Neuromodulation with Ultrasound: Hypotheses on the Directionality of Effects and a Community Resource

Reviewer #1 (Public review):

Summary:

This paper is a relevant overview of the currently published literature on low-intensity focussed ultrasound stimulation (TUS) in humans, with a meta-analysis of this literature that explores which stimulation parameters might predict the directionality of the physiological stimulation effects.

The pool of papers to draw from is small, which is not surprising given the nascent technology. It seems nevertheless relevant to summarize the current field in the way done here, not least to mitigate and prevent some of the mistakes that other non-invasive brain stimulation techniques have suffered from, most notably the theory- and data-free permutation of the parameter space.
The meta-analysis concludes that there are, at best, weak trends toward specific parameters predicting the direction of the stimulation effects. The data have been incorporated into an open database, that will ideally continue to be populated by the community and thereby become a helpful resource as the field moves forward.

Strengths:

The current state of human TUS is concisely and well summarized. The methods of the meta-analysis are appropriate. The database is a valuable resource.

Weaknesses:

These are not so much weaknesses but rather comments and suggestions that the authors may want to consider.

(1) I may have missed this, but how will the database be curated going forward? The resource will only be as useful as the quality of data entry, which, given the complexity of TUS can easily be done incorrectly.

(2) It would be helpful to report the full statistics and effect sizes for all analyses. At times, only p-values are given. The meta-analysis only provides weak evidence (judged by the p-values) for two parameters having a predictive effect on the direction of neuromodulation. This reviewer thinks a stronger statement is warranted that there is currently no good evidence for duty cycle or sonication direction predicting outcome (though I caveat this given the full stats aren't reported). The concern here is that some readers may gallop away with the impression that the evidence is compelling because the p-value is on the correct side of 0.05.

(3) This reviewer thinks the issue of (independent) replication should be more forcefully discussed and highlighted. The overall motivation for the present paper is clearly and thoughtfully articulated, but perhaps the authors agree that the role that replication has to play in a nascent field such as TUS is worth considering.

(4) A related point is that many of the results come from the same groups (the so-called theta-TUS protocol being a clear example). The analysis could factor this in, but it may be helpful to either signpost independent replications, which studies come from the same groups, or both.

(5) The recent study by Bao et al 2024 J Phys might be worth including, not least because it fails to replicate the results on theta TUS that had been limited to the same group so far (by reporting, in essence, the opposite result).

(6) The summary of TUS effects is useful and concise. Two aspects may warrant highlighting, if anything to safeguard against overly simplistic heuristics for the application of TUS from less experienced users. First, could the effects of sonication (enhancing vs suppressing) depend on the targeted structure? Across the cortex, this may be similar, but for subcortical structures such as the basal ganglia, thalamus, etc, the idiosyncratic anatomy, connectivity, and composition of neurons may well lead to different net outcomes. Do the models mentioned in this paper account for that or allow for exploring this? And is it worth highlighting that simple heuristics that assume the effects of a given TUS protocol are uniform across the entire brain risk oversimplification or could be plain wrong? Second, and related, there seems to be the implicit assumption (not necessarily made by the authors) that the effects of a given protocol in a healthy population transfer like for like to a patient population (if TUS protocol X is enhancing in healthy subjects, I can use it for enhancement in patient group Y). This reviewer does not know to which degree this is valid or not, but it seems simplistic or risky. Many neurological and psychiatric disorders alter neurotransmission, and/or lead to morphological and structural changes that would seem capable of influencing the impact of TUS. If the authors agree, this issue might be worth highlighting.

Reviewer #2 (Public review):

Summary:

This paper describes a number of aspects of transcranial ultrasound stimulation (TUS) including a generic review of what TUS might be used for; a meta-analysis of human studies to identify ultrasound parameters that affect directionality; a comparison between one postulated mechanistic model and results in humans; and a description of a database for collecting information on studies.

Strengths:

The main strength was a meta-analysis of human studies to identify which ultrasonic parameters might result in enhancement or suppression of modulation effects. The meta-analysis suggests that none of the US parameters correlate significantly with effects. This is a useful result for researchers in the field in trying to determine how the parameter space should be further investigated to identify whether it is possible to indeed enhance or suppress brain activity with ultrasound.

The database is a good idea in principle but would be best done in collaboration with ITRUSST, an international consortium, and perhaps should be its own paper.

Weaknesses:

The paper tries to cover too many topics and some of the technical descriptions are a bit loose. The review section does not add to the current literature. The comparison with a mechanistic model is limited to comparing data with a single model at a time when there is no general agreement in the field as to how ultrasound might produce a neuromodulation effect. The comparison is therefore of limited value.