperechoic, hypoechoic, or a combination thereof.

[0113] In some embodiments, visualization may include a combination of invasive (e.g., US, CTO, angioscopy) and non-invasive (fluoroscopy, US, CT, MR) imaging modalities. In some embodiments, the catheter 510 may include an optical sensor (e.g., a camera) and / or a light source for endoscopic visualization of one or more of catheter advancement in the subdural or epidural space and transvascular drainage of subdural collections. In some embodiments, the optical sensor may include one or more of an optical fiber, a complementary symmetry metal oxide semiconductor, a scanning fiber endoscope, combinations thereof, and the like.

[0114] In some embodiments, the system 500 may include one or more magnets configured to provide one or more of directionality, penetration, and guidance. For example, the catheter assembly 502 may include a first magnet, and an external source configured to be disposed on an outer surface of the head may include a second magnet, where the first magnet and the second magnet may be configured to provide one or more of directionality, penetration, and guidance. In some embodiments, the magnet may be a permanent magnet, a temporary magnet, and / or an electromagnet. In some embodiments, the magnet may be composed of one or more of neodymium, samarium-cobalt, platinum-cobalt, alnico, ceramic, and ferrite.

[0115] Illustrative Embodiments 6 is a schematic diagram of a system 600 including a catheter 610, a shaft 620, a connector 640, and a signal generator 650. Catheter 610 and shaft 620 may include structurally and / or functionally similar components to catheter 510 and shaft 520, respectively, as described above with reference to FIG. 5. System 600 may be configured to deliver a hemostatic element or RF device to form an opening between a blood vessel of a subject and the extravascular space and / or to close the opening formed by shaft 620. In some embodiments, catheter 610 may be slidably disposed within the lumen of a sheath.

[0116] In some embodiments, the shaft 620 can be coupled to the signal generator 650. The shaft 620 can include a distal tip portion 622 having a piercing element 624 configured to create (e.g., form) an opening in the wall of a target blood vessel and the dura mater. In some embodiments, the distal tip portion 622 can have a predetermined shape, such as, for example, a J-shaped curve, as described further below. Alternatively, in some embodiments, the distal tip portion 622 can have a different predetermined or preset shape, such as, for example, a U-shape, a C-shape, or other atraumatic shape. In some embodiments, the shaft 620 (e.g., the distal tip portion 622) can further include an offset (not shown) configured to orient the shaft 620 in a predetermined orientation when the shaft 620 is advanced within the lumen of the catheter 610 and the blood vessel. For example, the offset can be configured to rotate (e.g., self-orient) distal tip portion 622 about the longitudinal axis of shaft 620 so that the drilling element is directed toward the dura and brain, while the proximal portion of the J-shaped distal tip portion faces the skull, thereby ensuring that the opening created by drilling element 630 is formed in an arc facing the subdural space and not the skull. In this configuration, system 600 can function as a rotating lever, the fixed path of blood vessels, bone, and dura can function as a fulcrum, friction between system 600 and blood vessels acts as resistance, and the release of elastic potential energy corresponding to the predetermined curve of system 600 results in rotational movement and self-orientation for entry from the vasculature into the subdural space.

[0117] As described in more detail herein, the shaft 620 can have a generally rounder cross-sectional shape (e.g., circular or elliptical), and the offset can have a relatively flatter, oval cross-sectional shape configured to rotate or twist the distal tip portion 622 into a desired orientation (e.g., facing away from the skull and toward the dura) when advanced through a tortuous vasculature. The J-shaped curve of the distal tip portion 622 can be advantageous in facilitating atraumatic advancement of the shaft 620 through the subdural space. The J-shaped curve can be constrained as the shaft is advanced through the vasculature, but can naturally form within the subdural space after the shaft 620 creates an opening through the blood vessel and the dura. The distal end of the distal tip portion 622 can include a piercing element 630, such as an electrode configured to deliver RF energy. In some embodiments, the piercing element 630 can be angled relative to the distal tip portion 622.

[0118] In some embodiments, connector 640 may be configured to couple catheter 610 and shaft 620 to a signal generator 650 and a vacuum source (not shown). In some embodiments, signal generator 650 may be coupled to shaft 620. In particular, signal generator 650 may be configured to generate energy (e.g., RF energy) for delivery using piercing element 624 of distal tip portion 622.

[0119] In some embodiments, the catheter 610 and / or shaft 620 may include a set of reference points, including a first reference point 630 and a second reference point 632, configured to be imaged and to facilitate positioning of the system 600 within the intravascular and extravascular spaces of the subject.

[0120] Figures 7A and 7C are schematic diagrams of shaft assemblies 700, 704, and Figures 7B, 7D, and 7E are detailed schematic diagrams of shaft assemblies 702, 706, and 708, respectively, shown in Figures 7A and 7C. Shaft assemblies 700-708 may include structurally and / or functionally similar components to shafts 520, 620, respectively.

[0121] The shaft assemblies 700, 702 shown in FIGS. 7A and 7B may include a handle 710, a piercing element 720, a first reference point 732, a second reference point 734, and a third reference point 736. In some embodiments, the first reference point 732 corresponds to the location of the piercing element 720, the second reference point 734 facilitates confirmation of the shaft's self-orientation, and the third reference point 736 corresponds to the location of the shaft's maximum outer diameter. In some embodiments, the piercing element 720 and the first reference point 732 may form an angle with the second reference point 734 of about 5° to about 15°, including all ranges and subvalues ​​therebetween. In some embodiments, as shown in FIG. 7B, the bent portion of the shaft assembly formed by the piercing element 720 and the first reference point 732 may have a length extending along the longitudinal axis of the shaft assembly 700 of about 2.3 cm to about 2.7 cm, including all ranges and subvalues ​​therebetween.

[0122] The shaft assemblies 704, 706 shown in FIGS. 7C and 7D further illustrate a distal tip portion 740 of the shaft. The distal tip portion 740 can have a piercing element 720 configured to create (e.g., form) an opening in the wall of a target blood vessel and the dura. In some embodiments, the distal tip portion 740 can have a predetermined shape, such as a J-shaped curve. The distal end of the distal tip portion 740 can include a piercing element 720, such as an electrode configured to deliver RF energy. In some embodiments, as shown in FIGS. 7C and 7D , the piercing element 720 can be angled relative to the distal tip portion 740. While disposed within a blood vessel (e.g., the MMA), the shape of the distal tip portion 740 can be constrained by the blood vessel so that a J-shape is not formed within the blood vessel. The unconstrained shape of the distal tip portion 740 can be formed when the distal tip portion 740 is advanced through the opening in the blood vessel and the dura. In some embodiments, the set of reference points 732, 734, 736 may be configured to be imaged (e.g., visualized) to facilitate positioning of the shaft assemblies 700-708 within the intravascular and extravascular spaces of a subject.

[0123] In some embodiments, the shaft can have a length of at least about 130 cm (e.g., about 160 cm to about 180 cm) from the femoral or radial access point. The shaft may be shorter when using a cervical access point. In some embodiments, the piercing element 720 can be angled toward the shaft to focus energy delivery by the piercing element 720 on the tissue at the contact point to vaporize the tissue and minimize heat generation and tissue shrinkage. Additionally or alternatively, a higher energy level to vaporize (e.g., ablate) more tissue can be used to form the transvascular passage (e.g., if the piercing element 720 does not include a contact point to focus energy delivery). In some embodiments, as shown in FIGS. 7C and 7D , the piercing element 720 can form an angle of about 15° to about 35° (including all ranges and subvalues ​​therebetween) with respect to the distal end of the distal tip portion 740.

[0124] In some embodiments, the height of the curved portion of the distal tip portion can be from about 0.5 cm to about 2.0 cm, including all ranges and subvalues ​​therebetween. In some embodiments, the shaft forms a J-shape, as shown in Figures 7C and 7D.

[0125] The perforating element 720 can have an angle and length configured to provide depth-controlled perforation of the MMA and dura but not the brain. In some embodiments, the distance between the distal end of the perforating element 730 and the distal end of the shaft (e.g., defined by the curved portion of the distal tip portion 740) can be from about 1 cm to about 1.4 cm (including all ranges and subvalues ​​therebetween).

[0126] In some embodiments, the outer diameter of the shaft may vary in a predetermined manner along its length. For example, the shaft may have a first outer diameter 733 and a second outer diameter 735 that is larger than the first outer diameter 735. In some embodiments, the first outer diameter 733 of the shaft may generally be from about 0.020 inches to about 0.027 inches (including all ranges and subvalues ​​therebetween). The second outer diameter 735 of the shaft may generally be from about 0.0255 inches to about 0.0270 inches (including all ranges and subvalues ​​therebetween). The outer diameter of the shaft may taper from the first outer diameter 733 to the second outer diameter 735 and back to the first outer diameter 733 over a length of about 4 mm to about 6 mm (including all ranges and subvalues ​​therebetween), as shown in FIG. 7E. In some embodiments, the first reference point 732 (eg, the most distal reference point) may have a second outer diameter 735 and the remainder of the shaft has a first outer diameter 733 .

[0127] In some embodiments, the second outer diameter can substantially match (e.g., within 0.002 inches) the inner diameter of the corresponding catheter to reduce and / or limit longitudinal advancement of the shaft relative to the catheter. This can aid in parallel advancement of the shaft and catheter through the subdural space where the shaft and catheter are fixed relative to one another.

[0128] 8A-8C are images of different portions of shafts 800, 802, and 804. Shafts 800-804 may include structurally and / or functionally similar components to shafts 520, 620, and 700-708 described herein. Shaft 800 shown in FIG. 8A may include a distal tip portion 840 and a piercing element 820 attached to its distal end. In some embodiments, piercing element 820 may be angled relative to distal tip portion 840, as described herein. piercing element 820 may include an electrode configured to deliver RF energy. As shown in FIG. 8A, distal tip portion 840 may have a generally J-shaped curve.

[0129] 8B illustrates a portion of the shaft between the distal end of shaft 800 and the proximal portion of shaft 804. Shaft 802 may include a first reference point 832 and an offset 850 configured to orient at least a distal tip portion 840 of the shaft in a predetermined orientation as the shaft is advanced within a blood vessel. For example, offset 850 may have a relatively flattened oval cross-sectional shape relative to the remainder of the shaft, and offset 850 may be configured to rotate or twist distal tip portion 840 and perforated electrode 820 as it is advanced through angled vasculature. The flatter shape of offset 850 may be configured to bend in one plane over another.

[0130] In some embodiments, the first reference point 832 may be located a predetermined distance from the distal end of the shaft 804 corresponding to the minimum length required for the shaft 804 to advance past the spinous foramen for the offset 850 to self-orient by rotating about the longitudinal axis of the shaft 804. The location of the first reference point 832 may be determined empirically and / or based on the target anatomy (e.g., CT scan data of the bone MMA groove). Additionally or alternatively, the shape of the distal tip portion 840 may be modified based on the target anatomy. FIG. 8C shows the proximal portion 804 of the shaft including a second reference point 834 having a second outer diameter that is larger than the first outer diameter 833 of the shaft.

[0131] FIG. 9 is a schematic diagram of a shaft assembly 900 corresponding to a straight tip RF device. The shaft assembly 900 may include structurally and / or functionally similar components to the shafts 520, 620, 700-708, and 800-804 described herein. The shaft assembly 900 may include a handle 910 and a shaft 920. The shaft 920 may include a piercing element 930 and a reference point 940. The piercing element 930 may be configured to cut soft tissue and create (e.g., form) openings in the wall of a blood vessel and the dura mater of a target. The shaft 920 is shown in FIG. 9 as having a linear (e.g., straight) configuration without a predetermined curve. The reference point 940 may be configured to be imaged (e.g., visualized) to facilitate positioning of the shaft assembly 900 in the intravascular and extravascular spaces of a target.

[0132] In some embodiments, the piercing element 930 is approximately 16 mm 2 Less than 1mm 2 ~about 5mm 2 (including all ranges and subvalues ​​therebetween). In some embodiments, the energy delivery portion of the piercing element 930 may have a length of about 1.3 mm to about 1.7 mm (including all ranges and subvalues ​​therebetween).

[0133] In some embodiments, the piercing element 930 has a resistance of about 1,200 A / m 2 ~Approx. 12,000A / m 2 , approx. 2,000A / m 2 ~Approx. 10,000A / m 2 , approx. 2,000A / m 2 ~Approx. 5,000A / m 2 , approx. 5,000A / m 2 ~Approx. 10,000A / m 2 , approx. 1,200A / m 2 ~Approx. 6,000A / m 2 , about 8,000A / m 2 ~Approx. 12,000A / m 2In some embodiments, the piercing element 930 can be configured to deliver a power of about 10 W to about 100 W, about 20 W to about 75 W, including all ranges and subvalues ​​therebetween.

[0134] To navigate the small, delicate blood vessels of the brain, conventional neurovascular guidewires (e.g., Stryker Synchro 2, Aristotle 14) have low tip bending stiffness. However, the shafts disclosed herein require sufficient tip bending stiffness to penetrate blood vessels and the dura. In some embodiments, the piercing element 930 can have a tip bending stiffness of about 0.5 gf to about 15 gf (including all ranges and subvalues ​​therebetween) (e.g., when the distal end of the shaft 520 is attached about 5 mm, about 10 mm, and about 20 mm from the distal end of the distal tip portion 522). In some embodiments, the distal portion of the shaft 920 (e.g., up to about 300 mm from the piercing element 930) can have a column strength of up to about 100 gf, about 10 gf to about 50 gf, and about 50 gf to about 100 gf (including all ranges and subvalues ​​therebetween).

[0135] In some embodiments, one or more portions of shaft 920 can have a cross-section with a first transverse dimension that is greater than a second transverse dimension. In some embodiments, shaft 920 can include a wide section having a transverse dimension equal to or substantially equal to the inner diameter of the corresponding catheter lumen to prevent ovalization of the catheter as it is advanced through the opening, facilitate bending of the shaft in a first plane, and limit bending in a second plane perpendicular to the first plane.

[0136] II. Method Also described herein are methods for accessing the extravascular intracranial space using the systems and devices described herein to enable transvascular surgery without opening the skull. In particular, the systems and devices described herein can be configured to facilitate the removal of fluids (e.g., SDH). A method of using such systems and devices can include, for example, positioning a catheter disposed within a subject's intracranial blood vessel; advancing a shaft through a lumen of the catheter so that the curved section of the shaft curves in a direction that follows the curvature of the blood vessel; extending the curved section from the catheter to curve the curved section of the shaft toward a wall of the blood vessel; activating an RF element to deliver RF energy to the wall of the blood vessel and create an opening through the wall of the subject's blood vessel and the dura mater into the extravascular intracranial space; and advancing the shaft and catheter into the extravascular intracranial space. In some embodiments, suction can be applied to the lumen of the catheter to remove fluid from a subdural hematoma. The catheter can be retracted toward the arterial opening, and a hemostatic element or RF device can be delivered to close the opening.

[0137] The viscosity of SDH fluid is traditionally considered too thick to be aspirated through a catheter with the small diameter required to induce MMA. However, rheological analysis of a cohort of cSDH samples empirically demonstrates that the catheter described herein can consistently drain cSDH fluid, as shown in the plot of fluid shear rate versus viscosity in chronic and subacute subdural hematomas in Figure 18. Specifically, a set of 43 SDH samples from 35 subjects who underwent burr hole surgical drainage was obtained. The viscosity was approximately 0.1 s -1 , about 1.0 seconds -1 , about 10.0s -1 , about 100.0s -1 and approximately 1000.0s -1The flow rates were measured at variable shear rates of 1000 rpm. Variable shear rates were used because the samples are non-Newtonian fluids whose viscosity is shear rate dependent. The empirical flow rate for each sample was measured through a 0.027 inch internal diameter catheter, as this allowed it to be consistently advanced into the intracranial MMA trunk.

[0138] Figures 19A-19C show diagrams of topographic heat maps depicting the probability of hematomas located on the brain surface based on non-contrast head CT of a cohort of 71 subjects with cSDH. Figure 19A is a top view of the hematoma heat map 1900. The legend indicates probability on a scale from 0 to 1 in 0.1 increments, and in millimeters for x and y. Figure 19B shows the hematoma heat map 1902 overlaid with a set of arterial perforation trajectories 1940, 1950.

[0139] Through modeling and testing, it was found that the location and orientation of the perforations in the MMA correspond to the trajectories 1940, 1950 of the catheter and shaft advanced through the extravascular space. For example, FIG. 15A is a superior cross-sectional image of an open cadaveric head in which a catheter 1560 and shaft 1562 have been advanced out of a perforation 1544 in the MMA 1540. As shown in FIG. 15A, the catheter 1560 and shaft 1562 advance in a straight line from the perforation 1544 so that the perforation location can be selected to direct the catheter 1560 and shaft 1562 to an area of ​​high probability of SDH occurrence (e.g., toward the top of the patient's head). FIG. 15B is a side view of a 3D rendering of a computed tomography scan of a subject with a catheter 1560 advanced along a straight line trajectory from a perforation 1544 in the MMA.

[0140] FIG. 19B shows a set of catheter and shaft trajectories from perforation of the posterior branch of the MMA 1932, including hematoma trajectories 1940 that facilitate access to high-probability SDH regions (e.g., along the horizontal dashed lines) and non-hematoma trajectories 1950 that lead to low-probability SDH regions. FIG. 19C overlays a hematoma heat map 1904 with a set of arterial perforation locations 1920 (e.g., perforation maps) corresponding to the hematoma trajectories 1940 in FIG. 19A. FIG. 19D plots the probability that the set of arterial perforation trajectories intersects with different SDH regions. For example, the high-probability SDH region 1910 includes a significantly higher proportion of sets of arterial perforation trajectories 1920 than the medium-probability SDH region 1912 and the low-probability SDH region 1914. Thus, perforating the MMA within the set of arterial perforation locations 1920 results in a high probability of the catheter and shaft advancing into the high-probability SDH region of interest. For example, of the 107 cases studied, it was estimated that the device described herein could reach the SDH in 105 cases by selecting an appropriate puncture point and advancing up to approximately 5 cm into the subdural space. In the majority (92 / 105), the distal tip of the catheter reached an area where the SDH was likely to be present (e.g., greater than approximately 80%).

[0141] Morphometric analysis of MMA subjects undergoing MMAe found that the MMA angle at the spinous foramen was 100° ± 14°, and the MMA groove along the concave middle cranial fossa followed an angle of 160° ± 5.8°. A catheter with a distal outer diameter of 0.93 mm (0.036 in) could be sufficient to guide the MMA into the trunk in at least 84% of subjects. Anterior division of the MMA was not considered to provide an adequate transarterial route given the high incidence (up to 75%) of bony tunnels that prevented perforation and because of the medially projecting path along the sphenoid eminence that directed the emerging shaft toward the brain.

[0142] Methods for accessing the extravascular space may include navigating a catheter assembly to a predetermined location (e.g., a puncture point), creating a transvascular passageway from the intravascular compartment to the extravascular space, and advancing the catheter assembly to perform the procedure. For example, the catheter assembly may be advanced to penetrate the membrane and septum of a subdural hematoma, and then suction may be applied to drain the subdural hematoma. Methods using the systems and devices described herein may reduce blood extravasation while maintaining a patent passageway, enable navigation within the intracranial compartment without brain perforation or injury, allow evacuation of subdural collections, and facilitate arteriotomy (e.g., perforation of the arterial wall and / or dura) closure and arterial occlusion upon removal of the catheter system.

[0143] 10 is a flowchart of a method 100 for performing a medical procedure (e.g., evacuation of a subdural hematoma, delivery of a therapeutic agent, implantation of a device) within an extravascular space (e.g., a subject's intracranial space, extravascular space along the spinal cord). Method 1000 may include, at 1010, guiding a catheter through a subject's intracranial vessel to a perforation point. For example, a distal end of the catheter disposed within the subject's intracranial vessel may be positioned near a target location. In particular, a middle meningeal artery transvascular subdural hematoma procedure may include advancing a sheath into the MMA (before or after embolization of the MMA).

[0144] 17A, for example, illustrates the varying diameters of an MMA 1740 disposed between a brain 1720, a dura mater 1730, and a skull 1710. As shown in axial cross sections along lines AA, BB, and CC, respectively, the MMA 1740 is disposed between the dura mater 1730 and the skull 1712. In particular, the MMA 1740 extends within a recess 1712 in the skull 1710 and is generally parallel to the brain 1720. However, the diameter of the MMA 1740, as well as the diameter of the recess 1712, decreases distally such that the distally extending longitudinal axis of the MMA 1740 intersects with and is non-parallel to the dura mater 1730.

[0145] In some embodiments, a catheter including a proximal segment and a distal segment can be advanced through a sheath. The proximal segment can be, for example, a push wire configured to control movement (e.g., translation) of the catheter through the sheath. The tapered outer diameter of the distal segment can be configured to limit the length the distal segment can be advanced distally beyond the distal end of the sheath.

[0146] At 1020, the shaft may be advanced distally beyond the distal end of the catheter, or may be advanced flush with the end of the catheter, which may retract the shaft out of the sheath. For example, the shaft may be advanced through the lumen of the catheter so that the curved section of the shaft curves in a direction that follows the curvature of the blood vessel. The curved section may be constrained within the lumen of the catheter within the blood vessel. The curved section of the shaft may extend from the distal end of the catheter, where the curved section curves toward the wall of the blood vessel and positions a perforation element (e.g., RF element) disposed at the distal end of the shaft against the wall of the blood vessel. For example, the perforation element may be advanced distally to the catheter adjacent to a perforation point within a blood vessel, such as the MMA. Alternatively, FIG. 17B shows a catheter assembly (e.g., straight-tip RF device, shaft assembly 900) disposed within the MMA 1740 between the dura mater 1730 and the skull 1710. The catheter assembly may include a catheter 1760 and a shaft 1762 that is advanced distally beyond the distal end of the catheter 1760. The shaft 1762, including the piercing tip 1764, may be flexible but generally straight when unconstrained. That is, the distal portion of the shaft 1762 may be straight and have no predetermined curve.

[0147] At 1030, a perforating element on the shaft can be used to create an opening in the wall of an intracranial blood vessel and the dura mater. For example, the RF element can be activated to deliver RF energy to the wall of the blood vessel, creating an opening through the wall of the target blood vessel (e.g., MMA) and the dura mater into the extravascular intracranial space (e.g., subdural space). Optionally, a fluid (e.g., contrast agent, saline) can be injected adjacent to the opening to confirm the opening, cool the tissue, and / or increase the lubricity and width of the opening. As depicted in FIG. 17C , the perforating element 1764 can be configured to perforate the wall of the MMA and provide access to the epidural space (e.g., between the dura mater 1730 and the MMA 1740). Additionally or alternatively, the perforating element 1764 can be configured to perforate the wall of the MMA and the dura mater to provide access to the subdural space (e.g., below the dura mater 1730). For example, RF energy having a predetermined current density can be delivered to the perforating element 1742 to locally vaporize the MMA 1740, but insufficiently to damage the skull 1710. The longitudinal axis of the MMA 1740 can be angled relative to the dura 1730, allowing an opening created in the wall of the MMA to form an angle relative to the dura 1730 through which the perforating element 1764 and shaft 1762 can naturally advance into one or more of the epidural space and the dura. For example, FIG. 17C shows the shaft 1762 advanced at an oblique angle through the opening 1742 and into the dura 1730. As shown in the axial view of FIG. 17A, the decreasing diameter of the recess 1712 in the MMA 1740 and skull 1710 gradually increases the angle at which the longitudinal axis of the shaft 1762 intersects with the dura 1730. In some embodiments, the shaft 1762 may be advanced through the epidural space about 1 cm or more, which may ensure that the brain 1720 is not perforated.

[0148] At 1040, the shaft can be advanced into an extravascular space (e.g., extravascular intracranial space, extravascular spinal intradural space). For example, the shaft can be advanced into the subdural space. In some embodiments, the distal end of the shaft can be advanced into the extravascular intracranial space until the curved section transitions to an unconstrained configuration within the extravascular intracranial space. FIG. 17D shows the perforating element 1764 and shaft 1762 advanced through the dura 1730 and opening 1742 in the MMA 1740 when a predetermined amount of current density is delivered from the perforating element 1764. The opening 1742 in the dura 1730 is formed at an angle relative to the surface of the dura such that the shaft 1762 extends obliquely through the dura 1730 and naturally advances substantially parallel to the surface of the dura 1730. In this manner, brain perforation can be prevented during advancement of the shaft and catheter into the extravascular subdural space. In some embodiments, the catheter can be advanced over the shaft into the extravascular intracranial space. For example, FIG. 17E shows a catheter 1760 being advanced over a shaft 1764 into the subdural space.

[0149] At 1050, one or more of the catheter and shaft may optionally be advanced to the target site. For example, the catheter and / or shaft may be advanced to the subdural hematoma. In some embodiments, a proximal portion of the catheter may be actuated (e.g., pushed) to advance a distal portion of the catheter past the piercing element and into the extravascular space (e.g., the subdural space). In some embodiments, the piercing element may be withdrawn through the catheter and sheath. A sealing region of the catheter may remain disposed within the lumen of the sheath to seal the catheter against the sheath.

[0150] At 1060, a medical procedure may be performed. For example, suction may be applied to drain the subdural hematoma, deliver a therapeutic agent, implant a sensor or electrode, deliver a biopsy needle, etc. In some embodiments, the distal end of the shaft may be advanced into the subdural hematoma. A catheter may be advanced over at least a portion of the shaft into the subdural hematoma. After the catheter is positioned within the subdural hematoma, suction may be applied to the lumen of the catheter to remove fluid from the subdural hematoma.

[0151] In some embodiments, a vacuum source may be coupled to the sheath to apply negative pressure to the sheath lumen, which propagates from the sheath lumen to the lumen of the distal segment of the catheter, facilitating high-flow SDH evacuation. The sheath disposed within the MMA prevents antegrade blood flow, and embolization of the distal artery prevents retrograde blood flow, thus minimizing the risk of blood extravasation. Optionally, a flat-panel CT scan can be performed to assess, for example, the volume of residual subdural space or midline shift.

[0152] At 1070, the catheter can be retracted toward the opening in the wall of the intracranial vessel. For example, the catheter can be retracted toward an opening created in the wall of the artery (e.g., the MMA) using a proximal portion of the catheter.

[0153] Optionally, a hemostatic element can be used to close the opening in the wall of the intracranial vessel at 1080. For example, a hemostatic element or RF device can be delivered through the lumen of the catheter to close the opening.

[0154] Optionally, embolic material can be injected to occlude bleeding branch vessels at 1090. In some embodiments, the embolic material can be injected before creating the opening in the wall of the intracranial vessel and the dura mater of the brain (e.g., before step 1030). Steps 1080 and 1090 can be optional if the hole in the intracranial vessel (e.g., vein) is very small and / or if a device (e.g., implant) is disposed across the opening.

[0155] The steps in method 1000 are described and depicted in more detail with respect to Figures 11A-11L, 12A-12B, 13A-13J, 14A-14F, 15A-15B, 16, and 17A-17D. The catheter assemblies described in these figures may include components structurally and / or functionally similar to the catheter assembly components described with respect to Figures 5, 6, 7A-7D, 8A-8C, and 9.

[0156] 11A-11L are x-ray images and photographs of a method of accessing the extravascular intracranial space using the MMA 1120, corresponding to steps of method 1000. The anatomical structures shown in FIGS. 11A-11L include the MMA 1120 (e.g., the middle cranial fossa), the spinous foramen 1122, the frontal branch of the MMA 1124, the parietal branch of the MMA 1126, a bone 1150 (e.g., the skull), and the subdural space 1160. As shown in image 1100 of FIG. 11A, the distal end of a catheter may be disposed within a subject's intracranial vasculature near a target location. In particular, the catheter may be guided through the MMA 1120 distal to the spinous foramen (which has a sharp bend). The catheter may be imaged via a first catheter reference point 1130 disposed at the distal end of the catheter and a second catheter reference point 1132 disposed proximal to the first catheter reference point 1130. A second catheter reference point 1132 is disposed just proximal to the spinous foramen 1122 in FIG. 11A.

[0157] The shaft can be disposed within the lumen of the catheter. The shaft can include a piercing element (e.g., electrode, piercing tip) 1142, a first discontinuity between the piercing element and a curved section of the shaft (e.g., a distal tip portion), a second discontinuity disposed proximal to the curved section, a first shaft reference point 1144, and a second shaft reference point 1146. The second discontinuity can be located at or proximal to the first shaft reference point 1144. The second discontinuity can include an offset (e.g., a partial helix, a twist) configured to orient the curved section to follow the curvature of the blood vessel (following the curvature of the skull base and calvaria with an internal concavity) as the shaft is advanced within the lumen of the catheter.

[0158] In FIG. 11B , the perforating element 1142 is advanced beyond the sharp bend in the spinous foramen into the middle cranial fossa where the first shaft reference point 1144 is not advanced beyond the spinous foramen 1122. In some embodiments, the first shaft reference point 1144 does not self-orient (e.g., rotate) the distal end of the shaft until the first shaft reference point 1144 is advanced beyond the spinous foramen 1122. As shown in image 1102 of FIG. 11B , the perforating element 1142 is slightly biased toward the bone 1150 such that the perforating element 1142 faces toward the bone 1150 rather than the subdural space 1160. When RF energy is applied to electrodes positioned as in FIG. 11B , an opening in the MMA 1120 is formed facing the bone 1150 rather than the subdural space 1160. Thus, perforating the MMA at this location does not consistently form a clinically relevant passageway to the intracranial extravascular space.

[0159] Further advancement of the shaft in FIG. 11C advances the piercing element 1142 closer to the first catheter reference point 1130 and the first shaft reference point 1144 distal to the spinous foramen 1122. In this configuration, the potential energy stored in the second discontinuity is released, rotating the shaft and the distal end of the electrode 1142 and orienting the shaft toward the wall of the MMA facing the subdural space 1160. As shown in image 1104 of FIG. 11C , the electrode 1142 is urged toward the subdural space 1160 such that the electrode 1142 naturally contacts the dura mater and the wall of the MMA facing the subdural space 1160. In this manner, visualization of the position of the first shaft reference point 1144 relative to the spinous foramen 1122 can be used to determine that the shaft has been properly rotated to the desired orientation (e.g., the piercing element is curved toward the wall of the MMA 1120 facing the subdural space 1160).

[0160] As shown in image 1106 of FIG. 11D , the distal tip of the piercing element 1142 has been advanced beyond the first catheter reference point 1130, and the second shaft reference point 1146 has been advanced beyond the spinous foramen 1122. Thus, the shaft has been advanced beyond the distal end of the catheter. Again, due to the rotation provided by the second discontinuity, the shaft in image 1106 self-orients to curve toward the wall of the MMA 1120 and the subdural space 1160 (e.g., the dura mater). Other than longitudinal advancement of the shaft, the operator does not need to rotate the shaft to properly orient the piercing element 1142 to form the transvascular passageway, because rotation is induced by the tendency of the discontinuity (e.g., offset within the core of the shaft, superelastic material) to adapt to (e.g., follow) the geometry that most closely resembles its rest state. In some embodiments, a second shaft reference point 1146 located just distal to the spinous foramen 1122 can indicate to the operator that the piercing element 1142 is disposed in the desired piercing location. Figure 11E is an image 1107 of brain tissue with a catheter assembly disposed therein, corresponding to image 1106 in Figure 11D. The catheter and shaft electrode 1142 is disposed within the mural branch 1126 of the MMA 1120.

[0161] 11F is an image 1108 showing the position of the piercing element 1142 during RF tissue ablation, with the piercing element 1142 creating an opening through the MMA 1120 and into the subdural space 1160. The operator does not need to apply force (e.g., push) to the shaft to create the opening. Instead, the RF energy applied to the tissue by the piercing element 1142 and the predetermined bias of the distal tip portion (e.g., curved section) naturally pushes the tip of the piercing element 1142 into the subdural space 1160. Once energy is applied and the opening is formed, a slit may be created as the piercing element 1142 is biased into its unconstrained curved shape.

[0162] Figure 11G is an image 1109 of the middle cranial fossa (right side) corresponding to image 1108 of Figure 11F, in which the perforating element 1142 forms an opening through the MMA 1120 and dura mater. In Figure 11G, the tip of the perforating element 1142 is exposed. The curved section of the shaft is further configured to reduce damage to brain tissue as it naturally curves back toward the dura mater and away from the brain.

[0163] FIG. 11H is an image 1110 showing the perforating element 1142 disposed within the subdural space upon completion of tissue ablation. In some embodiments, the distal tip portion of the shaft can form a J-shape (e.g., a knuckle shape) when unconstrained. Due to the curved shape of the shaft and the curvature of the MMA along the concave surface of the lateral middle cranial fossa, the slit can occur only toward the subdural space (self-directing). The configuration (e.g., length) of the perforating element 1142 can provide depth-controlled perforation so that the slit does not go deeper than the dura mater (e.g., does not contact brain tissue). Thus, the curved section of the shaft can ensure that the perforating element 1142 does not contact and injure brain tissue.

[0164] FIG. 11I is an image 1111 of the middle cranial fossa (right side) corresponding to image 1110 of FIG. 11H, in which the distal tip portion (e.g., curved section) 1140 and perforating element 1142 have been advanced out of opening 1127 and into the subdural space. As shown in FIG. 11I, the first discontinuity (e.g., bend) between the perforating element 1142 and the distal tip portion 1140 provides an inward slope of the perforating element 1142, improving point contact between the perforating element 1140 and the wall of the vessel, which may focus the RF energy and vaporize tissue with minimal heat generation and tissue shrinkage. In some embodiments, the opening has a length equal to or substantially equal to the length of the perforating element 1142.

[0165] 11J is an image 1112 showing a shaft advanced from an opening between the MMA 1120 and the subdural space 1160 along a predetermined trajectory (e.g., a linear trajectory within the 2D plane of the image 1112). A first shaft reference point 1144 can be advanced to align with a first catheter reference point 1130. In some embodiments, the first shaft reference point 1144 can have an outer diameter substantially equal to the inner diameter of the catheter at the first catheter reference point 1130 to prevent ovalization of the catheter as described herein. Thus, the catheter and shaft can be advanced together from the slit opening 1127 without the edges of the catheter catching on tissue.

[0166] 11K is an image 1114 showing the first catheter reference point 1130, distal tip portion 1140, and piercing element 1142 advanced into the subdural space from opening 1127. The distal tip portion 1140 is completely unconstrained and forms an atraumatic shape (e.g., J-shape, knuckle) that may prevent tissue damage as the shaft is advanced through the extravascular space.

[0167] Figure 11L is an image 1115 of the middle cranial fossa (right side) corresponding to image 1114 of Figure 11K, showing the catheter and shaft advanced out of opening 1127 and into the subdural space. The catheter and shaft follow a straight trajectory from opening 1127.

[0168] Figures 13A-13J are schematic cross-sectional views of a subject's head corresponding to the steps and devices of method 1000 described herein. Figures 13A, 13B, 13D, 13E, 13G, and 13I are coronal cross-sectional views of a subject's head. Figure 13C is a schematic axial cross-sectional view of a subject's head. Figures 13F, 13H, and 13J are side views of a subject's head.

[0169] FIG. 13A is a coronal cross-sectional view 1300 of the head, including a bone (e.g., skull) 1310, a brain 1320, a dura mater 1330, an internal maxillary artery 1340, a middle meningeal artery (MMA) 1342, and an intradural space 1350. FIG. 13B is a detailed cross-sectional view 1301 of FIG. 13A. The MMA 1342 can include a spinous foramen 1343 and a middle cranial fossa 1345. As shown in FIG. 13A , a delivery catheter (e.g., a sheath) 1360 can be disposed within the internal maxillary artery and a proximal portion of the MMA. A catheter 1362 (e.g., a suction catheter, an occlusion catheter) can be slidably disposed within the lumen of the delivery catheter 1360. The catheter 1362 can be advanced from the distal end of the delivery catheter 1360, through the spinous foramen 1343, and into the middle cranial fossa 1345. 13B , shaft 1364 can be slidably disposed within the lumen of catheter 1362. Shaft 1364 can be advanced from the distal end of catheter 1362. Shaft 1364 can include a perforating element 1366 and a curved section configured to self-orient after being advanced across spinous foramen 1343 such that perforating element 1366 is urged toward the wall of MMA 1342 facing dura mater 1330 and subdural space 1350.

[0170] FIG. 13C is a schematic axial view 1302 of the head, including bone 1310, brain 1320, dura mater 1330, and MMA 1342. To create a transvascular passageway from the blood vessels to the extravascular space, an opening must be formed through the dura mater 1330 between the brain and MMA 1342. For example, the perforating element 1366 may be oriented along an arc (e.g., less than 180°), as shown in FIG. 13C. However, an opening formed in the MMA 1342 facing the bone 1310 would not provide access to the subdural space, let alone the hematoma. Therefore, proper positioning and orientation of the perforating element 1366 ensures successful access to the extravascular space.

[0171] Energy may be applied to the piercing element 1366 only to form openings to prevent ablation of brain tissue 1320. The piercing element 1366 may have an atraumatic shape (e.g., a blunt, rounded distal end) so that contact between the piercing element 1366 and the brain does not damage brain tissue.

[0172] 12A and 12B are schematic diagrams of tissue impedance. For example, impedance differences between the brain, subdural space, dura mater, contrast agent, blood vessels, and bone are such that impedance measurements can be used to determine the location of a device (e.g., shaft, catheter) within a subject. For example, an impedance measurement of approximately 700 Ω may correspond to a perforating element 1366 self-orienting relative to the wall of a blood vessel, while an impedance measurement of approximately 450 Ω may indicate that the shaft has not yet self-oriented and has insufficient point contact with the wall of the blood vessel. As shown in FIG. 12B, an opening made through the wall of an artery and the subdural space may correspond to an increase in impedance from approximately 700 Ω to approximately 900 Ω to approximately 1400 Ω. Energy delivery may be reduced and / or stopped when an impedance corresponding to the subdural space is measured. In some embodiments, the signal generator may be configured to stop energy delivery when the impedance measurement is outside this range. For example, an opening made through the wall of an artery and into bone may correspond to an increase in impedance from approximately 700 Ω to approximately 2000 Ω. Energy delivery may be stopped when an impedance of approximately 2000 Ω is measured, and a notification (e.g., an audible warning, a visual indicator) may be output to the operator by the input / output device. In some embodiments, impedance may be measured throughout the procedure. For example, after aspiration of the SDH, the catheter and shaft may be pulled back into the vessel, which may be confirmed by one or more of fluoroscopic visualization and impedance measurement (e.g., approximately 400 Ω). In some embodiments, tissue impedance and / or other dielectric properties may be measured before, during, and after one or more of transvascular passage creation, extravasation, and arterial occlusion and used to control the delivery of RF energy.

[0173] Figure 13D is a coronal cross-sectional view 1303 of the head showing the piercing element 1366 forming an opening (e.g., a slit) through the wall of the MMA 1342 and the dura 1330 in a pushless manner, such that the distal tip portion of the piercing element 1366 and shaft 1364 are disposed within the subdural space 1350. Figure 13E is a coronal cross-sectional view 1304 of the head showing the shaft 1364 being advanced further out of the opening 1346 and into the subdural space 1350, such that the distal tip portion of the shaft 1364 transitions from a radially constrained configuration (e.g., conforming to the shape of the MMA 1342) to a curved configuration (e.g., forming a J-shape or knuckle shape). Figure 13F is a lateral view 1305 of the head showing the shaft 1364 extending from the MMA 1342 into the subdural space. The trajectory of the shaft 1364 from the opening in the artery intersects the SDH 1370. For SDH 1370 with a large volume, shaft 1364 may enter SDH 1370 directly after exiting the arterial lumen and dura mater. The curved configuration of shaft 1364 may be parallel to the surface of the brain (opposite to facing the brain) during advancement within the subdural space. In some embodiments, a saline flush may be injected into the subdural space to facilitate one or more of the following: direct visualization using an optical sensor (e.g., a camera) of the advancement of the catheter assembly (e.g., to increase surface lubricity and create volume in the subdural space). Figure 13F further shows embolic material 1380 (e.g., 150 μm to 250 μm PVA particles) adjacent to SDH 1370 previously delivered into the arterial vessel.

[0174] Figure 13G is a coronal section view 1306 and Figure 13H is a lateral head view 1307 showing the shaft 1364 and catheter 1362 advanced into the subdural space towards the SDH. In particular, the shaft 1364 is advanced atraumatically through the subdural space into the SDH 1370, where the shaft 1364 traverses the sac of the SDH 1370.

[0175] Figure 13I is a coronal cross-sectional view 1308, and Figure 13H is a lateral cranial view 1309, in which the catheter 1362 is advanced into the SDH 1370 and the shaft 1364 is withdrawn through the lumen of the catheter 1362. Figures 13I and 13H show aspiration 1372 (e.g., suction, evacuation) of the SDH 1370 through the lumen of the catheter 1362. In some embodiments, the aspiration can be one or more of continuous, dynamic, cyclic, and pulsatile. Pulsatile pressure can induce clot fatigue and fracture, facilitating aspiration removal.

[0176] Other embodiments of SDH evacuation and arterial embolization are shown and described with respect to Figures 14A-14F. Figures 14A-14F are schematic cross-sectional views of a subject's head corresponding to the steps and devices of method 1000 described herein. Figures 14A, 14C, and 14E are coronal cross-sectional views of a subject's head. Figures 14B, 14D, and 14F are lateral views of a subject's head.

[0177] FIG. 14A is a coronal section view 1400 of the head, including a bone (e.g., skull) 1410, a brain 1420, a dura mater 1430, a carotid artery 1440, a middle meningeal artery (MMA) 1442, and an intradural space 1450. The MMA 1442 can include a spinous foramen 1443 and a middle cranial fossa 1445. As shown in FIG. 14A , a delivery catheter (e.g., a sheath) 1460 can be disposed within the internal maxillary artery and within a proximal portion of the MMA. A catheter 1462 (e.g., a suction catheter, an occlusion catheter) can be slidably disposed within the lumen of the delivery catheter 1460. The catheter 1462 can be advanced into the subdural space. In some embodiments, the shaft 1364 depicted in FIGS. 13A-13J can be withdrawn from the catheter to allow a second shaft 1464 (e.g., a second RF device having a second electrode) including a straight tip configured to penetrate the membrane of the subdural hematoma 1470. The second shaft 1464 can be slidably disposed within the lumen of the catheter 1462. The second shaft 1464 can be advanced from the distal end of the catheter 1462 and contact the outer layer (e.g., sac, membrane) of the SDH 1470. Energy (e.g., RF energy) can be applied by the second shaft 1464 to perforate the membrane of the SDH 1470 and facilitate entry of the second shaft 1464 and catheter 1462 into the SDH 1470. In some embodiments, the second shaft 1464 can have a straight distal end configured to deliver RF energy to form an opening in the SDH 1470. FIG. 14A further shows embolic material 1480 previously delivered to the blood vessel adjacent to the SDH.

[0178] Figure 14B is a side view 1401 of Figure 14A, with the catheter 1462 advanced into the SDH 1470 and the second shaft 1464 withdrawn. In Figure 14B, suction 1472 is applied to remove blood and fluids from the SDH 1470 through the lumen of the catheter 1462. Once the SDH 1470 is drained (e.g., expelled), the catheter 1462 can be withdrawn from the subdural space into the MMA 1442.

[0179] In some embodiments, the opening formed in the MMA by the first shaft can be closed using the second shaft as the catheter and second shaft are withdrawn from the subdural space. FIG. 14C shows coronal cross-sectional views 1402, 1403 of the head and vessel, respectively. FIG. 14D shows lateral views 1404, 1405 of the head and vessel, respectively. In FIGS. 14C and 14D, the distal ends of each of the catheter 1462 and second shaft 1464 are disposed within the MMA 1442. The second shaft 1464 can extend out of the catheter 1462 at or proximal to the opening formed in the MMA 1442. In some embodiments, the second shaft 1464 can be configured to deliver RF energy to thermally coagulate (e.g., solidify) the MMA to close the opening.

[0180] In some embodiments, the opening formed in the MMA by the shaft can be closed using a catheter to deliver embolic material as the catheter is withdrawn from the subdural space. FIG. 14E shows coronal cross-sectional views 1406, 1407 of the head and vessel, respectively. FIG. 14F shows lateral views 1408, 1409 of the head and vessel, respectively. In FIGS. 14E and 14F, a catheter 1462 is disposed within the MMA 1442 and used to deliver embolic material (e.g., a coil) 1482 into the MMA 1442 to close the opening formed in the wall of the MMA 1442 and / or to occlude branch vessels of the MMA 1442. The catheter assembly (e.g., catheter 1462, delivery catheter 1460) can then be withdrawn from the subject.

[0181] In some embodiments, the embolic material may comprise one or more of a balloon, gelfoam, collagen, thrombin, particles (e.g., polyvinyl alcohol, embospheres), coils (e.g., pushable, injectable, removable), liquid agents (e.g., adhesives, ethylene vinyl alcohol), sclerosing agents (e.g., sodium tetradecyl sulfate, alcohol, algel), plugs (e.g., including self-expandable cylindrical or hourglass shapes), stitches, electrocoagulation, combinations thereof, and the like. In some embodiments, the embolic material may be configured to prevent accidental retraction during device retrieval, such as gelfoam, collagen pledgets, and focal expansion on distal segments of flowering elements that radially expand after exposure, hydration, contact with ions, and the like. In some embodiments, the embolic material, such as a coil, may be cut at predetermined lengths by one or more chemical, mechanical, and electrical mechanisms.

[0182] Also described herein are methods for accessing the extravascular intracranial space (e.g., the supratentorial parasagittal intradural compartment) using a transvenous approach using the systems and devices described herein. It may be useful to briefly identify and describe the relevant anatomical structures. The intradural compartment consists of the subdural space, the subarachnoid space with its extensions (e.g., the cisterna magna), brain tissue, and the ventricles (e.g., the fluid-filled cavities within the brain). The supratentorial compartment is considered the intracranial space above the tentorium, and the infratentorial compartment is considered the intracranial space above the tentorium. FIG. 16 is an oblique cutaway view 1600 of a subject's head, including the skull 1610, brain 1620, dura 1630, and superior sagittal sinus 1640.

[0183] In some embodiments, the systems and devices described herein can be guided into the dural venous sinuses (including, for example, the superior sagittal and superior petrosal sinuses) from a peripheral venous approach to create an opening through the venous wall and dura mater to the subdural space for access to the extravascular space. Optionally, the subdural space can be expanded by delivery of a fluid or gas to facilitate delivery of one or more fluid-based therapeutic agents and devices through the transvascular access point.

[0184] For example, a delivery sheath can be guided from peripheral venous access into the jugular vein, the transverse sigmoid sinus, and the superior sagittal sinus. The sheath can be oriented toward the lateral wall of the ipsilateral sinus. The SSS is generally triangular in shape, with the largest side being the base oriented toward the skull. The delivery sheath can be disposed at the base of the triangle (e.g., the skull) and oriented toward the lateral wall of the sinus toward the subdural space. In some embodiments, the dural sinus wall can be penetrated by the shaft. One or more devices, including a catheter configured to aspirate fluid (e.g., from the SDH), can then be guided into the extravascular space. After completion of intervention in the extravascular space, the device can be withdrawn, and the opening can be closed using a hemostatic device as described herein. Thus, this method can minimize blood extravasation while the passage remains patent, enable navigation within the intracranial compartment without brain perforation or injury, allow evacuation of subdural collections (e.g., the SDH), and facilitate closure of the dural incision upon removal of the catheter assembly.

[0185] In some embodiments, one or more devices may be temporarily or permanently placed (e.g., implanted) in the extravascular space. For example, the devices may include one or more electrodes, sensors, transmitters, receivers, grids, ports, catheters, biopsy needles or punches, implantable chemotherapy wafers or radioactive seeds, combinations thereof, etc.

[0186] It should be understood that the devices, systems, and methods described herein are not intended solely for the evacuation of fluids, clots, and particulate matter from the subdural space. Instead, the methods and systems described herein can be adapted to obtain safe access and evacuate fluids and clots within the epidural space, such as for the drainage of acute epidural hematomas, cyst fluid, and pus.

[0187] Furthermore, the methods and systems described herein can be adapted to gain access to any intracerebral target within the epidural space and intradural compartment, including the subarachnoid space, cisterns, brain tissue, and ventricles. It should be understood that the methods and systems described herein can be adapted and used to gain safe access to the subdural or epidural space, as well as to drain fluids, particulate matter, and clots through veins, dural sinuses, and any other natural corridors. For example, the devices, systems, and methods described herein can be used to gain safe and stable transvascular access to any extravascular space and then close an arteriotomy or venotomy site. It should also be understood that the methods and systems described herein can be adapted and used to gain safe access to the intradural compartment within the spinal column.

[0188] Figure 20A is a three-dimensional image 2000 (e.g., a reconstruction) of a set of veins and dural sinuses in a subject's head, including the superior sagittal sinus 2020 and the cortical veins 2030 branching therefrom. Figure 21A is a corresponding schematic diagram 2100 of a top view of the cranial anatomy, including the brain 2110, the superior sagittal sinus 2120, and the cortical veins 2130. The SSS 2120 runs along the midline, and the cortical veins 2130 drain into the SSS 2120.

[0189] Figure 20B is a coronal section view 2010 of a subject's head. Figure 21B is a corresponding schematic illustration 2110 of the coronal section view of the cranial anatomy, including the brain 2110, SSS 2120, bones 2140, subdural space 2150 (e.g., between the brain 2110 and SSS 2120), and falx cerebri 2160.

[0190] FIG. 22 is a schematic top view and coronal section of a subject's head having a catheter assembly described herein. For example, the shaft 2230 and catheter 2240 of the catheter assembly are disposed within the superior sagittal sinus 2210. A delivery catheter 2250 can be configured to guide the catheter assembly into the SSS 2210. The shaft 2230 and catheter 2240 can include structurally and / or functionally similar components to the shafts and catheters described with respect to FIGS. 5-9. In some embodiments, the catheter 2240 can include a dilator having a tapered distal end with a distal opening. Similarly, the distal end of the shaft (e.g., the shaft tip) can have a smaller diameter than the remainder of the shaft 2230, allowing the distal end to create a small opening in the sinus wall and dura. Further advancement of the shaft 2230 (and its relatively large diameter) through the sinus wall and dura can temporarily dilate the tissue and facilitate advancement of a larger catheter.

[0191] In some embodiments, the distal portion of the shaft 2230 can be formed from a shape memory material (e.g., Nitinol) having a predetermined curvature such that the distal portion of the shaft 2230 curves as it is advanced from the distal end of the catheter 2240. The shape of the predetermined curve can include, but is not limited to, a simple curve, a compound curve, a reverse curve, a spiral curve, a compound curve, combinations thereof, and the like. The predetermined curve can be in one or more planes (e.g., a horizontal plane, a vertical plane). In some embodiments, the unconstrained curve of the shaft 2230 can be configured to contact the wall of the SSS 2210 opposite the puncture point such that the tip of the shaft contacts the wall of the SSS at the puncture point.

[0192] As shown in the cross-sectional view of 2200, when the length of a portion of shaft 2230 (e.g., the long chord of the curve of shaft 2230) is equal to or greater than the length of the base of triangular shaped SSS 2210, shaft 2230 can naturally conform (e.g., self-adapt) to the wider dimension of SSS 2210. Generally, SSS 2210 is longer in the medial-lateral direction than in the cranio-caudal direction such that SSS 2210 has approximately the shape of an obtuse isosceles triangle, however, SSS 2210 can be locally larger in the cranio-caudal direction, in which case SSS 2210 approximates an acute isosceles triangle with a base at bone. For example, the extension shaft 2230 can generally accommodate (e.g., conform to, spatially orient, and follow) the medial and lateral protrusions of the SSS 2210, thereby providing consistent wall apposition, which minimizes herniation and kickback while accommodating anterior longitudinal mechanical loads, and thereby provide a perforation point at the base corner (e.g., lateral apex) of the generally triangular-shaped sinus.

[0193] In some embodiments, the shaft 2230 may enter the subdural space along a trajectory substantially parallel to the dura mater and brain surface. For example, a transvascular access trajectory parallel to the base of the triangular-shaped SSS 2210 may facilitate implantation of the closure device away from the center of the venous space, which favors patency. In some embodiments, one or more of the shaft 2230, catheter 2240, and delivery catheter 2250 may have a predetermined curve to facilitate self-orientation into the SSS 2210. In some embodiments, a puncture point may be accessed using one or more of the predetermined curves and by applying a torque to one or more of the shaft 2230, catheter 2240, and delivery catheter 2250.

[0194] At 2202, energy (e.g., RF energy) can be delivered to the wall of the SSS 2210 and the dura to create an opening (e.g., hole, slit) 2212 through which the shaft 2230 is advanced. At 2204, the shaft 2230 is advanced further through the subdural space, and the catheter 2240 is advanced through the opening 2212. For example, the unconstrained shape of the shaft 2230 can form a J-shape. Although not shown, a delivery catheter 2250 can be advanced over the catheter 2240 through the opening 2212. The medical procedure can then be performed as described herein.

[0195] In some embodiments, the distal portion of the shaft 2230 can have a compound curve. For example, the shaft 2230 can have a first radius of curvature and a second radius of curvature proximal to the first radius of curvature. The first radius of curvature can be smaller than the second radius of curvature to facilitate self-orientation of the shaft within the SSS 2210 and point the tip of the shaft 2210 toward and contact the apex of the sinus. A shaft having a second radius of curvature further reduces the risk of shaft herniation within the sinus during advancement through the opening 2212. The tendency of the shaft 2210 to herniate (e.g., bend) toward the SSS 2210 after partially emerging into the extravascular space can be mitigated using one or more of a compound curve, a shape memory material, a tapered shape, and variable stiffness.

[0196] In some embodiments, the system 600 can be configured to puncture the wall of a blood vessel and enter the epidural space using a predetermined curve of the shaft having a first curve in a first plane (e.g., a horizontal plane) and a second curve in a second plane (e.g., a vertical plane). A medical procedure can then be performed in the epidural space. Alternatively, the medical procedure can be performed after accessing the subdural space via a durotomy.

[0197] 23 is a schematic cross-sectional side view 2300, 2302, 2304, 2306, and cross-sectional view 2308 of a catheter 2310. In some embodiments, the catheter 2310 may include a wire 2312, a piercing element 2320 (e.g., a nitinol needle), and a pusher 2330 configured to translate the piercing element 2320. A distal portion of the catheter may include a stopper 2316 having a bevel 2318 (e.g., a tapered portion, bend, slope, angle) configured to direct the piercing element 2320 out of an opening (e.g., a window) 2314 of the catheter 2310. The piercing element 2320 may be configured to be translated within and advanced out of the catheter 2310 using the pusher 2330 slidably disposed within the catheter 2310. The piercing element 2320 may include a cutting edge (e.g., a blade, bevel, cutter). For example, when the piercing element 2320 contacts the bevel 2318 of the stopper 2316, the piercing element 2320 may curve out of the opening 2314 in a predetermined manner. In FIG. 23 , the curvature of the piercing element 2320 increases as it advances out of the catheter 2310. In some embodiments, the predetermined curvature of the piercing element 2320 may determine the trajectory of the piercing element 2320 within the subdural space. This may facilitate, for example, delivery of a cortical implant to a predetermined portion of the brain.

[0198] In some embodiments, catheter 2310 may include a ring-shaped fluorescent marker configured to aid in visualization and guide positioning of the catheter within the subject. For example, ring-shaped fluorescent marker 2340 may have a C-shape as shown in cross-sectional view 2308. In particular, fluorescent marker 2340 may be disposed around opening 2314 of catheter 2310. In some embodiments, stopper 2316 may comprise an ultrasound device (e.g., intravascular ultrasound).

[0199] 24 is a schematic top view and coronal section of a subject's head having the catheter assembly shown and described with respect to FIG. 23. A catheter 2310 may be disposed within the subject's superior sagittal sinus 2410. In 2400, the catheter 2310 may be guided via imaging (e.g., x-ray) within the SSS 2410 so that the opening 2420 formed by the catheter 2310 does not form within a cortical vein. The opening 2314 of the catheter 2310 may be oriented toward the opening 2420 formed in the SSS 2410. A ring-shaped fluorescent marker may be visualized within the SSS 2410 and used to determine the orientation of the opening 2314 within the SSS 2410.

[0200] At 2402, the perforating element 2320 can be advanced from the catheter 2310 toward the wall of the SSS 2410 to form an opening 2420 in the SSS 2410. Due to the strength of the dura, a reaction force is generated where the catheter 2310 is pushed against the opposing sidewall of the SSS 2410 while the perforating element 2320 contacts and advances through the wall and dura of the SSS 2410. In some embodiments, the length of the curved distal tip portion of the perforating element 2320 can be from about 15 mm to about 25 mm (including all ranges and subvalues ​​therebetween). At 2404, the shaft 2430 can be advanced from the lumen of the perforating element 2320 into the subdural space to perform a medical procedure as described herein (e.g., evacuate SDH, deliver an electrode).

[0201] 25 is a schematic coronal cross-sectional view of a subject's head. In some embodiments, the delivery catheter 2520 can be articulated (e.g., using at least one pull wire) to curve the distal end of the catheter assembly. The predetermined curve of the catheter assembly can provide sufficient stiffness (e.g., by actuating a pull wire) to orient the distal opening of the delivery catheter 2520 toward and into contact with a predetermined wall of the SSS 2570 (e.g., at or near the basal corner or lateral apex), as well as to provide a counterforce against the resistance of the SSS 2570 and dura as the transvascular opening is created. That is, in 2502, the delivery catheter 2520 can be configured to be anchored against the wall of the SSS 2570. In some embodiments, the catheter 2530 can be configured to increase its stiffness when actively steered (e.g., via actuation of a pull wire) and decrease its stiffness when not actuated (e.g., via release of tension on the pull wire). Higher shaft stiffness may facilitate device delivery (e.g., shaft advancement) during transvascular access creation corresponding to the support mode, while lower stiffness may facilitate coaxial advancement over a wire corresponding to the tracking mode.

[0202] At 2504, the piercing element 2540 may be advanced through the wall of the SSS 2570 and the dura mater to form an opening. At 2506, a guidewire 2550 may be advanced through the lumen of the piercing element 2540 and into the subdural space. At 2508, a catheter 2530, such as a dilator, may be advanced over the piercing element 2540 and into the subdural space. One or more of the catheter 2530, piercing element 2540, and guidewire 2550 may be advanced into the subdural space for a medical procedure including evacuation of a subdural hematoma 2590. In this case, at 2510, the piercing element 2540 and guidewire 2550 are withdrawn to facilitate aspiration of the SDH 2590 through the lumen of the catheter 2530. At 2512, a device (e.g., a coil) may be delivered into the subdural space using the catheter 2530. At 2514, staples 2560 can be delivered using the catheter 2530. At 2516, the staples 2560 can be used to close the opening formed in the SSS 2570. However, if an implantable device (e.g., a catheter, a sensor, one or more wires, an electrode) remains through the transvascular passageway, staples (or other closure devices) may not be used.

[0203] In some embodiments, at least a portion of the catheter assembly disposed within the subdural space may articulate to facilitate navigation through the blood vessels and the subdural space. For example, dural venous sinuses generally house multiple draining veins that may be vulnerable to unintentional damage. In some variations, the draining veins (e.g., draining veins) may be imaged (e.g., via angiography) to facilitate perforation of the sinus wall without perforating the veins. In some variations, the catheter may be configured to articulate, and a shaft having a perforating element may be advanced through the lumen of the catheter and used to create an opening through the dura into the subdural space. A predetermined length of the shaft may be advanced into the subdural space, the catheter may be relaxed (e.g., by releasing tension on a pull wire), and then advanced over the shaft into the subdural space. The catheter within the subdural space may then be actuated (e.g., steered) to guide it toward a region of interest (e.g., a subdural hematoma). The shaft (or other wire) of the catheter assembly may be advanced toward the region of interest. If the shaft has a stiffness less than that of the curve, the shaft will follow the trajectory of the catheter and advance toward the region of interest. The catheter can then be relaxed and then advanced over the shaft to the region of interest to perform medical procedures, including, but not limited to, evacuation of a multi-sited subdural hematoma, delivery of diagnostic and / or therapeutic agents and / or devices to one or more extravascular intracranial targets.

[0204] Figure 26 plots the permittivity versus frequency for a set of tissue types including blood, brain gray matter, brain white matter, arterial wall, cancellous bone, dura mater, cortical bone, and cerebrospinal fluid. The ranking of permittivity did not change for RF frequencies below 520 kHz. At higher frequencies, the permittivity decreases in the following order: blood, brain gray matter, brain white matter, arterial wall or cancellous bone or dura mater, cortical bone, and cerebrospinal fluid. Figure 27 plots the permittivity of a set of tissue types versus a set of RF frequencies.

[0205] While various inventive embodiments have been described and illustrated herein, those skilled in the art will readily envision various other means and / or structures for performing the functions and / or obtaining the results and / or one or more of the advantages described herein, and each such variation and / or modification is deemed to be within the scope of the inventive embodiments described herein. More generally, those skilled in the art will readily appreciate that all parameters, dimensions, materials, and configurations described herein are meant to be exemplary, and that the actual parameters, dimensions, materials, and / or configurations will depend on one or more specific applications and anatomies (e.g., intracranial and extracranial vasculature) in which the teachings of the present invention are used. Those skilled in the art will recognize, or be able to ascertain using no more than routine experimentation, many equivalents to the specific inventive embodiments described herein. Accordingly, the foregoing embodiments are presented by way of example only, and it should be understood that, within the scope of the appended claims and their equivalents, inventive embodiments may be practiced otherwise than as specifically described and claimed. The inventive embodiments of the present disclosure are directed to each individual feature, system, article, material, kit, and / or method described herein. In addition, any combination of two or more such features, systems, articles, materials, kits, and / or methods is included within the inventive scope of the present disclosure, provided that such features, systems, articles, materials, kits, and / or methods are not mutually inconsistent.

[0206] Also, various inventive concepts may be embodied as one or more methods, examples of which are provided. The acts performed as part of a method may be ordered in any suitable manner. Thus, although illustrated embodiments show acts as sequential, embodiments can be constructed in which the acts are performed in a different order than illustrated, which may include performing some acts simultaneously.

[0207] As used herein, the terms "about" and / or "approximately," when used in conjunction with a numerical value and / or range, generally refer to those numerical values ​​and / or ranges that are close to the recited numerical value and / or range. In some cases, the terms "about" and "approximately" can mean within ±10% of the stated value. For example, in some cases, "about 100 units" can mean within ±10% of 100 (e.g., 90 to 110). The terms "about" and "approximately" can be used interchangeably.

[0208] Any and all references to publications or other documents, including but not limited to patents, patent applications, articles, web pages, books, etc., presented anywhere in this application are incorporated herein by reference in their entirety. All definitions defined and used herein should be understood to control over dictionary definitions, definitions within documents incorporated by reference, and / or ordinary meanings of the defined terms.

[0209] The specific examples and descriptions herein are exemplary in nature and embodiments may be developed by those skilled in the art based on the teachings herein without departing from the scope of the present invention.

Claims

1. 1. A device for evacuation of a subdural hematoma disposed in an intracranial extravascular space of a patient, comprising: an aspiration catheter positionable within the patient's intracranial vasculature and defining a lumen; a shaft configured to be advanced through the lumen of the catheter until a distal tip portion of the shaft is disposed within the intracranial vessel, the shaft comprising: a piercing element configured to cut through the wall of the intracranial blood vessel and the dura mater of the patient to create a slit that serves as a passageway from the intracranial blood vessel lumen to the intracranial extravascular space; a distal segment coupled to the distal tip portion, the distal segment having a cross section with a first transverse dimension greater than a second transverse dimension to facilitate bending of the shaft in a first plane and limit bending in a second plane perpendicular to the first plane; Including, The device is configured so that the aspiration catheter is advanced through the slit to the subdural hematoma to allow fluid or matter from the subdural hematoma to be drained from the intracranial extravascular space via the lumen of the catheter.

2. The piercing element has a current of about 1200 A / m ２ ~Approx. 12000A / m ２ 10. The device of claim 1, configured to deliver a current density of

3. The device of claim 1 , wherein the piercing element is configured to deliver between about 10 W and about 100 W of power.

4. The device of claim 1 , wherein the piercing element comprises a tip bending stiffness of up to about 15 gf.

5. 10. The device of claim 1, wherein the shaft has a column strength of up to about 100 gf.

6. 10. The device of claim 1, wherein the shaft further includes a widened section having a transverse dimension equal to or substantially equal to an inner diameter of the lumen of the aspiration catheter, preventing ovalization of the aspiration catheter as the aspiration catheter is advanced through the longitudinal slit.

7. 10. The device of claim 1, wherein the suction catheter includes a proximal end configured to be coupled to a suction source, the suction source capable of applying suction to the lumen to evacuate the fluid or material from the subdural hematoma.

8. The device of claim 1 , wherein the piercing element has an atraumatic shape.

9. 2. The device of claim 1, wherein the shaft further includes a proximal section having an outer diameter that tapers from a first outer diameter substantially equal to an inner diameter of the aspiration catheter to a second outer diameter, the proximal section configured to limit the length that the shaft can be advanced distally beyond the distal end of the aspiration catheter.

10. 10. The device of claim 1, further comprising a sheath defining a sheath lumen configured to receive the aspiration catheter, the aspiration catheter comprising a distal segment including a proximal portion having an outer diameter that tapers from a first outer diameter to a second outer diameter that is substantially equal to an inner diameter of the sheath, the proximal portion configured to limit the length that the distal segment can advance distally beyond the distal end of the sheath.

11. 1. A device for evacuation of a subdural hematoma disposed in an intracranial extravascular space of a patient, comprising: an aspiration catheter positionable within the patient's intracranial vasculature and defining a lumen; a shaft configured to be advanced through the lumen of the aspiration catheter until a distal tip portion of the shaft is disposed within the intracranial vessel, the distal tip portion being coaxial with the shaft, the shaft comprising: a piercing element disposed at the distal end of the distal tip portion and configured to obliquely cut the wall of the intracranial blood vessel and the dura mater of the patient to create a passageway from the intracranial blood vessel to the intracranial extravascular space, the aspiration catheter being configured to be advanced through the passageway to the subdural hematoma to allow fluid or material from the subdural hematoma to be drained from the intracranial extravascular space via the lumen of the catheter. Device.

12. The piercing element has a current of about 1200 A / m ２ ~Approx. 12000A / m ２ 12. The device of claim 11, configured to deliver a current density of

13. The device of claim 11 , wherein the piercing element is configured to deliver between about 10 W and about 100 W of power.

14. The device of claim 11 , wherein the piercing element comprises a tip bending stiffness of up to about 15 gf.

15. 12. The device of claim 11, wherein the shaft has a column strength of up to about 100 gf.

16. 12. The device of claim 11, wherein the shaft further includes a widened section having a transverse dimension equal to or substantially equal to an inner diameter of the lumen of the aspiration catheter to prevent ovalization of the aspiration catheter as the aspiration catheter is advanced through the longitudinal slit.

17. 12. The device of claim 11, wherein the suction catheter includes a proximal end configured to be coupled to a suction source, the suction source capable of applying suction to the lumen to evacuate the fluid or material from the subdural hematoma.

18. The device of claim 11 , wherein the piercing element has an atraumatic shape.

19. 12. The device of claim 11, wherein the shaft further includes a proximal section having an outer diameter that tapers from a first outer diameter substantially equal to an inner diameter of the aspiration catheter to a second outer diameter, the proximal section configured to limit the length that the shaft can be advanced distally beyond the distal end of the aspiration catheter.

20. 12. The device of claim 11, further comprising a sheath defining a sheath lumen configured to receive the aspiration catheter, the aspiration catheter comprising a distal segment including a proximal portion having an outer diameter that tapers from a first outer diameter to a second outer diameter that is substantially equal to an inner diameter of the sheath, the proximal portion configured to limit the length that the distal segment can be advanced distally beyond the distal end of the sheath.

21. 1. A method comprising: positioning a distal end of a catheter disposed within a subject's intracranial vessel near a target location; advancing a shaft through a lumen of the catheter; extending a distal tip portion of the shaft from and coaxially with the distal end of the catheter so that a radio frequency (RF) element of the distal tip portion is positioned at an oblique angle relative to the wall of the blood vessel and to the overlying surface of the dura mater; activating the radio frequency (RF) element to deliver RF energy to the wall of the blood vessel to create an opening through the wall of the blood vessel and the dura mater into an extravascular intracranial space of the subject; advancing the distal end of the shaft into the extravascular intracranial space substantially parallel to the surface of the dura mater; advancing the catheter over the shaft into the extravascular intracranial space; A method comprising:

22. advancing the distal end of the shaft into a subdural hematoma; advancing the catheter over at least a portion of the shaft and into the subdural hematoma; applying suction to the lumen of the catheter to remove fluid from the subdural hematoma after the catheter is positioned within the subdural hematoma; 22. The method of claim 21 further comprising:

23. retracting the catheter toward the opening created in the wall of the artery; delivering a hemostatic element or an RF device through the lumen of the catheter to close the opening; 22. The method of claim 21 further comprising:

24. 1. A device for evacuation of a subdural hematoma disposed in an intracranial extravascular space of a patient, comprising: an aspiration catheter positionable within the patient's intracranial vasculature and defining a lumen; a shaft configured to be advanced through the lumen of the catheter until a distal tip portion of the shaft is disposed within the intracranial vessel, the shaft comprising: a piercing element configured to cut through the wall of the intracranial blood vessel and the dura mater of the patient to create a slit that serves as a passageway from the intracranial blood vessel lumen to the intracranial extravascular space; a preset curved section configured to be constrained in a substantially straight configuration when disposed within the lumen of the catheter and to curve toward the wall of the intracranial blood vessel upon exiting the lumen of the catheter; a preset curved section further configured to transition to a curved configuration in response to the piercing element puncturing the wall of the intracranial blood vessel and the dura mater, causing the piercing element to follow an arc that forms the slit in the wall of the intracranial blood vessel and the dura mater; The device is configured so that the aspiration catheter is advanced through the slit to the subdural hematoma to allow fluid or matter from the subdural hematoma to be drained from the intracranial extravascular space via the lumen of the catheter.

25. 25. The device of claim 24, wherein the suction catheter includes a proximal end configured to be coupled to a suction source, the suction source capable of applying suction to the lumen to evacuate the fluid or material from the subdural hematoma.

26. 25. The device of claim 24, wherein the preset curved section has a J-shape or a U-shape in the curved configuration.

27. 25. The device of claim 24, wherein the piercing element has an atraumatic shape.

28. 25. The device of claim 24, wherein the piercing element is configured to generate radio frequency (RF) energy to cut the wall of the intracranial blood vessel and the dura mater.

29. 25. The device of claim 24, wherein the shaft further comprises an offset configured to orient the perforating element in a direction toward the wall of the intracranial vessel and the dura mater, while a proximal portion of the shaft faces the patient's skull.

30. 30. The apparatus of claim 29, wherein the offset has a non-circular cross-sectional shape configured to bend preferentially in a first plane relative to a second plane.

31. 25. The device of claim 24, wherein the shaft further includes a widened section having a transverse dimension equal to or substantially equal to an inner diameter of the lumen of the aspiration catheter to prevent ovalization of the aspiration catheter as the aspiration catheter is advanced through the longitudinal slit.

32. 32. The device of claim 31, wherein the wide section is disposed proximal to the curved section.

33. 32. The device of claim 31, wherein the distal end of the aspiration catheter includes a first radiopaque element and the shaft includes a second radiopaque element disposed near the widened section, the widened section being capable of being aligned with the distal end of the aspiration catheter prior to advancing the aspiration catheter through the longitudinal slit.

34. 25. The device of claim 24, wherein the shaft includes a first radiopaque element disposed on the piercing element and a second radiopaque element disposed proximal to the curved section, the first radiopaque element and the second radiopaque element configured to facilitate confirmation of the configuration of the curved section.

35. 35. The device of claim 34, wherein when the curved section is in the curved configuration, the piercing element and the first radiopaque element form an angle of about 5 degrees to about 15 degrees with respect to the second radiopaque element.

36. 25. The device of claim 24, wherein the shaft further comprises a proximal section having an outer diameter that varies along the length of the proximal section.

37. 37. The device of claim 36, wherein the proximal section tapers from a first outer diameter to a second outer diameter over a length of about 4 mm to about 6 mm.

38. 38. The device of claim 37, wherein the first outer diameter is substantially equal to the inner diameter of the aspiration catheter and limits the length that the shaft advances distally beyond the distal end of the aspiration catheter.

39. 1. A device for evacuation of a subdural hematoma disposed in an intracranial extravascular space of a patient, comprising: an aspiration catheter positionable within the patient's intracranial vasculature and defining a lumen; a shaft configured to be advanced through the lumen of the aspiration catheter until a distal tip portion of the shaft is disposed within the intracranial vessel, the shaft comprising: a piercing element disposed at a distal end of the distal tip portion and configured to cut through a wall of the intracranial blood vessel and the dura mater of the patient to create a passageway from the intracranial blood vessel to the intracranial extravascular space, a piercing element configured to be angled relative to the distal tip portion such that when the piercing element is disposed distally beyond the distal end of the aspiration catheter, the piercing element is directed toward the wall of the intracranial blood vessel and the dura mater and can cut the wall of the intracranial blood vessel and the dura mater at an oblique angle; The aspiration catheter is configured to be advanced through the passage to the subdural hematoma to allow fluid or material from the subdural hematoma to be drained from the intracranial extravascular space via the lumen of the catheter.

40. 40. The device of claim 39, wherein the piercing element forms an angle of about 1° to about 90° with respect to the distal tip portion when the piercing element is disposed distally beyond the distal end of the aspiration catheter.

41. 40. The device of claim 39, wherein the suction catheter includes a proximal end configured to be coupled to a suction source, the suction source capable of applying suction to the lumen to evacuate the fluid or material from the subdural hematoma.

42. 40. The device of claim 39, wherein the piercing element has an atraumatic shape.

43. 40. The device of claim 39, wherein the shaft further comprises an offset configured to orient the perforating element in a direction toward the wall of the intracranial vessel and the dura mater, while a proximal portion of the shaft faces the patient's skull.

44. 40. The device of claim 39, wherein the shaft further includes a widened section having a transverse dimension equal to or substantially equal to the inner diameter of the lumen of the aspiration catheter to prevent ovalization of the aspiration catheter as the aspiration catheter is advanced through the longitudinal slit.

45. 40. The device of claim 39, wherein the shaft further includes a proximal section having an outer diameter that tapers from a first outer diameter substantially equal to an inner diameter of the aspiration catheter to a second outer diameter, the proximal section configured to limit the length that the shaft can be advanced distally beyond the distal end of the aspiration catheter.

46. 1. A device for evacuation of a subdural hematoma disposed in an intracranial extravascular space of a patient, comprising: an aspiration catheter positionable within the patient's intracranial vasculature and defining a lumen; a shaft configured to be advanced through the lumen of the aspiration catheter until a distal tip portion of the shaft is disposed within the intracranial vessel, the shaft comprising: a piercing element configured to cut through the wall of the intracranial blood vessel and the dura mater of the patient to create a passageway from the intracranial blood vessel to the intracranial extravascular space; a curved section having a predetermined curvature, the curved section being configured to be radially constrained within the lumen of the aspiration catheter and to curve toward the wall of the intracranial vessel and the dura mater upon exiting the lumen of the catheter; a discontinuity disposed proximally of the curved section, the discontinuity configured to orient the preset curvature of the curved section to follow the curvature of the intracranial vessel when the shaft is advanced through the lumen of the aspiration catheter; The aspiration catheter is configured to be advanced through the passage to the subdural hematoma to allow fluid or material from the subdural hematoma to be drained from the intracranial extravascular space via the lumen of the catheter.

47. 47. The apparatus of claim 46, wherein the discontinuity is a first discontinuity and the shaft includes a second discontinuity at a location between the piercing element and the curved section.

48. 48. The device of claim 47, wherein the second discontinuity comprises a bend in the shaft configured to direct the perforating element toward the wall of the intracranial vessel and the dura mater.

49. 48. The apparatus of claim 47, wherein the preset curvature of the curved section has a first radius of curvature and the second discontinuity comprises a section of the shaft having a second radius of curvature that is smaller than the first radius of curvature.

50. 47. The apparatus of claim 46, wherein the curved section has a cross-section with a first lateral dimension that is greater than a second lateral dimension.

51. 47. The device of claim 46, wherein the discontinuity comprises a bend in the shaft.

52. 47. The device of claim 46, wherein the discontinuity comprises a partial spiral or twist in the shaft.

53. 47. The device of claim 46, wherein the curved section is a first curved section comprising a convex curvature, and the shaft further comprises a second curved section proximal to the first curved section, the second curved section comprising a concave curvature.

54. 1. An apparatus comprising: a shaft configured to be slidably disposed within a lumen of a catheter and configured to be disposed distally from a distal end of the catheter and within a blood vessel of a subject, the shaft comprising: a perforation tip including an energy element configured to generate radio frequency (RF) energy to form an opening through the wall of the blood vessel and the dura mater of the subject and into the extravascular space of the subject; a curved section configured to be radially constrained within the catheter lumen, the curved section configured to curve toward the wall of the blood vessel and the dura mater upon exiting the catheter lumen, the energy element positioned to form the opening; a first discontinuity disposed between the piercing tip and the curved section; a second discontinuity disposed proximal to the curved section, the second discontinuity configured to orient the curve to follow the curvature of the blood vessel when the shaft is advanced within the lumen of the catheter; 1. An apparatus comprising:

55. 55. The device of claim 54, wherein the first discontinuity comprises a bend in the shaft.

56. 55. The apparatus of claim 54, wherein the curved section has a first radius of curvature and the first discontinuity comprises a section of the shaft having a second radius of curvature that is smaller than the first radius of curvature.

57. 55. The device of claim 54, wherein the curved section is configured to transition to a curved configuration as the curved section moves through the opening and into the extravascular space.

58. 55. The apparatus of claim 54, wherein the curved section has a cross-section with a first lateral dimension that is greater than a second lateral dimension.

59. 55. The device of claim 54, wherein the second discontinuity comprises a bend in the shaft.

60. 55. The device of claim 54, wherein the second discontinuity comprises a partial helix or twist in the shaft.

61. 55. The device of claim 54, wherein the curved section is a first curved section comprising a convex curvature, and the shaft further comprises a second curved section proximal to the first curved section, the second curved section comprising a concave curvature.

62. 55. The device of claim 54, wherein the shaft includes a widened section having a transverse dimension equal to or substantially equal to the inner diameter of the lumen of the aspiration catheter to prevent ovalization of the catheter as it is advanced through the opening.

63. 55. The device of claim 54, wherein the opening has a length equal to or substantially equal to a length of the energy element.

64. 1. A system comprising: a catheter having a proximal end and a distal end defining a lumen therebetween, the distal end of the catheter being configured to be disposed within a blood vessel of a subject; a shaft slidably disposed within the lumen, the shaft including a perforating tip having an energy element configured to generate radio frequency (RF) energy and penetrate a wall of the blood vessel and the dura mater of the subject, the shaft further including a curved section configured to transition from a radially constrained configuration to a curved configuration; The shaft is configured to be advanced along the catheter, the curved section is curved along the direction of the curvature of the blood vessel and oriented to exit the distal end of the catheter, the curved section is configured to curve toward the wall of the blood vessel, and the perforating tip is positioned against the wall of the blood vessel and, upon activation of the energy element, is capable of penetrating the wall of the blood vessel and the dura mater and entering the extravascular space.

65. 65. The system of claim 64, wherein the distal end of the catheter includes a radiopaque element.

66. 66. The system of claim 65, wherein the shaft includes a first radiopaque element disposed at the drilling tip and a second radiopaque element disposed proximal to the curved section.

67. the catheter is configured to be advanced over the shaft into the extravascular space; 65. The system of claim 64, wherein the shaft further includes a widened section disposed proximal to the curved section, the widened section preventing ovalization of the catheter as the catheter is advanced into the extravascular space.

68. 68. The system of claim 67, wherein the distal end of the catheter includes a first radiopaque element and the shaft includes a second radiopaque element disposed near the widened section, and the widened section can be aligned with the distal end of the catheter before advancing the catheter into the extravascular space.

69. 65. The system of claim 64, wherein the shaft is a first RF device, and the system further comprises a second RF device including a straight tip configured to penetrate a membrane of a subdural hematoma.

70. 70. The system of claim 69, wherein the second RF device is configured to deliver RF energy to close a vascular lumen of the blood vessel.

71. 1. A method comprising: positioning a distal end of a catheter disposed within a subject's intracranial vessel near a target location; advancing a shaft through a lumen of the catheter, wherein a curved section of the shaft curves in a direction that follows the curvature of the blood vessel, the curved section being constrained within the lumen of the catheter; extending the curved section of the shaft from the distal end of the catheter, the curved section curving toward a wall of the blood vessel to position a radio frequency (RF) element disposed at the distal end of the shaft against the wall of the blood vessel; activating the radio frequency (RF) element to deliver RF energy to the wall of the blood vessel to create an opening through the wall of the blood vessel and the dura mater into an extravascular intracranial space of the subject; advancing the distal end of the shaft into the extravascular intracranial space until the curved section transitions to an unconstrained configuration within the extravascular intracranial space; advancing the catheter over the shaft into the extravascular intracranial space; A method comprising:

72. advancing the distal end of the shaft into a subdural hematoma; advancing the catheter over at least a portion of the shaft and into the subdural hematoma; applying suction to the lumen of the catheter to remove fluid from the subdural hematoma after the catheter is positioned within the subdural hematoma; 72. The method of claim 71, further comprising:

73. retracting the catheter toward the opening created in the wall of the artery; delivering a hemostatic element or an RF device through the lumen of the catheter to close the opening; 72. The method of claim 71, further comprising:

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