The role of GABA in semantic memory and its neuroplasticity

Reviewer #1 (Public Review):

Summary:
This study focuses on the role of GABA in semantic memory and its neuroplasticity. The researchers stimulated the left ATL and control site (vertex) using cTBS, measured changes in GABA before and after stimulation using MRS, and measured changes in BOLD signals during semantic and control tasks using fMRI. They analyzed the effects of stimulation on GABA, BOLD, and behavioral data, as well as the correlation between GABA changes and BOLD changes caused by the stimulation. The authors also analyzed the relationship between individual differences in GABA levels and behavioral performance in the semantic task. They found that cTBS stimulation led to increased GABA levels and decreased BOLD activity in the ATL, and these two changes were highly correlated. However, cTBS stimulation did not significantly change participants' behavioral performance on the semantic task, although behavioral changes in the control task were found after stimulation. Individual levels of GABA were significantly correlated with individuals' accuracy on the semantic task, and the inverted U-shaped (quadratic) function provides a better fit than the linear relationship. The authors argued that the results support the view that GABAergic inhibition can sharpen activated distributed semantic representations. They also claimed that the results revealed, for the first time, a non-linear, inverted-U-shape relationship between GABA levels in the ATL and semantic function, by explaining individual differences in semantic task performance and cTBS responsiveness

Strengths:
The findings of the research regarding the increase of GABA and decrease of BOLD caused by cTBS, as well as the correlation between the two, appear to be reliable. This should be valuable for understanding the biological effects of cTBS.

Weaknesses:
Regarding the behavioral effects of GABA on semantic tasks, especially its impact on neuroplasticity, the results presented in the article are inadequate to support the claims made by the authors. There are three aspects of results related to this: 1) the effects of cTBS stimulation on behavior, 2) the positive correlation between GABA levels and semantic task accuracy, and 3) the nonlinear relationship between GABA levels and semantic task accuracy. Among these three pieces of evidence, the clearest one is the positive correlation between GABA levels and semantic task accuracy. However, it is important to note that this correlation already exists before the stimulation, and there are no results supporting that it can be modulated by the stimulation. In fact, cTBS significantly increases GABA levels but does not significantly improve performance on semantic tasks. According to the authors' interpretation of the results in Table 1, cTBS stimulation may have masked the practice effects that were supposed to occur. In other words, the stimulation decreased rather than enhanced participants' behavioral performance on the semantic task.

The stimulation effect on behavioral performance could potentially be explained by the nonlinear relationship between GABA and performance on semantic tasks proposed by the authors. However, the current results are also insufficient to support the authors' hypothesis of an inverted U-shaped curve. Firstly, in Figure 3C and Figure 3D, the last one-third of the inverted U-shaped curve does not have any data points. In other words, as the GABA level increases the accuracy of the behavior first rises and then remains at a high level. This pattern of results may be due to the ceiling effect of the behavioral task's accuracy, rather than an inverted U-shaped ATL GABA function in semantic memory. Second, the article does not provide sufficient evidence to support the existence of an optimal level of GABA in the ATL. Fortunately, this can be tested with additional data analysis. The authors can estimate, based on pre-stimulus data from individuals, the optimal level of GABA for semantic functioning. They can then examine two expectations: first, participants with pre-stimulus GABA levels below the optimal level should show improved behavioral performance after stimulation-induced GABA elevation; second, participants with pre-stimulus GABA levels above the optimal level should exhibit a decline in behavioral performance after stimulation-induced GABA elevation. Alternatively, the authors can categorize participants into groups based on whether their behavioral performance improves or declines after stimulation, and compare the pre- and post-stimulus GABA levels between the two groups. If the improvement group shows significantly lower pre-stimulus GABA levels compared to the decline group, and both groups exhibit an increase in GABA levels after stimulation, this would also provide some support for the authors' hypothesis.

Another issue in this study is the confounding of simulation effects and practice effects. According to the results, there is a significant improvement in performance after the simulation, at least in the control task, which the authors suggest may reflect a practice effect. The authors argue that the results in Table 1 suggest a similar practice effect in the semantic task, but it is masked by the simulation of the ATL. However, since no significant effects were found in the ANOVA analysis of the semantic task, it is actually difficult to draw a conclusion. This potential confound increases the risk in data analysis and interpretation. Specifically, for Figure 3D, if practice effects are taken into account, the data before and after the simulation should not be analyzed together.

Reviewer #2 (Public Review):

Summary:
The authors combined inhibitory neurostimulation (continuous theta-burst stimulation, cTBS) with subsequent MRI measurements to investigate the impact of inhibition of the left anterior temporal lobe (ATL) on task-related activity and performance during a semantic task and link stimulation-induced changes to the neurochemical level by including MR spectroscopy (MRS). cTBS effects in the ATL were compared with a control site in the vertex. The authors found that relative to stimulation of the vertex, cTBS significantly increased the local GABA concentration in the ATL. cTBS also decreased task-related semantic activity in the ATL and potentially delayed semantic task performance by hindering a practice effect from pre to post. Finally, pooled data from their previous MRS study suggest an inverted U-shape between GABA concentration and behavioral performance. These results help to better understand the neuromodulatory effects of non-invasive brain stimulation on task performance.

Strengths:
Multimodal assessment of neurostimulation effects on the behavioral, neurochemical, and neural levels. In particular, the link between GABA modulation and behavior is timely and potentially interesting.

Weaknesses:
The analyses are not sound. Some of the effects are very weak and not all conclusions are supported by the data since some of the comparisons are not justified. There is some redundancy with a previous paper by the same authors, so the novelty and contribution to the field are overall limited. A network approach might help here.

Reviewer #3 (Public Review):

Summary:
The authors used cTBS TMS, magnetic resonance spectroscopy (MRS), and functional magnetic resonance imaging (fMRI) as the main methods of investigation. Their data show that cTBS modulates GABA concentration and task-dependent BOLD in the ATL, whereby greater GABA increase following ATL cTBS showed greater reductions in BOLD changes in ATL. This effect was also reflected in the performance of the behavioural task response times, which did not subsume to practice effects after AL cTBS as opposed to the associated control site and control task. This is in line with their first hypothesis. The data further indicates that regional GABA concentrations in the ATL play a crucial role in semantic memory because individuals with higher (but not excessive) GABA concentrations in the ATLs performed better on the semantic task. This is in line with their second prediction. Finally, the authors conducted additional analyses to explore the mechanistic link between ATL inhibitory GABAergic action and semantic task performance. They show that this link is best captured by an inverted U-shaped function as a result of a quadratic linear regression model. Fitting this model to their data indicates that increasing GABA levels led to better task performance as long as they were not excessively low or excessively high. This was first tested as a relationship between GABA levels in the ATL and semantic task performance; then the same analyses were performed on the pre and post-cTBS TMS stimulation data, showing the same pattern. These results are in line with the conclusions of the authors.

Strengths:
I thoroughly enjoyed reading the manuscript and appreciate its contribution to the field of the role of the ATL in semantic processing, especially given the efforts to overcome the immense challenges of investigating ATL function by neuroscientific methods such as MRS, fMRI & TMS. The main strengths are summarised as follows:

• The work is methodologically rigorous and dwells on complex and complementary multimethod approaches implemented to inform about ATL function in semantic memory as reflected in changes in regional GABA concentrations. Although the authors previously demonstrated a negative relationship between increased GABA levels and BOLD signal changes during semantic processing, the unique contribution of this work lies within evidence on the effects of cTBS TMS over the ATL given by direct observations of GABA concentration changes and further exploring inter-individual variability in ATL neuroplasticity and consequent semantic task performance.

• Another major asset of the present study is implementing a quadratic regression model to provide insights into the non-linear relationship between inhibitory GABAergic activity within the ATLs and semantic cognition, which improves with increasing GABA levels but only as long as GABA levels are not extremely high or low. Based on this finding, the authors further pinpoint the role of inter-individual differences in GABA levels and cTBS TMS responsiveness, which is a novel explanation not previously considered (according to my best knowledge) in research investigating the effect of TMS on ATLs.

• There are also many examples of good research practice throughout the manuscript, such as the explicitly stated exploratory analyses, calculation of TMS electric fields, using ATL optimised dual echo fRMI, links to open source resources, and a part of data replicates a previous study by Jung et. al (2017).

Weaknesses:
• Research on the role of neurotransmitters in semantic memory is still very rare and therefore the manuscript would benefit from more context on how GABA contributes to individual differences in cognition/behaviour and more justification on why the focus is on semantic memory. A recommendation to the authors is to highlight and explain in more depth the particular gaps in evidence in this regard.

• The focus across the experiments is on the left ATL; how do the authors justify this decision? Highlighting the justification for this methodological decision will be important, especially given that a substantial body of evidence suggests that the ATL should be involved in semantics bilaterally (e.g. Hoffman & Lambon Ralph, 2018; Lambon Ralph et al., 2009; Rice et al., 2017; Rice, Hoffman, et al., 2015; Rice, Ralph, et al., 2015; Visser et al., 2010).

• When describing the results, (Pg. 11; lines 233-243), the authors first show that the higher the BOLD signal intensity in ATL as a response to the semantic task, the lower the GABA concentration. Then, they state that individuals with higher GABA concentrations in the ATL perform the semantic task better. Although it becomes clearer with the exploratory analysis described later, at this point, the results seem rather contradictory and make the reader question the following: if increased GABA leads to less task-induced ATL activation, why at this point increased GABA also leads to facilitating and not inhibiting semantic task performance? It would be beneficial to acknowledge this contradiction and explain how the following analyses will address this discrepancy.

• There is an inconsistency in reporting behavioural outcomes from the performance on the semantic task. While experiment 1 (cTBS modulates regional GANA concentrations and task-related BOLD signal changes in the ATL) reports the effects of cTBS TMS on response times, experiment 2 (Regional GABA concentrations in the ATL play a crucial role in semantic memory) and experiment 3 (The inverted U-shaped function of ATL GABA concentration in semantic processing) report results on accuracy. For full transparency, the manuscript would benefit from reporting all results (either in the main text or supplementary materials) and providing further explanations on why only one or the other outcome is sensitive to the experimental manipulations across the three experiments.

Overall, the most notable impact of this work is the contribution to a better understanding of individual differences in semantic behaviour and the potential to guide therapeutic interventions to restore semantic abilities in neurological populations. While I appreciate that this is certainly the case, I would be curious to read more about how this could be achieved.