Modulation of Cerebellar Cortical Plasticity Using Low-Intensity Focused Ultrasound for Poststroke Sensorimotor Function Recovery

A systematic review of preclinical and clinical transcranial ultrasound neuromodulation and opportunities for functional connectomics

BACKGROUND

Low-intensity transcranial ultrasound has surged forward as a non-invasive and disruptive tool for neuromodulation with applications in basic neuroscience research and the treatment of neurological and psychiatric conditions.

OBJECTIVE

To provide a comprehensive overview and update of preclinical and clinical transcranial low intensity ultrasound for neuromodulation and emphasize the emerging role of functional brain mapping to guide, better understand, and predict responses.

METHODS

A systematic review was conducted by searching the Web of Science and Scopus databases for studies on transcranial ultrasound neuromodulation, both in humans and animals.

RESULTS

187 relevant studies were identified and reviewed, including 116 preclinical and 71 clinical reports with subjects belonging to diverse cohorts. Milestones of ultrasound neuromodulation are described within an overview of the broader landscape. General neural readouts and outcome measures are discussed, potential confounds are noted, and the emerging use of functional magnetic resonance imaging is highlighted.

CONCLUSION

Ultrasound neuromodulation has emerged as a powerful tool to study and treat a range of conditions and its combination with various neural readouts has significantly advanced this platform. In particular, the use of functional magnetic resonance imaging has yielded exciting inferences into ultrasound neuromodulation and has the potential to advance our understanding of brain function, neuromodulatory mechanisms, and ultimately clinical outcomes. It is anticipated that these preclinical and clinical trials are the first of many; that transcranial low intensity focused ultrasound, particularly in combination with functional magnetic resonance imaging, has the potential to enhance treatment for a spectrum of neurological conditions.

Extracellular Vesicles Maintain Blood-Brain Barrier Integrity by the Suppression of Caveolin-1/CD147/VEGFR2/MMP Pathway After Ischemic Stroke

Background

Ischemic stroke (IS) causes tragic death and disability worldwide. However, effective therapeutic interventions are finite. After IS, blood-brain barrier (BBB) integrity is disrupted, resulting in deteriorating neurological function. As a novel therapeutic, extracellular vesicles (EVs) have shown ideal restorative effects on BBB integrity post-stroke; however, the definite mechanisms remain ambiguous. In the present study, we investigated the curative effects and the mechanisms of EVs derived from bone marrow mesenchymal stem cells and brain endothelial cells (BMSC-EVs and BEC-EVs) on BBB integrity after acute IS.

Methods

EVs were isolated from BMSCs and BECs, and we investigated the therapeutic effect in vitro oxygen-glucose deprivation (OGD) insulted BECs model and in vivo rat middle cerebral artery occlusion (MCAo) model. The cell monolayer leakage, tight junction expression, and metalloproteinase (MMP) activity were evaluated, and rat brain infarct volume and neurological function were also analyzed.

Results

The administration of two kinds of EVs not only enhanced ZO-1 and Occludin expressions but also reduced the permeability and the activity of MMP-2/9 in OGD-insulted BECs. The amelioration of the cerebral infarction, BBB leakage, neurological function deficits, and the increasing ZO-1 and Occludin levels, as well as MMP activity inhibition was observed in MCAo rats. Additionally, the increased levels of Caveolin-1, CD147, vascular endothelial growth factor receptor 2 (VEGFR2), and vascular endothelial growth factor A (VEGFA) in isolated brain microvessels were downregulated after EVs treatment. In vitro, the employment of Caveolin-1 and CD147 siRNA partly suppressed the expressions of VEGFR2, VEGFA and MMP-2/9 activity and reduced the leakage of OGD insulted BECs and enhanced ZO-1 and Occludin expressions.

Conclusion

Our study firstly demonstrates that BEC and BMSC-EVs administrations maintain BBB integrity via the suppression of Caveolin-1/CD147/VEGFR2/MMP pathway after IS, and the efficacy of BMSC-EVs is superior to that of BEC-EVs.

Ultrasound Deep Brain Stimulation Regulates Food Intake and Body Weight in Mice

Given the widespread occurrence of obesity, new strategies are urgently needed to prevent, halt and reverse this condition. We proposed a noninvasive neurostimulation tool, ultrasound deep brain stimulation (UDBS), which can specifically modulate the hypothalamus and effectively regulate food intake and body weight in mice. Fifteen-min UDBS of hypothalamus decreased 41.4% food intake within 2 hours. Prolonged 1-hour UDBS significantly decreased daily food intake lasting 4 days. UDBS also effectively restrained body weight gain in leptin-receptor knockout mice (Sham: 96.19%, UDBS: 58.61%). High-fat diet (HFD) mice treated with 4-week UDBS (15 min / 2 days) reduced 28.70% of the body weight compared to the Sham group. Meanwhile, UDBS significantly modulated glucose-lipid metabolism and decreased the body fat. The potential mechanism is that ultrasound actives pro-opiomelanocortin (POMC) neurons in the hypothalamus for reduction of food intake and body weight. These results provide a noninvasive tool for controlling food intake, enabling systematic treatment of obesity.

Methods for evaluating gait associated dynamic balance and coordination in rodents

Balance is the dynamic and unconscious control of the body's centre of mass to maintain postural equilibrium. Regulated by the vestibular system, head movement and acceleration are processed by the brain to adjust joints. Several conditions result in a loss of balance, including Alzheimer's Disease, Parkinson's Disease, Menière's Disease and cervical spondylosis, all of which are caused by damage to certain parts of the vestibular pathways. Studies about the impairment of the vestibular system are challenging to carry out in human trials due to smaller study sizes limiting applications of the results and a lacking understanding of the human balance control mechanism. In contrast, more controlled research can be performed in animal studies which have fewer confounding factors than human models and allow specific conditions that affect balance to be replicated. Balance control can be studied using rodent balance-related behavioural tests after spinal or brain lesions, such as the Basso, Beattie and Bresnahan (BBB) Locomotor Scale, Foot Fault Scoring System, Ledged Beam Test, Beam Walking Test, and Ladder Beam Test, which are discussed in this review article along with their advantages and disadvantages. These tests can be performed in preclinical rodent models of femoral nerve injury, stroke, spinal cord injury and neurodegenerative diseases.

The effectiveness and safety of low-intensity transcranial ultrasound stimulation: A systematic review of human and animal studies

Low-intensity transcranial ultrasound stimulation (LITUS) is a novel non-invasive neuromodulation technique. We conducted a systematic review to evaluate current evidence on the efficacy and safety of LITUS neuromodulation. Five databases were searched from inception to May 31, 2023. Randomized controlled human trials and controlled animal studies were included. The neuromodulation effects of LITUS on clinical or pre-clinical, neurophysiological, neuroimaging, histological and biochemical outcomes, and adverse events were summarized. In total, 11 human studies and 44 animal studies were identified. LITUS demonstrated therapeutic efficacy in neurological disorders, psychiatric disorders, pain, sleep disorders and hypertension. LITUS-related changes in neuronal structure and cortical activity were found. From histological and biochemical perspectives, prominent findings included suppressing the inflammatory response and facilitating neurogenesis. No adverse effects were reported in controlled animal studies included in our review, while reversible headache, nausea, and vomiting were reported in a few human subjects. Overall, LITUS alleviates various symptoms and modulates associated brain circuits without major side effects. Future research needs to establish a solid therapeutic framework for LITUS.

Ultrasonic therapies for seizures and drug-resistant epilepsy

Ultrasonic therapy is an increasingly promising approach for the treatment of seizures and drug-resistant epilepsy (DRE). Therapeutic focused ultrasound (FUS) uses thermal or nonthermal energy to either ablate neural tissue or modulate neural activity through high- or low-intensity FUS (HIFU, LIFU), respectively. Both HIFU and LIFU approaches have been investigated for reducing seizure activity in DRE, and additional FUS applications include disrupting the blood-brain barrier in the presence of microbubbles for targeted-drug delivery to the seizure foci. Here, we review the preclinical and clinical studies that have used FUS to treat seizures. Additionally, we review effective FUS parameters and consider limitations and future directions of FUS with respect to the treatment of DRE. While detailed studies to optimize FUS applications are ongoing, FUS has established itself as a potential noninvasive alternative for the treatment of DRE and other neurological disorders.

Neuromodulation for Post-Stroke Motor Recovery: a Narrative Review of Invasive and Non‑Invasive Tools

PURPOSE OF REVIEW

Stroke remains a leading disabling condition, and many survivors have permanent disability despite acute stroke treatment and subsequent standard-of-care rehabilitation therapies. Adjunctive neuromodulation is an emerging frontier in the field of stroke recovery. In this narrative review, we aim to highlight and summarize various neuromodulation techniques currently being investigated to enhance recovery and reduce impairment in patients with stroke.

RECENT FINDINGS

For motor recovery, repetitive transcranial magnetic simulation (rTMS) and direct current stimulation (tDCS) have shown promising results in many smaller-scale trials. Still, their efficacy has yet to be proven in large-scale pivotal trials. A promising large-scale study investigating higher dose tDCS combined with constraint movement therapy to enhance motor recovery is currently underway. MRI-guided tDCS studies in subacute and chronic post-stroke aphasia showed promising benefits for picture-naming recovery. rTMS, particularly inhibitory stimulation over the contralesional homolog, could represent a pathway forward in post-stroke motor recovery in the setting of a well-designed and adequately powered clinical trial. Recently evidenced-based guideline actually supported Level A (definite efficacy) for the use of low-frequency rTMS of the primary motor cortex for hand motor recovery in the post-acute stage of stroke based on the meta-analysis result. Adjunctive vagal nerve stimulation has recently received FDA approval to enhance upper limb motor recovery in chronic ischemic stroke with moderate impairment, and progress has been made to implement it in real-world practice. Despite a few small and large-scale studies in epidural stimulation (EDS), further research on the utilization of EDS in post-stroke recovery is needed. Deep brain stimulation or stent-based neuromodulation has yet to be further tested regarding safety and efficacy. Adjunctive neuromodulation to rehabilitation therapy is a promising avenue for promoting post-stroke recovery and decreasing the overall burden of disability. The pipeline for neuromodulation technology remains strong as they span from the preclinical stage to the post-market stage. We are optimistic to see that more neuromodulation tools will be available to stroke survivors in the not-to-distant future.

Patient-specific modeling for guided rehabilitation of stroke patients: the BrainX3 use-case

BrainX3 is an interactive neuroinformatics platform that has been thoughtfully designed to support neuroscientists and clinicians with the visualization, analysis, and simulation of human neuroimaging, electrophysiological data, and brain models. The platform is intended to facilitate research and clinical use cases, with a focus on personalized medicine diagnostics, prognostics, and intervention decisions. BrainX3 is designed to provide an intuitive user experience and is equipped to handle different data types and 3D visualizations. To enhance patient-based analysis, and in keeping with the principles of personalized medicine, we propose a framework that can assist clinicians in identifying lesions and making patient-specific intervention decisions. To this end, we are developing an AI-based model for lesion identification, along with a mapping of tract information. By leveraging the patient's lesion information, we can gain valuable insights into the structural damage caused by the lesion. Furthermore, constraining whole-brain models with patient-specific disconnection masks can allow for the detection of mesoscale excitatory-inhibitory imbalances that cause disruptions in macroscale network properties. Finally, such information has the potential to guide neuromodulation approaches, assisting in the choice of candidate targets for stimulation techniques such as Transcranial Ultrasound Stimulation (TUS), which modulate E-I balance, potentiating cortical reorganization and the restoration of the dynamics and functionality disrupted due to the lesion.

Real-Time Acoustic Simulation Framework for tFUS: A Feasibility Study Using Navigation System

Transcranial focused ultrasound (tFUS), in which acoustic energy is focused on a small region in the brain through the skull, is a non-invasive therapeutic method with high spatial resolution and depth penetration. Image-guided navigation has been widely utilized to visualize the location of acoustic focus in the cranial cavity. However, this system is often inaccurate because of the significant aberrations caused by the skull. Therefore, acoustic simulations using a numerical solver have been widely adopted to compensate for this inaccuracy. Although the simulation can predict the intracranial acoustic pressure field, real-time application during tFUS treatment is almost impossible due to the high computational cost. In this study, we propose a neural network-based real-time acoustic simulation framework and test its feasibility by implementing a simulation-guided navigation (SGN) system. Real-time acoustic simulation is performed using a 3D conditional generative adversarial network (3D-cGAN) model featuring residual blocks and multiple loss functions. This network was trained by the conventional numerical acoustic simulation program (i.e., k-Wave). The SGN system is then implemented by integrating real-time acoustic simulation with a conventional image-guided navigation system. The proposed system can provide simulation results with a frame rate of 5 Hz (i.e., about 0.2 s), including all processing times. In numerical validation (3D-cGAN vs. k-Wave), the average peak intracranial pressure error was 6.8 ± 5.5%, and the average acoustic focus position error was 5.3 ± 7.7 mm. In experimental validation using a skull phantom (3D-cGAN vs. actual measurement), the average peak intracranial pressure error was 4.5%, and the average acoustic focus position error was 6.6 mm. These results demonstrate that the SGN system can predict the intracranial acoustic field according to transducer placement in real-time.

Protective effects of low-intensity pulsed ultrasound (LIPUS) against cerebral ischemic stroke in mice by promoting brain vascular remodeling via the inhibition of ROCK1/p-MLC2 signaling pathway

Vascular remodeling is essential for patients with cerebral ischemic stroke (CIS). Our previous study proved that low-intensity pulsed ultrasound (LIPUS) could increase cortical hemodynamics. However, the effects and mechanisms of LIPUS on cerebral vascular remodeling after CIS are still unknown. In this study, we applied LIPUS to the mouse brain at 0.5 h after distal middle cerebral artery occlusion (dMCAO) and subsequently daily for a stimulation time of 30 min. Results showed that compared with the dMCAO group, LIPUS markedly increased cerebral blood flow (CBF), reduced brain swelling, and improved functional recovery at day 3 after CIS. LIPUS promoted leptomeningeal vasculature remodeling, enlarged vascular diameter, and increased the average vessel length and density at day 3 after CIS. Proteomic analysis highlighted that LIPUS mainly participated in the regulation of actin cytoskeleton pathway. Rho kinase 1 (ROCK1) was downregulated by LIPUS and participated in regulation of actin cytoskeleton. Subsequently, we verified that ROCK1 was mainly expressed in pericytes. Furthermore, we demonstrated that LIPUS inhibited ROCK1/p-MLC2 signaling pathway after CIS, which had positive effects on vascular remodeling and cerebral blood circulation. In conclusion, our preliminary study revealed the vascular remodeling effects and mechanism of LIPUS in CIS, provided evidence for potential clinical application of LIPUS.

Advanced rehabilitation in ischaemic stroke research

At present, due to the rapid progress of treatment technology in the acute phase of ischaemic stroke, the mortality of patients has been greatly reduced but the number of disabled survivors is increasing, and most of them are elderly patients. Physicians and rehabilitation therapists pay attention to develop all kinds of therapist techniques including physical therapy techniques, robot-assisted technology and artificial intelligence technology, and study the molecular, cellular or synergistic mechanisms of rehabilitation therapies to promote the effect of rehabilitation therapy. Here, we discussed different animal and in vitro models of ischaemic stroke for rehabilitation studies; the compound concept and technology of neurological rehabilitation; all kinds of biological mechanisms of physical therapy; the significance, assessment and efficacy of neurological rehabilitation; the application of brain-computer interface, rehabilitation robotic and non-invasive brain stimulation technology in stroke rehabilitation.

Development and validation of a computational method to predict unintended auditory brainstem response during transcranial ultrasound neuromodulation in mice

BACKGROUND

Transcranial ultrasound stimulation (TUS) is a promising noninvasive neuromodulation modality. The inadvertent and unpredictable activation of the auditory system in response to TUS obfuscates the interpretation of non-auditory neuromodulatory responses.

OBJECTIVE

The objective was to develop and validate a computational metric to quantify the susceptibility to unintended auditory brainstem response (ABR) in mice premised on time frequency analyses of TUS signals and auditory sensitivity.

METHODS

Ultrasound pulses with varying amplitudes, pulse repetition frequencies (PRFs), envelope smoothing profiles, and sinusoidal modulation frequencies were selected. Each pulse's time-varying frequency spectrum was differentiated across time, weighted by the mouse hearing sensitivity, then summed across frequencies. The resulting time-varying function, computationally predicting the ABR, was validated against experimental ABR in mice during TUS with the corresponding pulse.

RESULTS

There was a significant correlation between experimental ABRs and the computational predictions for 19 TUS signals (R2 = 0.97).

CONCLUSIONS

To reduce ABR in mice during in vivo TUS studies, 1) reduce the amplitude of a rectangular continuous wave envelope, 2) increase the rise/fall times of a smoothed continuous wave envelope, and/or 3) change the PRF and/or duty cycle of a rectangular or sinusoidal pulsed wave to reduce the gap between pulses and increase the rise/fall time of the overall envelope. This metric can aid researchers performing in vivo mouse studies in selecting TUS signal parameters that minimize unintended ABR. The methods for developing this metric can be adapted to other animal models.

Low-intensity ultrasound directly modulates neural activity of the cerebellar cortex

BACKGROUND

Low-intensity ultrasound is a noninvasive neuromodulation technique with the potential to focally manipulate deep brain activity at millimeter-scale resolution. However, there have been controversies over the direct influence of ultrasound on neurons, due to an indirect auditory activation. Besides, the capacity of ultrasound to stimulate the cerebellum remains underestimated.

OBJECTIVE

To validate the direct neuromodulation effects of ultrasound on the cerebellar cortex from both cellular and behavioral levels.

METHODS

Two-photon calcium imaging were used to measure the neuronal responses of cerebellar granule cells (GrCs) and Purkinje cells (PCs) to ultrasound application in awake mice. And a mouse model of paroxysmal kinesigenic dyskinesia (PKD), in which direct activation of the cerebellar cortex leads to dyskinetic movements, was used to assess the ultrasound-induced behavioral responses.

RESULTS

Low-intensity ultrasound stimulus (0.1 W/cm2) evoked rapidly increased and sustained neural activity in GrCs and PCs at targeted region, while no significant changes in calcium signals were observed responding to off-target stimulus. The efficacy of ultrasonic neuromodulation relies on acoustic dose modified by ultrasonic duration and intensity. In addition, transcranial ultrasound reliably triggered dyskinesia attacks in proline-rich transmembrane protein 2 (Prrt2) mutant mice, suggesting that the intact cerebellar cortex were activated by ultrasound.

CONCLUSION

Low-intensity ultrasound directly activates the cerebellar cortex in a dose-dependent manner, and thus serves as a promising tool for cerebellar manipulation.

Application of subject-specific helmets for the study of human visuomotor behavior using transcranial focused ultrasound: a pilot study

BACKGROUND AND OBJECTIVE

As a novel non-invasive human brain stimulation method, transcranial focused ultrasound (tFUS) is receiving growing attention due to its superior spatial specificity and depth penetrability. Since the focal point of tFUS needs to be fixated precisely to the target brain region during stimulation, a critical issue is to identify and maintain the accurate position and orientation of the tFUS transducer relative to the subject's head. This study aims to propose the entire framework of tFUS stimulation integrating the methods previously proposed by the authors for tFUS transducer configuration optimization and a subject-specific 3D-printed helmet, and to validate this complete setup in a human behavioral neuromodulation study.

METHODS

To find the optimal configuration of the tFUS transducer, a numerical method based on subject-specific tFUS beamlines simulation was used. Then, the subject-specific 3D-printed helmet has been applied to effectively secure the transducer at the estimated optimal configuration. To validate this tFUS framework, a common behavioral neuromodulation paradigm was chosen; the effect of the dorsolateral prefrontal cortex (DLPFC) stimulation on anti-saccade (AS) behavior. While human participants (n=2) were performing AS tasks, tFUS stimulations were randomly applied to the left DLPFC right after the fixation target disappeared.

RESULTS

The neuromodulation result strongly suggests that the cortical stimulation using the proposed tFUS setup is effective in significantly reducing the error rates of anti-saccades (about -10 %p for S1 and -16 %p for S2), whereas no significant effect was observed on their latencies. These observed behavioral effects are consistent with the previous results based on conventional brain stimulation or lesion studies.

CONCLUSIONS

The proposed subject-specific tFUS framework has been effectively used in human neuromodulation study. The result suggests that the tFUS stimulation targeted to the DLPFC can generate a neuromodulatory effect on AS behavior.

Development of a wireless ultrasonic brain stimulation system for concurrent bilateral neuromodulation in freely moving rodents

Bilateral brain stimulation is an important modality used to investigate brain circuits and treat neurological conditions. Recently, low-intensity pulsed ultrasound (LIPUS) received significant attention as a novel non-invasive neurostimulation technique with high spatial specificity. Despite the growing interest, the typical ultrasound brain stimulation study, especially for small animals, is limited to a single target of sonication. The constraint is associated with the complexity and the cost of the hardware system required to achieve multi-regional sonication. This work presented the development of a low-cost LIPUS system with a pair of single-element ultrasound transducers to address the above problem. The system was built with a multicore processor with an RF amplifier circuit. In addition, LIPUS device was incorporated with a wireless module (bluetooth low energy) and powered by a single 3.7 V battery. As a result, we achieved an ultrasound transmission with a central frequency of 380 kHz and a peak-to-peak pressure of 480 kPa from each ultrasound transducer. The developed system was further applied to anesthetized rats to investigate the difference between uni- and bilateral stimulation. A significant difference in cortical power density extracted from electroencephalogram signals was observed between uni- and bilateral LIPUS stimulation. The developed device provides an affordable solution to investigate the effects of LIPUS on functional interhemispheric connection.

Transcranial ultrasound stimulation applied in ischemic stroke rehabilitation: A review

Ischemic stroke is a serious medical condition that is caused by cerebral vascular occlusion and leads to neurological dysfunction. After stroke, patients suffer from long-term sensory, motor and cognitive impairment. Non-invasive neuromodulation technology has been widely studied in the field of stroke rehabilitation. Transcranial ultrasound stimulation (TUS), as a safe and non-invasive technique with deep penetration ability and a tiny focus, is an emerging technology. It can produce mechanical and thermal effects by delivering sound waves to brain tissue that can induce the production of neurotrophic factors (NFs) in the brain, and reduce cell apoptosis and the inflammatory response. TUS, which involves application of an acoustic wave, can also dissolve blood clots and be used to deliver therapeutic drugs to the ischemic region. TUS has great potential in the treatment of ischemic stroke. Future advancements in imaging and parameter optimization will improve the safety and efficacy of this technology in the treatment of ischemic stroke.

Noninvasive Low-Intensity Focused Ultrasound Mediates Tissue Protection following Ischemic Stroke

Objective and Impact Statement. This study examined the efficacy and safety of pulsed, low-intensity focused ultrasound (LIFU) and determined its ability to provide neuroprotection in a murine permanent middle cerebral artery occlusion (pMCAO) model. Introduction. Focused ultrasound (FUS) has emerged as a new therapeutic strategy for the treatment of ischemic stroke; however, its nonthrombolytic properties remain ill-defined. Therefore, we examined how LIFU influenced neuroprotection and vascular changes following stroke. Due to the critical role of leptomeningeal anastomoses or pial collateral vessels, in cerebral blood flow restoration and tissue protection following ischemic stroke, we also investigated their growth and remodeling. Methods. Mice were exposed to transcranial LIFU (fundamental frequency: 1.1 MHz, sonication duration: 300 ms, interstimulus interval: 3 s, pulse repetition frequency: 1 kHz, duty cycle per pulse: 50%, and peak negative pressure: -2.0 MPa) for 30 minutes following induction of pMCAO and then evaluated for infarct volume, blood-brain barrier (BBB) disruption, and pial collateral remodeling at 24 hrs post-pMCAO. Results. We found significant neuroprotection in mice exposed to LIFU compared to mock treatment. These findings correlated with a reduced area of IgG deposition in the cerebral cortex, suggesting attenuation of BBB breakdown under LIFU conditions. We also observed increased diameter of CD31-postive microvessels in the ischemic cortex. We observed no significant difference in pial collateral vessel size between FUS and mock treatment at 24 hrs post-pMCAO. Conclusion. Our data suggests that therapeutic use of LIFU may induce protection through microvascular remodeling that is not related to its thrombolytic activity.

Mechanistic insights into ultrasonic neurostimulation of disconnected neurons using single short pulses

Ultrasonic neurostimulation is a potentially potent noninvasive therapy, whose mechanism has yet to be elucidated. We designed a system capable of applying ultrasound with minimal reflections to neuronal cultures. Synaptic transmission was pharmacologically controlled, eliminating network effects, enabling examination of single-cell processes. Short single pulses of low-intensity ultrasound were applied, and time-locked responses were examined using calcium imaging. Low-pressure (0.35MPa) ultrasound directly stimulated ∼20% of pharmacologically disconnected neurons, regardless of membrane poration. Stimulation was resistant to the blockade of several purinergic receptor and mechanosensitive ion channel types. Stimulation was blocked, however, by suppression of action potentials. Surprisingly, even extremely short (4μs) pulses were effective, stimulating ∼8% of the neurons. Lower-pressure pulses (0.35MPa) were less effective than higher-pressure ones (0.65MPa). Attrition effects dominated, with no indication of compromised viability. Our results detract from theories implicating cavitation, heating, non-transient membrane pores >1.5nm, pre-synaptic release, or gradual effects. They implicate a post-synaptic mechanism upstream of the action potential, and narrow down the list of possible targets involved.

Review of Noninvasive or Minimally Invasive Deep Brain Stimulation

Brain stimulation is a critical technique in neuroscience research and clinical application. Traditional transcranial brain stimulation techniques, such as transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and deep brain stimulation (DBS) have been widely investigated in neuroscience for decades. However, TMS and tDCS have poor spatial resolution and penetration depth, and DBS requires electrode implantation in deep brain structures. These disadvantages have limited the clinical applications of these techniques. Owing to developments in science and technology, substantial advances in noninvasive and precise deep stimulation have been achieved by neuromodulation studies. Second-generation brain stimulation techniques that mainly rely on acoustic, electronic, optical, and magnetic signals, such as focused ultrasound, temporal interference, near-infrared optogenetic, and nanomaterial-enabled magnetic stimulation, offer great prospects for neuromodulation. This review summarized the mechanisms, development, applications, and strengths of these techniques and the prospects and challenges in their development. We believe that these second-generation brain stimulation techniques pave the way for brain disorder therapy.

Ultrasound Neuromodulation: Integrating Medicine and Engineering for Neurological Disease Treatment

Abstract Neurological diseases associated with dysfunctions of neural circuits, including Alzheimer’s disease (AD), depression and epilepsy, have been increasingly prevalent. To tackle these issues, artificial stimulation or regulation of specific neural circuits and nuclei are employed to alleviate or cure certain neurological diseases. In particular, ultrasound neuromodulation has been an emerging interdisciplinary approach, which integrates medicine and engineering methodologies in the treatment. With the development of medicine and engineering, ultrasound neuromodulation has gradually been applied in the treatment of central nervous system diseases. In this review, we aimed to summarize the mechanism of ultrasound neuromodulation and the advances of focused ultrasound (FUS) in neuromodulation in recent years, with a special emphasis on its application in central nervous system disease treatment. FUS showed great feasibility in the treatment of epilepsy, tremor, AD, depression, and brain trauma. We also suggested future directions of ultrasound neuromodulation in clinical settings, with a focus on its fusion with genetic engineering or nanotechnology.

Transcranial Focused Ultrasound Neuromodulation: A Review of the Excitatory and Inhibitory Effects on Brain Activity in Human and Animals

Non-invasive neuromodulation technology is important for the treatment of brain diseases. The effects of focused ultrasound on neuronal activity have been investigated since the 1920s. Low intensity transcranial focused ultrasound (tFUS) can exert non-destructive mechanical pressure effects on cellular membranes and ion channels and has been shown to modulate the activity of peripheral nerves, spinal reflexes, the cortex, and even deep brain nuclei, such as the thalamus. It has obvious advantages in terms of security and spatial selectivity. This technology is considered to have broad application prospects in the treatment of neurodegenerative disorders and neuropsychiatric disorders. This review synthesizes animal and human research outcomes and offers an integrated description of the excitatory and inhibitory effects of tFUS in varying experimental and disease conditions.

New Horizons on Non-invasive Brain Stimulation of the Social and Affective Cerebellum

The cerebellum is increasingly attracting scientists interested in basic and clinical research of neuromodulation. Here, we review available studies that used either transcranial magnetic stimulation (TMS) or transcranial direct current stimulation (tDCS) to examine the role of the posterior cerebellum in different aspects of social and affective cognition, from mood regulation to emotion discrimination, and from the ability to identify biological motion to higher-level social inferences (mentalizing). We discuss how at the functional level the role of the posterior cerebellum in these different processes may be explained by a generic prediction mechanism and how the posterior cerebellum may exert this function within different cortico-cerebellar and cerebellar limbic networks involved in social cognition. Furthermore, we suggest to deepen our understanding of the cerebro-cerebellar circuits involved in different aspects of social cognition by employing promising stimulation approaches that have so far been primarily used to study cortical functions and networks, such as paired-pulse TMS, frequency-tuned stimulation, state-dependent protocols, and chronometric TMS. The ability to modulate cerebro-cerebellar connectivity opens up possible clinical applications for improving impairments in social and affective skills associated with cerebellar abnormalities.

Mechanical and mechanothermal effects of focused ultrasound elicited distinct electromyographic responses in mice

The objective of this study was to compare focused ultrasound (FUS) neuromodulation-induced motor responses under two physical mechanisms: mechanical and mechanothermal effects. Mice were divided into two groups. One group was subjected to short-duration FUS stimulation (0.3 s) that induced mechanical effects (mechanical group). The other group underwent long-duration FUS stimulation (15 s) that produced not only mechanical but also thermal effects (mechanothermal group). FUS was targeted at the deep cerebellar nucleus in the cerebellum to induce motor responses, which were evaluated by recording the evoked electromyographic (EMG) signals and tail movements. Brain tissue temperature rise associated with the FUS stimulation was quantified by noninvasive magnetic resonance thermometryin vivo. Temperature rise was negligible for the mechanical group (0.2 °C ± 0.1 °C) but did rise within the range of 0.6 °C ± 0.2 °C-3.3 °C ± 0.9 °C for the mechanothermal group. The elongated FUS beam also induced heating in the dorsal brain (below the top skull) and ventral brain (above the bottom skull) along the beam path for the mechanothermal group. Both mechanical and mechanothermal groups achieved successful FUS neuromodulation. EMG response latencies were within the range of 0.03-0.1 s at different intensity levels for the mechanical group. The mechanothermal effect of FUS could induce both short-latency EMG (0.2-1.4 s) and long-latency EMG (8.7-13.0 s) under the same intensity levels as the mechanical group. The different temporal dynamics of evoked EMG suggested that FUS-induced mechanical and mechanothermal effects could evoke different responses in the brain.

Wearable Transcranial Ultrasound System for Remote Stimulation of Freely Moving Animal

OBJECTIVE

Transcranial focused ultrasound (tFUS) has drawn considerable attention in the neuroscience field as a noninvasive approach to modulate brain circuits. However, the conventional approach requires the use of anesthetized or immobilized animal models, which places considerable restrictions on behavior and affects treatment. Thus, this work presents a wireless, wearable system to achieve ultrasound brain stimulation in freely behaving animals.

METHODS

The wearable tFUS system was developed based on a microcontroller and amplifier circuit. Brain activity induced by tFUS was monitored through cerebral hemodynamic changes using near-infrared spectroscopy. The system was also applied to stroke rehabilitation after temporal middle cerebral artery occlusion (tMCAO) in rats. Temperature calculations and histological results showed the safety of the application even with prolonged 40 min sonication.

RESULTS

The output ultrasonic wave produced from a custom PZT transducer had a central frequency of 457 kHz and peak to peak pressure of 426 kPa. The device weight was 20 g, allowing a full range of motion. The stimulation was found to induce hemodynamic changes in the sonicated area, while open-field tests showed that ultrasound applied to the ipsilateral hemisphere for 5 consecutive days after the stroke facilitated recovery.

CONCLUSION

The wearable tFUS system has been designed and implemented on moving rats. The results showed the ability of device to cause both short- and long lasting effects.

SIGNIFICANCE

The proposed device provides a more natural environment to investigate the effects of tFUS for behavioral and long-term studies.

Entrainment of cerebellar Purkinje cell spiking activity using pulsed ultrasound stimulation

BACKGROUND

Focused ultrasound (FUS) has excellent characteristics over other non-invasive stimulation methods in terms of spatial resolution and steering capability of the target. FUS has not been tested in the cerebellar cortex and cellular effects of FUS are not fully understood.

OBJECTIVE/HYPOTHESIS

To investigate how the activity of cerebellar Purkinje cells (PCs) is modulated by FUS with varying pulse durations and pulse repetition frequencies.

METHODS

A glass microelectrode was inserted into the cerebellar vermis lobule 6 from the dorsal side to extracellularly record single unit activity of the PCs in anesthetized rats. Ultrasonic stimulation (500 kHz) was applied through a coupling cone, filled with degassed water, from the posterior side to target the recording area with varying pulse durations and frequencies.

RESULTS

Simple spike (SS) activity of PCs was entrained by the FUS pattern where the probability of spike occurrences peaked at around 1 ms following the onset of the stimulus regardless of its duration (0.5, 1, or 2 ms). The level of entrainment was stronger with shorter pulse durations at 50-Hz pulse repetition frequency (PRF), however, peri-event histograms spread wider and the peaks delayed slightly at 100-Hz PRF, suggesting involvement of a long-lasting inhibitory mechanism. There was no significant difference between the average firing rates in the baseline and stimulation periods.

CONCLUSION

FUS can entrain spiking activity of single cells on a spike-by-spike basis as demonstrated here in the rat cerebellar cortex. The observed modulation potentially results from the aggregate of excitatory and inhibitory effects of FUS on the entire cortical network rather than on the PCs alone.

Transcranial focused ultrasound stimulation with high spatial resolution

BACKGROUND

Low-intensity transcranial focused ultrasound stimulation is a promising candidate for noninvasive brain stimulation and accurate targeting of brain circuits because of its focusing capability and long penetration depth. However, achieving a sufficiently high spatial resolution to target small animal sub-regions is still challenging, especially in the axial direction.

OBJECTIVE

To achieve high axial resolution, we designed a dual-crossed transducer system that achieved high spatial resolution in the axial direction without complex microfabrication, beamforming circuitry, and signal processing.

METHODS

High axial resolution was achieved by crossing two ultrasound beams of commercially available piezoelectric curved transducers at the focal length of each transducer. After implementation of the fixture for the dual-crossed transducer system, three sets of in vivo animal experiments were conducted to demonstrate high target specificity of ultrasound neuromodulation using the dual-crossed transducer system (n = 38).

RESULTS

The full-width at half maximum (FWHM) focal volume of our dual-crossed transducer system was under 0.52 μm³. We report a focal diameter in both lateral and axial directions of 1 mm. To demonstrate successful in vivo brain stimulation of wild-type mice, we observed the movement of the forepaws. In addition, we targeted the habenula and verified the high spatial specificity of our dual-crossed transducer system.

CONCLUSIONS

Our results demonstrate the ability of the dual-crossed transducer system to target highly specific regions of mice brains using ultrasound stimulation. The proposed system is a valuable tool to study the complex neurological circuitry of the brain noninvasively.

Deep Cerebellar Low-Intensity Focused Ultrasound Stimulation Restores Interhemispheric Balance after Ischemic Stroke in Mice

Ischemic damage after stroke disrupts the complex balance of inhibitory and excitatory activity within cortical network causing brain functional asymmetry. Cerebellar deep nuclei with its extensive projections to cortical regions could be a prospective target for stimulation to restore inter-hemispheric balance and enhance neural plasticity after stroke. In our study, we repeatedly stimulated the lateral cerebellar nucleus (LCN) by low-intensity focused ultrasound (LIFU) for 3 days to enhance rehabilitation after middle cerebral artery occlusion (MCAO) in a mouse stroke model. The neural activity of the mice sensorimotor cortex was measured using epidural electrodes and analyzed with quantified electroencephalography (qEEG). Pairwise derived Brain Symmetry Index (pdBSI) and delta power were used to assess the neurorehabilitative effect of LIFU stimulation. Compared to the Stroke (non-treated) group, the LIFU group exhibited a decrease in cortical pathological delta activity, significant recovery in pdBSI and enhanced performance on the balance beam walking test. These results suggest that cerebellar LIFU stimulation could be a non-invasive method for stroke rehabilitation through the restoration of interhemispheric balance.

Consensus Paper: Experimental Neurostimulation of the Cerebellum

The cerebellum is best known for its role in controlling motor behaviors. However, recent work supports the view that it also influences non-motor behaviors. The contribution of the cerebellum towards different brain functions is underscored by its involvement in a diverse and increasing number of neurological and neuropsychiatric conditions including ataxia, dystonia, essential tremor, Parkinson's disease (PD), epilepsy, stroke, multiple sclerosis, autism spectrum disorders, dyslexia, attention deficit hyperactivity disorder (ADHD), and schizophrenia. Although there are no cures for these conditions, cerebellar stimulation is quickly gaining attention for symptomatic alleviation, as cerebellar circuitry has arisen as a promising target for invasive and non-invasive neuromodulation. This consensus paper brings together experts from the fields of neurophysiology, neurology, and neurosurgery to discuss recent efforts in using the cerebellum as a therapeutic intervention. We report on the most advanced techniques for manipulating cerebellar circuits in humans and animal models and define key hurdles and questions for moving forward.

Method to optimize the placement of a single-element transducer for transcranial focused ultrasound

BACKGROUND AND OBJECTIVE

Transcranial focused ultrasound (tFUS) is a promising neuromodulation technique because of its non-invasiveness and high spatial resolution (within millimeter scale). However, the presence of the skull can lead to disrupting and shifting the acoustic focus in the brain. In this study, we propose a computationally efficient way to determine the optimal position of a single-element focused ultrasound transducer which can effectively deliver acoustic energy to the brain target. We hypothesized that the placement of a single element transducer with the lowest average reflection coefficient would be the optimal position.

METHODS

The reflection coefficient is defined by the ratio of the amplitude of the reflected wave to the incident wave. To calculate the reflection coefficient, we assumed ultrasound waves as straight lines (beam lines). At each beam line, the reflection coefficient was calculated from the incidence angle at the skull interface (outer/inner skull surfaces). The average reflection coefficient (ARC) was calculated at each possible placement of the transducer using a custom-built software. For comparison purposes, acoustic simulations (k-Wave MATLAB toolbox) which numerically solved the linear wave equation were performed with the same transducer positions used in the ARC calculation. In addition, the experimental validation of our proposed method was also performed by measuring acoustic wave propagation through the calvaria skull phantom in water. The accuracy of our method was defined as the distance between the two optimal transducer placements which were determined from the acoustic simulations and from the ARC method.

RESULT

Simulated acoustic pressure distribution corresponding to each ARC showed an inverse relationship with peak acoustic pressures produced in the brain. In comparison to the acoustic simulations, the accuracy of our method was 5.07 ± 4.27 mm when targeting the cortical region in the brain. The computing time of ARC calculations were 0.08% of the time required for acoustic pressure simulations.

CONCLUSION

We calculated the ARC to find the optimal position of the tFUS transducer used in the present study. The optimal placement of the transducer was found when the ARC was the lowest. Our numerical and experimental results showed that the proposed ARC method can effectively be used to find the optimal position of a single-element tFUS transducer for targeting the cortex region of the brain in a computationally inexpensive way.

Safety of transcranial focused ultrasound stimulation: A systematic review of the state of knowledge from both human and animal studies

BACKGROUND

Low-intensity transcranial focused ultrasound stimulation (TFUS) holds great promise as a highly focal technique for transcranial stimulation even for deep brain areas. Yet, knowledge about the safety of this novel technique is still limited.

OBJECTIVE

To systematically review safety related aspects of TFUS. The review covers the mechanisms-of-action by which TFUS may cause adverse effects and the available data on the possible occurrence of such effects in animal and human studies.

METHODS

Initial screening used key term searches in PubMed and bioRxiv, and a review of the literature lists of relevant papers. We included only studies where safety assessment was performed, and this results in 33 studies, both in humans and animals.

RESULTS

Adverse effects of TFUS were very rare. At high stimulation intensity and/or rate, TFUS may cause haemorrhage, cell death or damage, and unintentional blood-brain barrier (BBB) opening. TFUS may also unintentionally affect long-term neural activity and behaviour. A variety of methods was used mainly in rodents to evaluate these adverse effects, including tissue staining, magnetic resonance imaging, temperature measurements and monitoring of neural activity and behaviour. In 30 studies, adverse effects were absent, even though at least one Food and Drug Administration (FDA) safety index was frequently exceeded. Two studies reported microhaemorrhages after long or relatively intense stimulation above safety limits. Another study reported BBB opening and neuronal damage in a control condition, which intentionally and substantially exceeded the safety limits.

CONCLUSION

Most studies point towards a favourable safety profile of TFUS. Further investigations are warranted to establish a solid safety framework for the therapeutic window of TFUS to reliably avoid adverse effects while ensuring neural effectiveness. The comparability across studies should be improved by a more standardized reporting of TFUS parameters.

Development of a subject-specific guide system for Low-Intensity Focused Ultrasound (LIFU) brain stimulation

Low-Intensity Focused Ultrasound (LIFU) has recently been considered as a promising neuromodulation technique because it can noninvasively stimulate the brain with a high spatial resolution. As spatial resolution is improved, there is a growing demand for developing more accurate and convenient guide systems. Therefore, in the present study, we have developed and prototyped a 3D printed wearable subject-specific helmet for LIFU stimulation that is guaranteed to be accurate. The spatial relationship between the target position and the full-width at half-maximum (FWHM) of acoustic pressure of the transducer, i.e. focal volume, was compared using the conventional image-guided navigation system. According to the distribution of positional errors, the target position was located well within the focal volume.