Focused ultrasound in modern medicine: bioengineering interfaces, molecular effects, and clinical breakthroughs

Abstract

Ultrasound technology, first utilized in 1947–1948 for diagnostic applications in obstetrics and gynecology, has significantly expanded its scope to include both diagnostic and therapeutic uses in modern medicine. The advent of continuous therapeutic ultrasound has allowed for its application in treating musculoskeletal pathologies, enhancing fracture healing, and even facilitating tumor treatment when paired with MRI. Ultrasonic cavitation, gas body activation, and mechanical stress are primary non-thermal mechanisms responsible for its biological effects. Recent advancements have expanded ultrasound’s potential to enhance drug delivery, as seen in the sonoporation phenomenon, where ultrasound triggers cell membrane permeability. This process can be reversible or irreversible, offering exciting possibilities for targeted treatments. Additionally, microbubbles are used to intensify US-induced effects, contributing to therapeutic applications such as high-intensity focused ultrasound (HIFU) for cancer ablation and drug delivery. Molecular ultrasound imaging, which incorporates microbubbles targeted to specific biomarkers, allows for the non-invasive visualization of molecular processes such as angiogenesis, inflammation, and thrombosis. This capability holds significant promise for early disease detection and monitoring, particularly in cancer and cardiovascular conditions. The aim of this review is to explore the diverse molecular mechanisms underlying ultrasound’s therapeutic and diagnostic capabilities, assess its potential for improving patient outcomes, and highlight the future directions for clinical integration of ultrasound in medicine.

1 Introduction

Ultrasound technology has rapidly evolved from a diagnostic imaging modality into a multifaceted therapeutic tool capable of precise tissue targeting and molecular modulation. In the contemporary medical landscape, ultrasound-based therapies—including high-intensity focused ultrasound (HIFU), extracorporeal shockwave lithotripsy, and ultrasound-mediated drug delivery—are increasingly recognized for their ability to induce biological effects that extend beyond traditional imaging (Gliklich et al., 2007; Ninet et al., 2005; Zini et al., 2012; Taran et al., 2009; Kaneko and Willmann, 2012; Deshpande et al., 2010). The therapeutic potential of ultrasound lies in its capacity to deliver focused energy deep within tissues, achieving site-specific intervention while minimizing collateral damage to surrounding structures. This selectivity is central to modern approaches that seek to leverage physical energy for minimally invasive, yet highly effective, clinical interventions.

The underlying mechanisms by which ultrasound exerts therapeutic effects are diverse and depend on the mode, frequency, and intensity of the energy delivered (O'Brien, 2007). At the molecular level, ultrasound can enhance cell membrane permeability through processes such as sonoporation, enabling the targeted delivery of therapeutic agents into cells (Bess, 2023; Awal et al., 2021) (Figure 1). Additionally, the thermal and mechanical effects of focused ultrasound can induce protein denaturation, tissue ablation, and stimulation of tissue regeneration, making it a versatile platform for treating conditions ranging from solid tumors to musculoskeletal injuries (Kremkau, 1979). These molecular and cellular responses are the result of complex biophysical interactions, including acoustic cavitation, radiation force, and localized heating, all of which can be harnessed to modulate biological systems in a controlled manner.

FIGURE 1

Recent advancements in ultrasound technology have greatly expanded its range of clinical applications. For example, the combination of ultrasound with imaging modalities such as MRI has facilitated precise targeting for both benign and malignant tumors, improving treatment outcomes and reducing side effects (Gliklich et al., 2007; Ninet et al., 2005; Zini et al., 2012; Taran et al., 2009; Kaneko and Willmann, 2012; Deshpande et al., 2010). The integration of ultrasound with molecular techniques has further broadened its potential, allowing for the development of novel strategies in areas such as gene therapy and immunomodulation (Gheorghe et al., 2023; Sun S. et al., 2022). Moreover, focused ultrasound is being explored as a means of enhancing the efficacy of conventional therapies. By temporarily increasing vascular and cellular permeability, ultrasound can improve the distribution and uptake of chemotherapeutic drugs, as well as biological agents used in immunotherapy. This synergistic approach aims to maximize therapeutic benefit while reducing systemic toxicity—a longstanding challenge in cancer treatment and other chronic diseases (Miller et al., 2012; Bader et al., 2025; Laganà et al., 2024).

While the early use of ultrasound in medicine can be traced back to 1947–1948, when Karl Dussik and his brother Friederick introduced hyperphonography for visualizing cerebral ventricles (Shung, 2011), its therapeutic applications have advanced remarkably in recent decades. Initially, ultrasound gained widespread acceptance in diagnostic imaging due to its safety, affordability, and portability. It became a mainstay for monitoring pregnancies, guiding joint injections, and identifying soft tissue disorders (Analan et al., 2015; Robertson and Baker, 2001). However, as engineering innovations enabled more precise control of ultrasound energy, the technology found new roles in clinical interventions. The introduction of extracorporeal shockwave lithotripsy in the 1980s revolutionized the treatment of kidney stones, and HIFU has since emerged as a promising modality for non-invasive tumor ablation and the treatment of prostate cancer (Yu and Xu, 2014; Lentacker et al., 2014; Wang et al., 2017; Boissenot et al., 2016).

Despite these successes, therapeutic ultrasound is not without challenges. The biological effects of ultrasound are influenced by numerous factors, including tissue composition, energy dose, and treatment duration. Tissues with higher protein content, such as muscle, tend to absorb mechanical energy more efficiently than those with higher water content, such as fat, while bone primarily reflects ultrasound waves due to its density and impedance mismatch (O'Brien, 2007; Bess, 2023; Awal et al., 2021). Unintended bioeffects—including thermal injury and mechanical damage—underscore the importance of standardized protocols, dosimetry, and rigorous safety assessments in clinical practice (Miller et al., 2012; Bader et al., 2025).

While ultrasound-mediated delivery has attracted significant attention for its non-invasive and targeted capabilities, other bioengineering-based methods are also being explored for therapeutic applications. Electroporation, for example, uses brief electric pulses to transiently permeabilize cell membranes, thereby enhancing the delivery of drugs or genetic material (Jacobs et al., 2025; Balantič et al., 2021; Rubinsky, 2007). Although highly effective for gene transfer, electroporation is generally limited to localized or superficial applications and may cause significant discomfort or tissue damage in some settings (Young and Dean, 2015; Mahnič-Kalamiza and Miklavčič, 2022; Choi et al., 2022). Nanoparticle-mediated therapies offer another promising approach, enabling the encapsulation and targeted delivery of therapeutics with high specificity; however, challenges remain regarding biodistribution, long-term safety, and clearance (Li X. et al., 2024; Verma et al., 2023). Compared to these methods, ultrasound-based administration offers the advantage of deep tissue penetration, real-time imaging guidance, and the ability to combine with microbubbles or nanocarriers for spatiotemporally controlled release.

The objective of this review is to explore the molecular mechanisms underlying therapeutic ultrasound, assess its diverse clinical applications, and evaluate its impact on patient care. By bridging the gap between basic biophysical principles and practical clinical outcomes, we aim to highlight how ultrasound technology is shaping the future of precision medicine and transforming the therapeutic landscape. The central hypothesis guiding this work is that ultrasound, beyond its well-established diagnostic utility, can be harnessed to induce beneficial molecular changes—enabling the treatment of disease, enhancement of tissue repair, and targeted drug delivery. In doing so, we seek to provide a comprehensive overview that not only summarizes current knowledge but also identifies future directions for research and clinical practice.

2 A mechanistic overview about ultrasound

Ultrasound energy is a powerful method for producing biological impacts. With enough understanding of the causes and measurement of exposure, biological effects can be either utilized for treatment or prevented in diagnostic settings. In medical treatments, ultrasound can produce effects by generating heat or through nonthermal techniques such as inducing ultrasonic cavitation, triggering gas bubbles, applying mechanical stress, or utilizing other unexplained nonthermal processes (Nyborg et al., 2002). From a diagnostic viewpoint, ultrasound is generally produced by a piezoceramic emitting brief pulses, which typically contain 1–5 cycles. Diagnostic ultrasound is commonly characterized by the primary frequency of its sound waves, which typically falls within the 2–12 MHz range. The thickness of the ceramic in the device is often associated with its frequency. Devices for therapeutic ultrasound can utilize either intermittent pulses or steady waves to transmit efficient ultrasonic energy to tissues. Certain devices function at increased amplitude, which often results in the generation of shocked or distorted waves (Miller et al., 2012).

Heating caused by ultrasound occurs when biological tissue absorbs ultrasonic energy. In diagnostic ultrasound, the increase in temperature and the likelihood of bioeffects are minimized or almost nonexistent (Fowlkes, 2008) In diagnostic ultrasound, temperature increases and the risk of biological effects are minimized by following specific usage guidelines. This entails following the ALARA principle (ensuring exposure is minimized as much as feasible), keeping average intensity low over time, and making sure that exposure durations are generally short. Therapeutic uses of ultrasonic heating involve either extended periods of exposure with unfocused beams or the application of more intense focused ultrasound compared to diagnostic levels. In physical therapy, applying unfocused heat to highly absorptive tissues like bones or tendons can be regulated to promote improved healing while avoiding damage (Li et al., 2020). Alternatively, heat can be directed by concentrated beams to coagulate tissue, aiming for its ablation (Ter, 2016). Ultrasound-induced heating, which may cause permanent alterations in tissues, depends on the relationship between time and temperature (Sapareto and Dewey, 1984). The impact of ultrasound exposure may result in slight heating, tissue vaporization, coagulative necrosis, or a combination of these effects, depending on the temperature variations (Ter, 2016). Figure 2 provides a simplified overview of how ultrasound impacts thermal, mechanical, and chemical processes.

FIGURE 2

To clarify the distinct mechanisms by which ultrasound affects biological tissues, Table 1 summarizes the key differences between thermal and mechanical effects, particularly in therapeutic contexts such as HIFU. Understanding these mechanisms is crucial for optimizing safety and maximizing therapeutic benefit in clinical practice.

Ultrasonic cavitation and gas body activation (refer to Figure 3) are interconnected processes reliant on the low-pressure amplitude generated by ultrasound waves (Rooze et al., 2013). When ultrasound waves move through tissue, they can generate rarefying pressure levels that reach several megaPascals (MPa) (Xu et al., 2009; Zhang et al., 2021). Elevated rarefactional pressure can potentially trigger cavitation in tissues if appropriate nuclei are available, or it may directly cause pulsation in existing gas pockets, such as those found in the lungs and intestines, or when using ultrasound contrast agents (Parsons et al., 2006; Miller, 2007). Local tissue damage, such as cell death and blood vessel hemorrhage, is mainly caused by cavitation and the activation of gas bodies occurring right around the areas where cavitational activity takes place (Arvanitis et al., 2011; Izadifar et al., 2019). Recent studies have expanded our understanding of ultrasound’s biological effects, especially in the context of targeted drug delivery and noninvasive tissue modulation. For instance, the development of microbubble-assisted focused ultrasound has enabled more precise opening of the blood-brain barrier, facilitating delivery of therapeutics for neurological conditions (Burge et al., 2016; Ea et al., 2025). Similarly, high-intensity focused ultrasound (HIFU) is being refined for safer and more effective ablation of deep-seated tumors, with real-time thermal monitoring and adaptive dosing to minimize collateral tissue damage (Shin and Kim, 2024; Ponomarchuk et al., 2022). These innovations not only enhance the clinical utility of ultrasound but also address safety concerns by improving targeting accuracy and reducing undesired bioeffects. Ongoing research aims to optimize parameter selection for different tissue types and disease contexts, suggesting a trend toward more personalized ultrasound therapies (Beiu et al., 2023).

FIGURE 3

Various ways in which ultrasound might biologically impact organisms involve the direct application of compressional, tensile, and shear forces (Wells et al., 2011; Prado-Costa et al., 2018). Moreover, the secondary effects influenced by the energy of the transmitted ultrasound encompass radiation pressure, forces impacting particles, and the movement of materials known as acoustic streaming. When therapy utilizes high-power or high-intensity ultrasound, multiple mechanisms can simultaneously affect the treatment’s overall biological results. In addition to the immediate physical mechanisms that cause biological effects, there are also indirect physical, biological, and physiological processes that further impact the organism. Instances encompass the narrowing of blood vessels, limited blood circulation (ischemia), fluid leakage from blood vessels (extravasation), tissue harm resulting from the return of blood supply (reperfusion injury), and reactions from the immune system (Silberstein et al., 2008; Hundt et al., 2007; Alves et al., 2009). At times, the indirect consequences can be more significant than the immediate impact of the ultrasound.

3 Ultrasound molecular applications

3.1 Induction of cell death by ultrasound

Since ultrasound first causes distortions in the cell membrane through mechanical impact, the external kinetic energy can penetrate deeply within the cell through intricate mechanotransduction pathways, altering the cell’s function (Furusawa et al., 2014). Mechanotransduction is the process by which cells convert mechanical stimuli into biochemical signals, allowing them to respond to changes in their environment (Ingber, 2006). This pathway involves the detection of mechanical forces, such as stretch, shear stress, or pressure, through mechanoreceptors on the cell surface (Di et al., 2023). These receptors include integrins, ion channels, and cell adhesion molecules. Mechanical forces applied by ultrasound are transduced via cell surface receptors—such as integrins and ion channels—into intracellular signaling cascades that regulate gene expression and cell behavior (Di et al., 2023; Ohashi et al., 2024; Xie et al., 2023; Gargalionis et al., 2024; Di-Luoffo et al., 2021; Li et al., 2023; Wang et al., 2023). These pathways can regulate cellular functions such as gene expression, cell growth, differentiation, and migration (Ohashi et al., 2024; Xie et al., 2023; Gargalionis et al., 2024; Di-Luoffo et al., 2021; Li et al., 2023; Wang et al., 2023). In tissues like muscle, bone, and endothelial cells, mechanotransduction is critical for processes such as tissue remodeling, bone formation, and vascular health (Wang, 2017; Ingber, 2003; Bakhshandeh et al., 2023). Abnormalities in mechanotransduction pathways are implicated in various diseases, including cancer, fibrosis, and cardiovascular disorders (Lammerding et al., 2004; Garoffolo and Pesce, 2019; Kuehlmann et al., 2020; Chin et al., 2016). So far, many studies have documented a range of cellular changes induced by ultrasound, such as reduced cell viability (Lai et al., 2006), disruption of cell membrane potential (Tran et al., 2008; Tran et al., 2007), changes in calcium signaling (Fan et al., 2010; Park et al., 2010), generation of reactive oxygen molecules (Hassan et al., 2010a; Okada et al., 2009) or the generation of shear force (Park et al., 2011; Collis et al., 2010). Mechanisms established by the US, among others, are crucial in affecting the biological changes that significantly alter the intracellular environment as a result of drug-induced sonoporation, ultimately determining the therapeutic results.

An ultrasound creates a series of pressure changes by transmitting sound waves through tissue. When these waves encounter reflective surfaces, such as tissue interfaces or structures with different acoustic impedances, they can form a spatial standing wave pattern (Zhu et al., 2003; Scorer, 1967). Standing waves occur when incident and reflected waves interfere with each other, creating regions of constructive and destructive interference, known as pressure nodes and antinodes (Prants, 2009; Sanlı et al., 2014). This can lead to non-uniform energy deposition, which may cause localized heating or other unintended effects.

The occurrence of standing waves in ultrasound is particularly relevant in therapeutic applications, such as HIFU, where precise energy delivery is critical (Song et al., 2010; Song et al., 2011). While standing waves are relatively common in areas where ultrasound waves reflect off hard surfaces or large tissue interfaces, their impact can be mitigated by using techniques such as real-time monitoring of the ultrasound field, beam steering, or changing the frequency of the ultrasound waves (Casper et al., 2013; Xiao et al., 2024). Solutions like phased-array transducers, which allow for dynamic beam focusing and steering, are commonly used to minimize the formation of standing waves and ensure more even energy distribution (Bosma et al., 2022; Ca et al., 2019; Bawart et al., 2020). Addressing standing wave formation is crucial in therapeutic ultrasound to prevent tissue damage and improve treatment precision.

Overall, the biological effects are greatly affected by the specific ultrasound parameters utilized, the distance between the energy source and the target cells, the transducer or any components causing a standing wave, and the presence of acoustically active microbubbles (Hassan et al., 2010b; Nyborg et al., 1985). Multiple investigations employing scanning electron microscopy and atomic force microscopy have verified that physical pores develop in the cell membrane after being exposed to ultrasound (Zhao et al., 2008; Taniyama et al., 2002; Mehier-Humbert et al., 2005; Duvsha et al., 2006). Reversible sonoporation (RS) enhances the absorption of drugs by cells without resulting in cell death. In contrast, irreversible sonoporation (IRS) is thought to be deadly, often causing rapid cell necrosis (Lentacker et al., 2014; Fan et al., 2014; Qin et al., 2018; van Rooij et al., 2016). Additionally, these phenomena become significantly more pronounced when gas-filled microbubbles are present. When sound waves come into contact with microbubbles, the interaction between ultrasound and the microbubbles creates significantly stronger forces, enhancing the bioeffects initiated by the ultrasound (Schlicher et al., 2006; Deng et al., 2004; Zhong et al., 2011).

In the past few years, research on ultrasound-mediated cell death and sonoporation has moved beyond fundamental mechanistic studies, with a focus on translating these findings into clinical and preclinical settings. For example, recent studies have explored the use of ultrasound-induced sonoporation for targeted gene and drug delivery in cancer therapy, with promising results in animal models and early-phase clinical trials (Krut et al., 2022; Entzian and Aigner, 2021; Sitta and Howard, 2021). Innovations such as acoustic cluster therapy and smart microbubble formulations have demonstrated enhanced specificity and controllability in delivering therapeutic agents (Edwards et al., 2023; Del Campo Fonseca, 2024; Tsirkin et al., 2021). There is growing interest in using ultrasound in combination with immunotherapies to potentiate immune cell infiltration and enhance antitumor responses (Sun S. et al., 2022; Yang et al., 2024). Furthermore, high-resolution real-time imaging modalities now enable researchers to visualize membrane pore formation and cytoskeletal changes dynamically during and after ultrasound exposure (Wen et al., 2023; Jia et al., 2022). Collectively, these advances are shaping a new generation of ultrasound-based molecular therapies, while also revealing important challenges regarding selectivity, safety, and optimal parameter settings for clinical applications (Przystupski and Ussowicz, 2022; Rich et al., 2022).

Previous studies have shown that sonoporation can occur in two ways: using microbubbles, which is called bubble-based sonoporation (BBS), or without the use of microbubbles, known as non-bubble-based sonoporation (NBBS). While each mechanism leads to membrane permeabilization, the underlying biophysical processes that create pores are notably distinct. When sound waves pass through fluid-filled cells, the cells undergo shear forces due to the concurrent effects of acoustic streaming and the acoustic radiation force. This setup could weaken the cell membrane, resulting in the development of holes (Rich et al., 2022; Liu et al., 2017; Ahmed et al., 2016). These phenomena were utilized to create a range of mechanisms aimed at facilitating NBBS. This involves using traveling sound waves to eject cells through nozzle openings (Zarnitsyn VG. et al., 2008), exposing cells to stationary sound waves within resonators that measure a quarter of the wavelength (Carugo et al., 2011; Carugo et al., 2014), or using Lamb waves with cells grown on delicate substrates (Gedge and Hill, 2012; Friend and Yeo, 2011; Huang et al., 2021). Some researchers also utilized bulk acoustic waves traveling across the transducer to activate NBBS. Multiple options emerge when the target cells are located near the US origin. In this scenario, concentrated areas of strong acoustic energy can be created by focusing bulk acoustic waves into a small region (Kim et al., 2021; Yoon et al., 2017; Yoon et al., 2016), As another method, using high-frequency bulk acoustic waves can induce acoustic streaming, which leads to the formation of pores in the cell membrane (Kamenac et al., 2021; Ramesan et al., 2021). In the United States, ultrasound contrast agents frequently comprise microbubbles (MBs) with a gas-filled center encased by a stabilizing layer of lipids, polymers, or albumin. Due to their size, usually between 1 and 8 μm in diameter, they can easily pass through capillaries throughout the human body (Polat et al., 2011; Goldberg et al., 1994; Kooiman et al., 2014). Utilizing microbubbles as cavitation nuclei reduces the cavitation threshold by enhancing sound energy absorption, which in turn amplifies the effects produced by ultrasound (Yang et al., 2020; Chen W-S. et al., 2003; Chen W- et al., 2003). When subjected to ultrasound, microbubbles exhibit various behaviors leading to acoustic cavitation (Shamout et al., 2015; Yu et al., 2015). Rapid changes in volume during acoustic cavitation cause various mechanical, chemical, and thermal effects that significantly alter the surrounding environment, ultimately resulting in bubble-induced sonoporation (Kooiman et al., 2020). It is important to recognize that different forms of acoustic cavitation can occur depending on the intensity of the ultrasound, known as the mechanical index. To calculate the mechanical index (MI), you need to divide the peak negative pressure in megapascals (MPa) by the square root of the acoustic wave’s central frequency in megahertz (MHz) (Snipstad et al., 2018). The effect of ultrasound on cellular biology is significantly determined by the mechanical index. When the mechanical index drops below 0.2, microbubble volumes continuously fluctuate, leading to pressure and tension on the cell membrane, ultimately causing it to break (Doinikov and Bouakaz, 2010). This method is referred to as stable cavitation (Postema et al., 2012).

The relationship between ultrasound parameters and biological outcomes is critical for both safety and therapeutic efficacy. Table 2 summarizes key ultrasound parameters, their typical values, and the main biological or therapeutic effects observed at different thresholds, with emphasis on cavitation phenomena and tissue response.

Understanding that microbubbles attaching to the cell membrane can produce oscillations that result in fluid motion is crucial, as this can create a local shear stress capable of rupturing the cell membrane. This occurrence is known as microstreaming (Escoffre et al., 2020). In this case, microbubbles could potentially traverse the lipid bilayer, resulting in membrane permeabilization. When the MI value surpasses 0.2, the intensity of the acoustic pressure grows, resulting in a notable rise in the kinetic energy released. In instances like this, the MBs experience intense oscillations, resulting in a phenomenon known as inertial cavitation. This happens when they fall apart and break down, creating shock waves or tiny jets that penetrate the lipid bilayer (Zhou, 2011; Ohl and Wolfrum, 2003; Junge et al., 2003). Figure 4 illustrates the mechanical effects produced by microbubbles. When ultrasound is applied, it causes repeated cycles of compression and expansion at varying pressures among the molecules, significantly increasing the medium’s temperature due to the energy transferred. The rise in temperature leads to the heat-induced effects seen in BBS. The rise in temperature is directly connected to the original energy converted into the sound wave, leading to overheating in specific areas (Kooiman et al., 2020). This process is utilized in HIFU-ablation treatment for cancer therapy (Zhou, 2011). Furthermore, it was asserted that hyperthermia caused by ultrasound in the US could enhance drug absorption by altering membrane permeability, particularly in cells resistant to multiple drugs (Liu et al., 2001). Given that BBS involves significant mechanical and thermal effects, both factors can play a role in the chemical reactions taking place at BBS. A significant rise in gas pressure or a rapid temperature increase when microbubbles collapse can result in the creation of reactive oxygen species (ROS) and the release of electromagnetic waves, a phenomenon known as sonoluminescence. Interestingly, both sonoluminescence and reactive oxygen species (ROS) have the ability to modify drug resistance (Trachootham et al., 2009; Ros et al., 2004; Be et al., 2019).

FIGURE 4

3.2 Cell membrane modifications

Ultrasound exposure causes openings to develop in the cell membrane. Numerous scientists have attempted to ascertain the dimensions of these pores, proposing that they are circular with a specific diameter. Their study was based on the premise that passive diffusion serves as the main mechanism by which ultrasound enhances the entry of molecules into cells. SEM analysis offered clear proof of membrane permeabilization, revealing irregularly shaped pores ranging in size from 100 nm to several micrometers (Mehier-Humbert et al., 2005; Fan et al., 2014). A range of studies using various cell models and techniques have found that sonoporation-induced membrane pores typically range from approximately 50–2,500 nm, with smaller pores more likely to reseal quickly. The efficiency of molecular uptake correlates with pore size and exposure conditions (Zarnitsyn V. et al., 2008; Zhou et al., 2009; Fan et al., 2012). Multiple microscopy studies have shown that ultrasound-induced sonoporation generates membrane pores ranging from tens to thousands of nanometers, often with increased surface roughness and bleb formation (Sanlı et al., 2014; Song et al., 2010; Song et al., 2011; Bawart et al., 2020; Chen W-S. et al., 2003; Chen W- et al., 2003). The extent of these changes correlates with acoustic exposure and pressure, though reported pore sizes can vary due to methodological differences in imaging and sample preparation (Zhao et al., 2008; Taniyama et al., 2002; Mehier-Humbert et al., 2005; Schlicher et al., 2006; Duvshani-Eshet et al., 2006; Yang et al., 2008).

Some researchers have also explained how the diameter of bubbles and the distance between bubbles and cells relate to the extent of permeabilization caused by ultrasound. As an illustration, Qin and colleagues explored the immediate response of individual cells to sonoporation when initiated by the vaporization of acoustic droplets. They contended that substantial ADV bubbles resulted in permanent sonoporation only when located close to the cell, as those positioned far from the cell membrane did not succeed in initiating sonoporation. This finding suggested that the final effect of sonoporation was affected by both the size of the microbubble and how close it was to the cell. A higher likelihood of irreversible sonoporation occurred when the bubble was nearer to the cell and had a larger diameter (Qin et al., 2018). In a study conducted by Hu and colleagues (Hu et al., 2013) It was discovered that the ability of sonoporation to reverse was dependent on the size of the pores formed; pores with a surface area smaller than 30 μm² sealed within a minute following ultrasound treatment, whereas those larger than 100 μm² stayed open for as long as 30 min. Additionally, post-sonoporation cell viability was influenced by how quickly the membrane resealed: cells remained viable after ultrasound treatment only if their pores closed within 1 minute (Hu et al., 2013; van Wamel et al., 2006; Zhou et al., 2012). It is crucial to understand that the degree of membrane damage in BBS is affected by the sonoporation technique. When microbubbles undergo inertial cavitation, they produce tiny openings that can measure up to several hundred nanometers. Conversely, stable microbubble cavitation results in the creation of larger openings, which can range in size from several hundred nanometers to a few micrometers (Forbes et al., 2008; Wang et al., 2018).

The degree of effectiveness of sonoporation can differ among sonoporated cells at a specific moment because the ultrasound-induced process of making the cell membrane permeable can be affected by various factors simultaneously. These factors include the bubble’s size, its proximity to the cell, and the acoustic wave’s energy. Multiple studies have furnished evidence supporting the variation in particle uptake. Guzmán and his team proposed that the varying levels of ultrasound and cavitation experienced by different cells explained this occurrence. Nonetheless, they were unable to observe a complete spectrum of uptake intensities in the sonoporated cells. Additionally, De Cock and his team identified only two separate cell groups that showed differing levels of molecule uptake. Through the use of confocal microscopy to examine different subgroups of sonoporated cells, researchers discovered that these cells demonstrated multiple uptake processes. Specifically, at lower levels of uptake intensity, endocytic uptake was noticed, whereas at higher uptake intensity, cell membrane permeabilization was observed. They also observed that raising the acoustic pressure led to an increased number of sonoporated cells with significant uptake. Consequently, they determined that decreasing the pressure enhances endocytosis, while increasing the pressure fosters pore creation, suggesting that modifying the acoustic wave pressure can influence the uptake method (De Cock et al., 2015; Gu et al., 2001).

To promote cell survival and limit the movement of different substances through the membrane, the openings formed in the cell membrane by ultrasound should be closed before they naturally seal up. Fixing membranes is essential to stop ions from building up inside the cell, which can disturb its internal balance. Previous research suggests that sonoporation may activate two mechanisms for membrane resealing (see Figure 5): membrane repair initiated by endocytosis and vesicular patching associated with exocytosis (Leow et al., 2015). The mechanical influence applied by the US can lead to deformation of cell membranes by either pushing microbubbles against them or through stable cavitation, which creates microstreaming in the surrounding fluid. These occurrences alter the cell membrane’s tension without compromising the plasma membrane’s structure, creating shear stress that collectively results in the rearrangement of cytoskeletal fibers. Mechanosensors, like integrins or stretch-activated ion channels, can detect these mechanical forces and convert them into signals that alter cell activities (Hauser et al., 2009). The processes of rebuilding, called exocytosis, and removal, known as endocytosis, are said to restore the cell membrane’s initial tension and structural integrity (Lentacker et al., 2014). It is widely thought that the primary mechanism for sealing small openings formed by oscillating microbubbles is endocytosis (Qin et al., 2018). Conversely, large membrane pores caused by collapsing microbubbles are repaired through exocytosis and lysosomal patches (Yang et al., 2008; Schlicher et al., 2010). Additionally, only pores with a size less than 0.2 µm are capable of being effectively resealed (McNeil and Steinhardt, 2003). This accounts for the inconsistent findings from various groups, with some reporting only US-induced exocytosis and others reporting endocytosis in experiments related to drug uptake.

FIGURE 5

After undergoing US treatment (Ogawa et al., 2001; Chen et al., 2013), the cells exhibited a reduction in size, and their surfaces appeared flatter and smoother (Duvshani-Eshet and Machluf, 2005). The examination of sonoporated DU-145 prostate cancer cells through scanning electron microscopy (SEM) and confocal microscopy showed cell damage, which was marked by circular projections known as ‘balloons' and ‘blister' blebs. The extensions in the shape of balloons held small lipid vesicles produced by the endoplasmic reticulum, while the blister-like extensions consisted of lipids that fused with the cell membrane and contained a clear fluid. Schlicher and colleagues (Schlicher et al., 2010) noted a variety of occurrences such as several types of membrane protrusions, the expulsion of the nucleus, the creation of structures surrounding the nucleus, and even the breakdown of cells. Zeghimi and colleagues employed TEM and SEM microscopy methods to study how the plasma membrane of U-87 MG cells changes over time. They noticed a large amount of exposed holes and tears in the membrane, almost all of which were fixed within an hour (Zeghimi et al., 2015). Nevertheless, certain structural changes, including the formation of pit-like characteristics and increased membrane roughness, persisted up to 24 h after ultrasound treatment with opsonin microbubbles (Taniyama et al., 2002; Duvshani-Eshet et al., 2006). Cell membrane blebs were among the morphological changes seen following sonoporation. Qin and colleagues noted the appearance of blebs 90 s post-exposure, which subsequently grew and led to the formation of additional blebs. These structures were detected in cells that underwent both reversible and irreversible sonoporation (Qin et al., 2018). Additionally, Leow and colleagues (Leow et al., 2015) observed secondary blebs forming in areas not directly affected by sonoporation. Blebs are believed to develop as a defensive mechanism to alleviate heightened hydrostatic pressure and restore equilibrium, caused by ultrasound-induced disruption of the actin cytoskeleton (Leow et al., 2015; Chen et al., 2014). Honda and colleagues additionally identified apoptotic cells 6 hours following sonication. The nucleus and cell body notably shrank, accompanied by chromatin condensation and fragmentation of the nucleus. However, only some dying cells exhibited cytoplasmic swelling and an enlarged endoplasmic reticulum. In addition, vacuolar formations were observed and identified as autophagic vacuoles and secondary lysosomes (Honda et al., 2004). Tachibana et al. (Tachibana et al., 1999) noticed a decrease in the quantity of microvilli and membranous laminar ruffles in HL-60 cells following ultrasound exposure. In the subsequent years, confocal imaging revealed that lipid concentrations rose in specific damaged regions and progressively spread outwards. Furthermore, linear arrangements of lipids were observed on the cell membranes of HL-60 cells exposed to ultrasound. The researchers demonstrated that the newly formed lipids originated from within the cell (Hu et al., 2019). In addition, after undergoing sonoporation, sonoporated MCF-7 cells lacked microvilli, leading to a smooth cell surface. Many of these cells appeared round and shrunken. The damage to the membranes was notably more extensive in MCF-7/ADR cells that were resistant to doxorubicin (Jia et al., 2015). Ovarian cancer cells exposed to US displayed enlarged mitochondria and vacuoles within the cytoplasm (Yu et al., 2004).

3.3 Cytoskelton

Ultrasound-induced sonoporation leads to rapid and reversible changes in the cytoskeleton, including disruption of F-actin filaments, cytoskeletal rearrangement, and altered cell adhesion and migration (Escoffre et al., 2020; Duvshani-Eshet et al., 2006; Zhou et al., 2012; Forbes et al.; Wang et al., 2018; De Cock et al., 2015; Gu et al., 2001; Leow et al., 2015). These changes are thought to facilitate membrane repair and may influence cellular signaling and mechanical properties. However, the specific pathways involved and their long-term impact on cellular function require further investigation. (Wang et al., 2018; Chen et al., 2014; Gourlay and Ayscough, 2005; Revenu et al., 2004; Juffermans et al., 2009; Fan et al., 2013; Helfield et al., 2016). Despite considerable progress in elucidating the mechanisms of ultrasound-induced cellular effects, future studies will be critical for optimizing parameter selection and integrating real-time monitoring to enhance both safety and therapeutic efficacy in clinical applications.

4 Ultrasound in molecular imaging

4.1 An overview of using ultrasound in molecular imaging

The purpose of various molecular ultrasound imaging and quantification methods is to distinguish the signal generated by microbubbles that are bound to specific molecular targets (the molecular signal) from the signals of unbound microbubbles, which do not exhibit molecular-specific binding, and from the background tissue signal. Targeted molecular imaging allows for the visualization of specific biological processes at a molecular level, which provides much greater sensitivity and specificity compared to traditional ultrasound (Deffieux et al., 2021; Jiang et al., 2023). This technique can be used to detect early-stage diseases, identify tumors, assess blood flow, or monitor the effectiveness of therapies by targeting specific biomarkers associated with disease (Eisenbrey et al., 2021; Laghi et al., 2021). In cases where precision is crucial—such as in oncology, cardiology, or neurology—these microbubbles can significantly improve the diagnostic accuracy, aiding in earlier intervention and better patient outcomes (Laghi et al., 2021; Wang et al., 2021). While the simplicity and affordability of traditional ultrasound are valuable, targeted microbubbles offer a more sophisticated approach when the clinical need for detailed, molecular-level insights outweighs the cost and complexity.

In numerous early ultrasound systems, untargeted microbubbles were rendered visible by using high-intensity ultrasound pulses to disintegrate them. This method is often called Loss of Correlation (LOC). When a microbubble bursts, it generates several acoustic signals across different imaging pulses, leading to a notable decorrelation detected during the analysis of Power Doppler signals (Becher and Burns, 2012). Although this method is compatible with current Power Doppler imaging systems, it has limitations in distinguishing between contrast agents (microbubbles) and surrounding tissues (Correas et al., 2006; Quaia, 2007; Sridharan et al., 2021). This is because both tissues and contrast agents can produce similar Doppler signals, making it challenging to differentiate the specific signal originating from the microbubbles, which are designed to enhance imaging (Sridharan et al., 2021). As a result, the method may not provide the level of specificity needed for accurate molecular imaging, where the goal is to isolate signals from targeted microbubbles bound to specific biomarkers, rather than from general tissue or untargeted microbubbles. Furthermore, molecular ultrasound imaging is inappropriate due to the fact that the required microbubble signal is rapidly disrupted during the imaging procedure. Consequently, innovative imaging methods have been created that take advantage of the distinct characteristics of microbubbles. Due to their high compressibility and the adaptable structure of their shells, microbubbles undergo nonlinear oscillations when subjected to an ultrasound field (Leighton, 2012). As a result, the ultrasound waves disperse in a nonlinear fashion, generating harmonics at multiples of the main frequency, which can include both higher-order harmonics, such as second and third harmonics, as well as subharmonics and fractional harmonics (e.g., 3/2 of the main frequency). This includes twice the frequency (the second harmonic) and further multiples like the third, fourth harmonics, and more (Bouakaz et al., 2002; De Jong et al., 1994), or at a fraction of the central frequency, specifically one-half (subharmonic) (Forsberg et al., 2000). Consequently, most ultrasound imaging techniques focus on detecting this nonlinear energy generated by microbubbles, enabling them to distinguish the imaging signals from the microbubbles from those coming from the tissue (Deng and Lizzi, 2002). As acoustic pressure rises, tissue exhibits a nonlinear response to ultrasound (Hamilton and Blackstock, 2024), regularly generating a non-linear signal distinct from the tissue background. Using low acoustic pressures, generally less than 500 kPa, significantly reduces signals from the surrounding tissue, enhancing the contrast between the ultrasound image and the tissue. Harmonic Imaging (Chang et al., 1995; Burns et al., 1994) was developed to visualize microbubbles non-linearly, overcoming the natural limitations present in contrast-enhanced ultrasound using LOC methods. The ultrasound system’s analog electronics utilized frequency-based filters to retain particular nonlinear frequency components, referred to as harmonics. These implementations enhanced detection relative to LOC, yet they were constrained by a limited signal bandwidth because of the way analog harmonic filters were designed. This is because frequency-based filters are unable to differentiate between the linear and nonlinear parts of a signal when both share the same frequency. Limiting the frequency range used in imaging helps reduce signal overlap, but this comes at the cost of decreased resolution along the axial direction.

In the last few years, molecular ultrasound imaging has rapidly advanced from primarily preclinical proof-of-concept work to early-phase clinical translation. Novel microbubble designs—such as dual-targeted, drug-loaded, and stimuli-responsive agents—are being explored to increase specificity and sensitivity for disease biomarkers (Park et al., 2024; Ma et al., 2022; Kida and Tachibana, 2023). Integration of artificial intelligence and machine learning algorithms into ultrasound image analysis has also enabled automated, more quantitative, and reproducible assessment of molecular signals (Fu et al., 2024; Li H. et al., 2024; Saba et al., 2025). Despite this progress, key challenges remain, including large-scale agent manufacturing, regulatory approval, and robust validation of quantification protocols for routine clinical use. Nevertheless, these ongoing innovations signal a major shift toward personalized, image-guided therapy and monitoring using molecular ultrasound technologies.

The most frequently used two-pulse sequences are Pulse Inversion (PI) and Amplitude Modulation (AM), also known as Power Modulation. Various multi-pulse methods are generally founded on the principles of PI, AM, or a combination of both (PIAM). The standard setup uses two pulses, but it can be extended to include several sequential pulse pairs (Eckersley et al., 2005; Phillips, 2001). Overall, increasing the number of pulses in a sequence improves the signal-to-noise ratio, thereby enhancing sensitivity, although it does not directly reduce tissue motion. However, this results in a reduced frame rate, which in turn lowers the temporal resolution (Simpson et al., 2001; Averkiou, 2001).

4.2 Ultrasound in tumor angiogenesis

Tumor angiogenesis refers to the formation and recruitment of new blood vessels from the surrounding tissue of the host. During this process, a range of molecular markers are prominently expressed on the endothelial cells lining the tumor’s blood vessels (Hanahan and Weinberg, 2000; Folkman, 2006). Microbubbles designed to attach to specific molecular markers associated with angiogenesis, including vascular endothelial growth factor receptor type 2 (VEGFR2), αvβ3 integrin, or endoglin, have been used to monitor tumor angiogenesis through molecular ultrasound imaging methods. In the study carried out by Lee and his team (Lee et al., 2008), a clear positive relationship was found between the ultrasound imaging signals from living subjects and the true levels of VEGFR2 expression on endothelial cells in subcutaneous breast cancer tumors. Due to the fact that the expression of angiogenesis markers differs depending on the type of tumor and the stage of its development, another team has focused on this area (Willmann et al., 2008) investigated the application of microbubbles engineered to simultaneously target VEGFR2 and αvβ3 integrin, aiming to enhance imaging signals in human ovarian cancer xenografts grown under the skin in mice. The in vivo imaging results displayed a substantial improvement in signal when dual-targeted microbubbles were employed, compared to using separately targeted microbubbles or a mixture of two different singly-targeted microbubbles. This implies that utilizing contrast microbubbles directed at various targets might enhance the detection of tumor blood vessel formation. This could be vital for molecular ultrasound imaging in the early identification of tumors during cancer progression, as unique markers appear at various stages.

Recent studies have demonstrated that microbubbles conjugated with multiple ligands can not only improve detection sensitivity but also enable dynamic imaging of angiogenic responses to emerging immunotherapies and small-molecule inhibitors (Zhong et al., 2023; Jugniot et al., 2021). Machine-learning-driven analysis of these signals is providing more nuanced characterization of tumor microenvironment changes during therapy in preclinical and pilot clinical studies (Kierski, 2022).

Furthermore, three independent studies have demonstrated that molecular ultrasound enables continuous monitoring of anti-angiogenic treatment in human cancer xenograft tumors implanted in mice. Subcutaneously and orthotopically implanted pancreatic tumors were treated using anti-VEGF monoclonal antibodies along with or without gemcitabine. For monitoring purposes, continuous molecular imaging was carried out utilizing microbubbles that were specifically engineered to bind with VEGFR2, the VEGF-VEGFR complex, or endoglin (Korpanty et al., 2007). In tumors treated with anti-angiogenic or cytotoxic therapies, the imaging signal from targeted microbubbles diminished. This reduction was associated with the expression levels of the target and the density of microvessels. In untreated subcutaneous human squamous cell xenografts in mice, the levels of VEGFR2 and αvβ3 integrin were elevated. However, after administering a matrix metalloproteinase inhibitor, both markers demonstrated a reduction (Palmowski et al., 2008). Pysz et al. (Pysz et al., 2010) We examined the molecular ultrasound imaging signals in mouse models simulating human colon cancer, both with and without the application of anti-angiogenic therapy. This was achieved using ultrasound technology and a new human VEGFR2-targeted microbubble, which holds promise for clinical use. Just 1 day after starting anti-angiogenic treatment, molecular ultrasound revealed a notable reduction in imaging signals in the treated mice compared to the untreated ones, even though there was no change in tumor size at this initial phase of therapy. The study showed that molecular ultrasound has the capability to assess the efficacy of anti-angiogenic therapy at an early phase, prior to when visible morphological or anatomical alterations become evident in tumors.

4.3 Ultrasound for imaging of inflammatory processes

Inflammation is a typical bodily reaction involved in a variety of diseases. Consequently, a noninvasive imaging technique that can evaluate inflammation at the molecular level in the body could be advantageous for early diagnosis and tracking the effectiveness of treatment. A typical feature of inflammation is the activation of white blood cells in the bloodstream, causing them to move into tissues outside the blood vessels. The interaction between adhesion molecules on white blood cells and different receptors on the surface of endothelial cells facilitates the movement and distribution of these white blood cells (Lindner et al., 2000; Kunkel and Butcher, 2003). Molecules like E-selectin and P-selectin play a crucial role in the initial phase of white blood cell capture, facilitating their movement along the interior lining of blood vessels. As depicted in Figure 6, adhesion molecules like VCAM1 play a key role in the stable attachment of rolling leukocytes, which is essential for their movement into tissue. A novel contrast agent system model has been created by emulating the behavior of white blood cells when they encounter inflammation (Ferrante et al., 2009). This study aimed to enhance the ability of microbubbles to adhere under the shear stress caused by blood flow, in order to detect inflammation associated with atherosclerosis. In cell culture experiments, microbubbles designed to simultaneously target both P-selectin and VCAM1 showed increased adherence efficiency compared to those targeting only one of these molecules. The hypothesis suggested that, much like the process involving leukocytes, directing the microbubbles towards the P-selectin marker helped capture them on the endothelial cell wall, enabling them to roll along the endothelial cells. Meanwhile, concentrating on VCAM1 enabled the microbubbles to firmly attach to the blood vessel walls, as illustrated in Figure 6 (Deshpande et al., 2010).

FIGURE 6

Microbubbles have been utilized to evaluate inflammation in different organs, including the heart, colon, and kidneys, by targeting inflammatory markers such as E-selectin, P-selectin, ICAM1, and VCAM1 (Kaufmann et al., 2007a; Bachmann et al., 2006). By employing microbubbles targeting P-selectin in a rat model of myocardial ischemia-reperfusion, researchers were able to detect heart tissue that had undergone recent ischemic events without signs of cell death (Kaufmann et al., 2007b). In a related investigation, sialyl Lewis was associated with microbubbles in a rat model of myocardial ischemia-reperfusion. The substance then bound to the inflamed endothelial cells within the heart tissue, which had recently experienced decreased blood flow (Villanueva et al., 2007). Both studies emphasize the promise of molecular ultrasound imaging as a quick and easy bedside method to detect “ischemic memory” in patients experiencing unusual chest pain. Ischemic Memory refers to the phenomenon where tissues, particularly in the brain or heart, exhibit a form of “memory” after an ischemic event (restricted blood flow that leads to oxygen deprivation) (Aras and Dilsizian, 2007; Villanueva et al., 2007; Taegtmeyer and Dilsizian, 2008). After such an event, tissues may undergo changes in cellular signaling, gene expression, and structural adaptations that make them more susceptible to future ischemic injury or, conversely, potentially more resistant depending on how the tissue adapts (Taegtmeyer and Dilsizian, 2008; Sun, 1999). This memory is thought to arise from cellular and molecular changes that persist after the acute phase of ischemia, possibly influencing the response to subsequent ischemic events or interventions (Aras and Dilsizian, 2007). Moreover, ultrasound imaging aimed at P-selectin could potentially be applicable in diagnosing other inflammatory heart conditions, like myocarditis and transplant rejection. Ultrasound, particularly contrast-enhanced ultrasound molecular imaging, has shown promise in detecting myocarditis, even before functional decline in left ventricular performance is observable. In a study with mice, MB targeted at specific markers, such as CD4⁺ T cells (MBCD4) and endothelial P-selectin (MBPSel), were used for imaging myocardial inflammation and leukocyte infiltration. The study found that molecular imaging with targeted microbubbles provided increased signal detection in moderate and severe myocarditis, correlating with CD4⁺ T-cell infiltration in the myocardium. This technique was sensitive enough to detect endothelial inflammation and leukocyte activity, offering a valuable diagnostic tool for myocarditis, particularly in cases where traditional functional imaging, like left ventricular ejection fraction or strain, did not show significant changes. The ability to image immune cells such as CD4⁺ T cells involved in autoimmune responses may enhance early diagnosis and monitoring of myocarditis (Steinl et al., 2016). A key potential use of molecular ultrasound in medicine is to evaluate the level of inflammation in patients suffering from inflammatory bowel disease. In a pioneering study, researchers were able to observe inflammation at the molecular level in the terminal ileum of genetically modified mice using non-invasive methods. This was achieved by using microbubbles that targeted the mucosal address in cell adhesion molecule 1 (MAdCAM1) (Bachmann et al., 2006).

4.4 US for intravascular thrombosis formation

Utilizing molecular ultrasound to visualize blood clot formation shows great potential, not only in diagnosing conditions but also in informing treatment decisions for stroke patients or individuals at higher risk for cerebral embolic disease. Moreover, employing microbubbles in conjunction with ultrasound energy can be an effective method for dissolving blood clots. While research on molecular imaging of blood clots is still in its early stages, various studies have demonstrated that molecular ultrasound can successfully image thrombi in animals by directing contrast agents towards the elements involved in blood clotting. Research conducted by Schumann and colleagues demonstrated that targeted microbubbles adhered to blood clots in the arteries and veins within the cremaster muscle of mice (Schumann et al., 2002). To create these particular agents, the microbubble shell was incorporated with peptides that attach to the Platelet glycoprotein (GP) IIb/IIIa receptor. A related study employed microbubbles coated with peptides aimed at GP IIb/IIIa to identify blood clots in the femoral veins of canines (Wang et al., 2006).

4.5 Emerging vascular applications of ultrasound

Beyond thrombosis, ultrasound-triggered drug and gene delivery to the vascular endothelium is now being explored for conditions such as atherosclerosis, vascular inflammation, and restenosis (Sitta and Howard, 2021; Fan et al., 2022). Contrast-enhanced ultrasound is increasingly used in the early detection of vascular pathologies, including endoleaks after endovascular aneurysm repair, assessment of neovascularization in atherosclerotic plaques, and monitoring of angiogenesis in tissue-engineered grafts (Jawad et al., 2016; Bredahl et al., 2017). Furthermore, ongoing clinical trials are evaluating the safety and efficacy of ultrasound-assisted vascular interventions, aiming to enhance precision and minimize reliance on systemic therapies (Dieter and Nanjundappa, 2025; Avgerinos et al., 2021). These developments are moving ultrasound technology from diagnostic imaging toward a platform for minimally invasive, image-guided vascular therapy. Recent technological advances in foam sclerotherapy highlight the importance of bubble size distribution and foam stability for effective and safe vascular interventions. For example, ultrasound-generated foams have been shown to produce smaller, more uniform bubbles and enhanced stability compared to traditional manual methods, as demonstrated by Critello et al. (Critello et al., 2020). These innovations are particularly relevant for the treatment of small veins, where precise occlusion and minimal adverse events are desired. Such advances in foam engineering are expected to make sclerotherapy even safer and more versatile, broadening its clinical applications in vascular medicine (Critello et al., 2020; Critello et al., 2019).

4.6 Recent developments in ultrasound-mediated therapies

The field of therapeutic ultrasound has witnessed rapid advancements, with several new modalities reaching clinical or near-clinical translation. High-intensity focused ultrasound (HIFU) and low-intensity pulsed ultrasound (LIPUS) are now being investigated for vascular tissue regeneration, modulation of vascular permeability, and targeted ablation of vascular malformations (Harrison and Alt, 2021; Uddin et al., 2021). In oncology, ultrasound-mediated delivery of chemotherapeutic agents or immunomodulators to tumor vasculature is being refined through the use of smart microbubbles and nanodroplets, enabling site-specific release and reducing systemic toxicity (Fan et al., 2022; Ayana et al., 2022).

5 Ultrasound in medicine: current limitations and future direction

Ultrasound technology has evolved from its early applications in diagnostic imaging to encompass a wide array of therapeutic and molecular uses. Despite its numerous benefits, such as non-invasiveness, low cost, and portability, the field of ultrasound, especially in therapeutic and molecular applications, faces several limitations that must be addressed for further advancement.

5.1 Current limitations and strategic solutions

One of the most significant limitations of ultrasound is its restricted depth penetration, especially for therapeutic applications (Jensen et al., 2006; Gorny et al., 2005). High-frequency ultrasound provides excellent resolution but is limited to superficial tissues (Gorny et al., 2005). This presents challenges when treating deep-seated tumors or internal organs without damaging overlying healthy tissues (Sun M. et al., 2022; Wu et al., 2023). Advances such as focused ultrasound, phased-array transducers, and adaptive beamforming are improving energy delivery to deeper tissues while minimizing collateral damage (Deng et al., 2021; Goudarzi et al., 2024). Ongoing research into novel coupling materials and alternative acoustic windows may further enhance penetration in anatomically challenging regions.

The biological effects of therapeutic ultrasound can be inconsistent and are highly dependent on parameters such as frequency, intensity, and exposure duration (Chen S. et al., 2022; Quarato et al., 2023). The same ultrasound settings may have different effects on different tissues, posing risks of under- or over-treatment (Chen L. et al., 2022). Standardization through large-scale clinical trials and development of real-time monitoring systems (such as MRI guidance or thermal mapping) can help ensure consistent dosing and outcomes. Personalized treatment algorithms that optimize parameters for individual patient characteristics are also under development.

Microbubbles have revolutionized drug delivery and molecular imaging (Chen L. et al., 2022; Liu et al., 2024), but their short lifespan and need for high-intensity ultrasound for cavitation remain limitations (Critello et al., 2019). Achieving precise targeting and avoiding non-specific adhesion to healthy tissue can also be problematic (Chen L. et al., 2022; Liu et al., 2024; Sanwal et al., 2021). Engineering of longer-circulating, ligand-targeted, or stimuli-responsive microbubbles is ongoing (Lohse and Zhang, 2015; Zylberberg and Matosevic, 2016; Mishra et al., 2025). Techniques such as the use of nanodroplets, low-intensity ultrasound activation, and improved surface modifications are being developed to enhance stability, targeting precision, and therapeutic efficacy.

There is a lack of widely accepted protocols for the clinical use of therapeutic and molecular ultrasound. Variation in equipment, manufacturer parameters, and operator technique leads to inconsistent outcomes and hinders broader adoption. International expert panels and professional societies are working to create consensus guidelines for ultrasound parameters, dosimetry, and clinical reporting. Standardization will facilitate reproducibility, cross-study comparison, and regulatory approval.

While generally safe, therapeutic applications—especially high-intensity focused ultrasound (HIFU)—carry risks such as tissue damage, burns, nerve injury, and hemorrhage (Bachu et al., 2021; Cranston et al., 2021; Lu et al., 2024). Prolonged or excessive exposure can result in unintended thermal and mechanical effects (Filippou et al., 2021).

Safety monitoring technologies—including real-time temperature mapping and acoustic emission feedback—are being integrated into modern devices. Preclinical safety testing and the establishment of safety threshold values are becoming standard in clinical trials.

Regulatory approval processes for ultrasound devices—particularly for new molecular or therapeutic applications—are lengthy and complex, requiring comprehensive demonstration of safety and efficacy (Deshpande et al., 2010). Early engagement with regulatory agencies (such as the FDA and EMA), inclusion of standardized clinical endpoints, and multidisciplinary collaboration in trial design are crucial for streamlining the approval process and expediting clinical translation.

There is no universally accepted framework for measuring key ultrasound parameters (e.g., intensity, frequency, exposure time) (Shaw et al., 2015; Shaw and Hodnett, 2008). Variability across machines and clinics can lead to inconsistent results and limit comparability (Shaw et al., 2015; Chung et al., 1999). The development and validation of international dosimetry standards, reference phantoms, and calibration protocols are underway. Open-source data sharing and harmonized reporting standards will further support reproducibility and safe clinical practice.

Unintended bioeffects, particularly in oncological HIFU applications, raise ethical concerns—including risks of thermal damage, cavitation, and microvascular rupture (Schmid et al., 2020; Fleury et al., 2005). The long-term effects of microbubbles and targeted agents in molecular imaging are not fully understood (Newson, 2008; Uyyala, 2023). Robust ethical guidelines, transparent patient consent procedures, and long-term post-treatment surveillance are necessary. Continued research on biological effects and clear communication of risks will be essential, especially for use in vulnerable populations.

5.2 Future directions

6 Conclusion

Ultrasound technology has evolved into a multifaceted tool in modern medicine, not only serving as a diagnostic tool but also holding substantial promise for therapeutic applications. Techniques like sonoporation and microbubble-based therapies have shown potential in enhancing drug delivery, facilitating cellular repair, and improving cancer treatments. In parallel, molecular ultrasound imaging offers significant advances in non-invasive monitoring, allowing for real-time observation of disease processes such as angiogenesis and inflammation. The integration of these two domains—therapeutic ultrasound and molecular imaging—presents a unique synergy. Molecular imaging can guide therapeutic interventions by targeting specific biomarkers, while therapeutic ultrasound enhances the precision and effectiveness of these treatments. As research continues to uncover novel applications and refine these approaches, ultrasound is poised to become an essential tool in personalized medicine, providing a dynamic means to not only monitor but also directly impact disease progression, making it an invaluable asset in future clinical practice.

References

• 1

  AhmedD.OzcelikA.BojanalaN.NamaN.UpadhyayA.ChenY.et al (2016). Rotational manipulation of single cells and organisms using acoustic waves. Nat. Commun.7, 11085. 10.1038/ncomms11085

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 2

  AhnJ. S.ShinS.YangS.-A.ParkE. K.KimK. H.ChoS. I.et al (2023). Artificial intelligence in breast cancer diagnosis and personalized medicine. J. Breast Cancer26 (5), 405. 10.4048/jbc.2023.26.e45

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 3

  AlvesE. M.AngrisaniA. T.SantiagoM. B. (2009). The use of extracorporeal shock waves in the treatment of osteonecrosis of the femoral head: a systematic review. Clin. Rheumatol.28 (11), 1247–1251. 10.1007/s10067-009-1231-y

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 4

  AminiA.ChienS.BayatM. (2020). Impact of ultrasound therapy on stem cell differentiation-a systematic review. Curr. Stem Cell Res. Ther.15 (5), 462–472. 10.2174/1574888x15666200225124934

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 5

  AnalanP. D.LeblebiciB.AdamM. (2015). Effects of therapeutic ultrasound and exercise on pain, function, and isokinetic shoulder rotator strength of patients with rotator cuff disease. J. Phys. Ther. Sci.27 (10), 3113–3117. 10.1589/jpts.27.3113

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 6

  ArasO.DilsizianV. (2007). Targeting ischemic memory. Curr. Opin. Biotechnol.18 (1), 46–51. 10.1016/j.copbio.2006.11.002

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 7

  ArvanitisC. D.Bazan-PeregrinoM.RifaiB.SeymourL. W.CoussiosC. C. (2011). Cavitation-enhanced extravasation for drug delivery. Ultrasound Med. Biol.37 (11), 1838–1852. 10.1016/j.ultrasmedbio.2011.08.004

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 8

  AverkiouM. A. (2001). Tissue harmonic ultrasonic imaging. Comptes Rendus l'Académie Sciences-Series IV-Physics2 (8), 1139–1151. 10.1016/s1296-2147(01)01259-8

  • CrossRef
  • Google Scholar
  • View reference in article

• 9

  AvgerinosE. D.JaberW.LacomisJ.MarkelK.McDanielM.Rivera-LebronB. N.et al (2021). Randomized trial comparing standard versus ultrasound-assisted thrombolysis for submassive pulmonary embolism: the SUNSET sPE trial. Cardiovasc. Interv.14 (12), 1364–1373. 10.1016/j.jcin.2021.04.049

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 10

  AwalM. R.JusohM.YahyaM. S.RahmanS. A.DagangA. N.LatiffN. A. A.et al (2021). Acoustic wave propagation in high scale impedance mismatch mediums. IIUM Eng. J.22 (2), 1–9. 10.31436/iiumej.v22i2.1563

  • CrossRef
  • Google Scholar
  • View reference in article

• 11

  AyanaG.RyuJ.ChoeS.-w. (2022). Ultrasound-responsive nanocarriers for breast cancer chemotherapy. Micromachines13 (9), 1508. 10.3390/mi13091508

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 12

  BachmannC.KlibanovA. L.OlsonT. S.SonnenscheinJ. R.Rivera-NievesJ.CominelliF.et al (2006). Targeting mucosal addressin cellular adhesion molecule (MAdCAM)-1 to noninvasively image experimental Crohn’s disease. Gastroenterology130 (1), 8–16. 10.1053/j.gastro.2005.11.009

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 13

  BachuV. S.KeddaJ.SukI.GreenJ. J.TylerB. (2021). High-intensity focused ultrasound: a review of mechanisms and clinical applications. Ann. Biomed. Eng.49 (9), 1975–1991. 10.1007/s10439-021-02833-9

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 14

  BaderK. B.PadillaF.HaworthK. J.EllensN.DaleckiD.MillerD. L.et al (2025). Overview of therapeutic ultrasound applications and safety considerations: 2024 update. J. Ultrasound Med.44 (3), 381–433. 10.1002/jum.16611

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 15

  BakhshandehB.SorboniS. G.RanjbarN.DeyhimfarR.AbtahiM. S.IzadyM.et al (2023). Mechanotransduction in tissue engineering: insights into the interaction of stem cells with biomechanical cues. Exp. Cell Res.431 (2), 113766. 10.1016/j.yexcr.2023.113766

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 16

  BalantičK.MiklavčičD.KrižajI.KramarP. (2021). The good and the bad of cell membrane electroporation. Acta Chim. Slov.68 (4), 753–764. 10.17344/acsi.2021.7198

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 17

  BawartM.BregenzerN.BernetS.Ritsch-MarteM. (2020). Dynamic beam-steering by a pair of rotating diffractive elements. Opt. Commun.460, 125071. 10.1016/j.optcom.2019.125071

  • CrossRef
  • Google Scholar
  • View reference in article

• 18

  BeguinE.ShrivastavaS.DezhkunovN. V.McHaleA. P.CallanJ. F.StrideE. (2019). Direct evidence of multibubble sonoluminescence using therapeutic ultrasound and microbubbles. ACS Appl. Mater. Interfaces11 (22), 19913–19919. 10.1021/acsami.9b07084

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 19

  BecherH.BurnsP. N. (2012). Handbook of contrast echocardiography: left ventricular function and myocardial perfusion. Berlin: Springer Science and Business Media.

  • Google Scholar
  • View reference in article

• 20

  BeiuC.PopaL. G.Bălăceanu-GurăuB.IliescuC. A.RacovițăA.PopescuM. N.et al (2023). Personalization of minimally-invasive aesthetic procedures with the use of ultrasound compared to alternative imaging modalities. Diagnostics13 (23), 3512. 10.3390/diagnostics13233512

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 21

  BessE. (2023). Exploring the use of audible sound in bone density diagnostic devices.Orono, United States: The University of Maine.

  • Google Scholar
  • View reference in article

• 22

  BoissenotT.BordatA.FattalE.TsapisN. (2016). Ultrasound-triggered drug delivery for cancer treatment using drug delivery systems: from theoretical considerations to practical applications. J. Control Release241, 144–163. 10.1016/j.jconrel.2016.09.026

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 23

  BosmaS.Van RooijenN.Alonso-DelpinoM.SpiritoM.LlombartN. (2022). First demonstration of dynamic high-gain beam steering with a scanning lens phased array. IEEE J. Microwaves2 (3), 419–428. 10.1109/jmw.2022.3179953

  • CrossRef
  • Google Scholar
  • View reference in article

• 24

  BouakazA.FrigstadS.Ten CateF. J.de JongN. (2002). Super harmonic imaging: a new imaging technique for improved contrast detection. Ultrasound Med. Biol.28 (1), 59–68. 10.1016/s0301-5629(01)00460-4

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 25

  BredahlK.MestreX. M.CollR. V.GhulamQ. M.SillesenH.EibergJ. (2017). Contrast-enhanced ultrasound in vascular surgery: review and update. Ann. Vasc. Surg.45, 287–293. 10.1016/j.avsg.2017.05.032

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 26

  BurgessA.HynynenK. (2016). Microbubble-assisted ultrasound for drug delivery in the brain and central nervous system. Ther. Ultrasound880, 293–308. 10.1007/978-3-319-22536-4_16

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 27

  BurnsP.PowersJ.Hope-SimpsonD.BrezinaA.KolinA.ChinC.et al (1994). Harmonic power mode doppler using contrast agents: an improved method for small vessel flow imaging. J. Ech Med. Ultra16, 132–142. 10.1109/ULTSYM.1994.401886

  • CrossRef
  • Google Scholar
  • View reference in article

• 28

  CasolaroA.ToscanoA.AlùA.BilottiF. (2019). Dynamic beam steering with reconfigurable metagratings. IEEE Trans. Antennas Propag.68 (3), 1542–1552. 10.1109/TAP.2019.2951492

  • CrossRef
  • Google Scholar
  • View reference in article

• 29

  CarugoD.AnkrettD. N.Glynne-JonesP.CaprettoL.BoltrykR. J.ZhangX.et al (2011). Contrast agent-free sonoporation: the use of an ultrasonic standing wave microfluidic system for the delivery of pharmaceutical agents. Biomicrofluidics5 (4), 044108. 10.1063/1.3660352

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 30

  CarugoD.OctonT.MessaoudiW.FisherA. L.CarboniM.HarrisN. R.et al (2014). A thin-reflector microfluidic resonator for continuous-flow concentration of microorganisms: a new approach to water quality analysis using acoustofluidics. Lab. Chip14 (19), 3830–3842. 10.1039/c4lc00577e

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 31

  CasperA. J.LiuD.BallardJ. R.EbbiniE. S. (2013). Real-time implementation of a dual-mode ultrasound array system: in vivo results. IEEE Trans. Biomed. Eng.60 (10), 2751–2759. 10.1109/tbme.2013.2264484

  • Pubmed Abstract
  • CrossRef
  • Google Scholar
  • View reference in article

• 32

  ChangP. H.ShunK.WuS.-J.LeveneH. B. (1995). Second harmonic imaging and harmonic doppler measurements with Albunex. IEEE Trans. Ultrasonics, Ferroelectr. Freq. Control42 (6), 1020–1027. 10.1109/58.476546

  • CrossRef
  • Google Scholar

• 33

  ChenW.-S.BraymanA. A.MatulaT. J.CrumL. A.MillerM. W. (2003a). The pulse length-dependence of inertial cavitation dose and hemolysis. Ultrasound Med. Biol.29 (5), 739–748. 10.1016/s0301-5629(03)00029-2

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 34

  ChenW.-S.BraymanA. A.MatulaT. J.CrumL. A. (2003b). Inertial cavitation dose and hemolysis produced in vitro with or without optison®. Ultrasound Med. Biol.29 (5), 725–737. 10.1016/s0301-5629(03)00013-9

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 35

  ChenX.WanJ. M.YuA. C. (2013). Sonoporation as a cellular stress: induction of morphological repression and developmental delays. Ultrasound Med. Biol.39 (6), 1075–1086. 10.1016/j.ultrasmedbio.2013.01.008

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 36

  ChenX.LeowR. S.HuY.WanJ. M. F.YuA. C. H. (2014). Single-site sonoporation disrupts actin cytoskeleton organization. J. R. Soc. Interface11 (95), 20140071. 10.1098/rsif.2014.0071

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 37

  ChenS.NazeriA.BaekH.YeD.YangY.YuanJ.et al (2022a). A review of bioeffects induced by focused ultrasound combined with microbubbles on the neurovascular unit. J. Cereb. Blood Flow Metabolism42 (1), 3–26. 10.1177/0271678x211046129

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 38

  ChenL.CruzE.OikariL. E.PadmanabhanP.SongJ.GötzJ. (2022b). Opportunities and challenges in delivering biologics for Alzheimer’s disease by low-intensity ultrasound. Adv. Drug Deliv. Rev.189, 114517. 10.1016/j.addr.2022.114517

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 39

  ChinL.XiaY.DischerD. E.JanmeyP. A. (2016). Mechanotransduction in cancer. Curr. Opin. Chem. Eng.11, 77–84. 10.1016/j.coche.2016.01.011

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 40

  ChoiS.-E.KhooH.HurS. C. (2022). Recent advances in microscale electroporation. Chem. Rev.122 (13), 11247–11286. 10.1021/acs.chemrev.1c00677

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 41

  ChungA. H.JoleszF. A.HynynenK. (1999). Thermal dosimetry of a focused ultrasound beam in vivo by magnetic resonance imaging. Med. Phys.26 (9), 2017–2026. 10.1118/1.598707

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 42

  CollisJ.ManassehR.LiovicP.ThoP.OoiA.Petkovic-DuranK.et al (2010). Cavitation microstreaming and stress fields created by microbubbles. Ultrasonics50 (2), 273–279. 10.1016/j.ultras.2009.10.002

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 43

  CorreasJ.-M.ClaudonM.TranquartF.HélénonO. (2006). The kidney: imaging with microbubble contrast agents. Ultrasound Q.22 (1), 53–66.

  • Pubmed Abstract
  • Google Scholar

• 44

  CranstonD.LeslieT.Ter HaarG. (2021). A review of high-intensity focused ultrasound in urology. Cancers13 (22), 5696. 10.3390/cancers13225696

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 45

  CritelloC. D.MtJ.StefanoD. F.RaffaeleS.FiorilloA. S. (2019). Recent developments on foaming mechanical and electronic techniques for the management of varicose veins. Expert Rev. Med. Devices16 (11), 931–940. 10.1080/17434440.2019.1682549

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 46

  CritelloD. C.PullanoS. A.GalloG.MatulaT. J.FiorilloA. S. (2020). Low frequency ultrasound as a potentially viable foaming option for pathological veins. Colloids Surfaces A Physicochem. Eng. Aspects599, 124919. 10.1016/j.colsurfa.2020.124919

  • CrossRef
  • Google Scholar

• 47

  De CockI.ZagatoE.BraeckmansK.LuanY.de JongN.De SmedtS. C.et al (2015). Ultrasound and microbubble mediated drug delivery: acoustic pressure as determinant for uptake via membrane pores or endocytosis. J. Control. Release197, 20–28. 10.1016/j.jconrel.2014.10.031

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 48

  De JongN.CornetR.LanceeC. (1994). Higher harmonics of vibrating gas-filled microspheres. Part two: measurements. Ultrasonics32 (6), 455–459. 10.1016/0041-624x(94)90065-5

  • CrossRef
  • Google Scholar

• 49

  DeffieuxT.DemenéC.TanterM. (2021). Functional ultrasound imaging: a new imaging modality for neuroscience. Neuroscience474, 110–121. 10.1016/j.neuroscience.2021.03.005

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 50

  Del Campo FonsecaA. (2024). Acoustic microbubble microrobots for biomedical applications in the brain. Stuttgart, Germany: ETH Zurich.

  • Google Scholar

• 51

  Dell'ItaliaJ.SanguinettiJ. L.MontiM. M.BystritskyA.ReggenteN. (2022). Current state of potential mechanisms supporting low intensity focused ultrasound for neuromodulation. Front. Hum. Neurosci.16, 872639. 10.3389/fnhum.2022.872639

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 52

  DengC. X.LizziF. L. (2002). A review of physical phenomena associated with ultrasonic contrast agents and illustrative clinical applications. Ultrasound Med. Biol.28 (3), 277–286. 10.1016/s0301-5629(02)00475-1

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 53

  DengC. X.SielingF.PanH.CuiJ. (2004). Ultrasound-induced cell membrane porosity. Ultrasound Med. Biol.30 (4), 519–526. 10.1016/j.ultrasmedbio.2004.01.005

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 54

  DengL.YangS. D.O'ReillyM. A.JonesR. M.HynynenK. (2022). An ultrasound-guided hemispherical phased array for microbubble-mediated ultrasound therapy. IEEE Trans. Biomed. Eng.69 (5), 1776–1787. 10.1109/TBME.2021.3132014

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 55

  DeshpandeN.NeedlesA.WillmannJ. K. (2010). Molecular ultrasound imaging: current status and future directions. Clin. Radiol.65 (7), 567–581. 10.1016/j.crad.2010.02.013

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 56

  DiX.GaoX.PengL.AiJ.JinX.QiS.et al (2023). Cellular mechanotransduction in health and diseases: from molecular mechanism to therapeutic targets. Signal Transduct. Target. Ther.8 (1), 282. 10.1038/s41392-023-01501-9

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 57

  Di-LuoffoM.Ben-MeriemZ.LefebvreP.DelarueM.Guillermet-GuibertJ. (2021). PI3K functions as a hub in mechanotransduction. Trends Biochem. Sci.46 (11), 878–888. 10.1016/j.tibs.2021.05.005

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 58

  DieterE. G.NanjundappaA. (2025). Revisiting ultrasound‐assisted catheter‐directed thrombolysis for pulmonary embolism: insights from new data. J. Am. Heart. Assoc.14 (9): e039096. 10.1161/JAHA.124.039096

  • CrossRef
  • Google Scholar

• 59

  DoinikovA. A.BouakazA. (2010). Acoustic microstreaming around a gas bubble. J. Acoust. Soc. Am.127 (2), 703–709. 10.1121/1.3279793

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 60

  Duvshani-EshetM.BaruchL.KesselmanE.ShimoniE.MachlufM. (2006). Therapeutic ultrasound-mediated DNA to cell and nucleus: bioeffects revealed by confocal and atomic force microscopy. Gene Ther.13 (2), 163–172. 10.1038/sj.gt.3302642

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 61

  Duvshani-EshetM.MachlufM. (2005). Therapeutic ultrasound optimization for gene delivery: a key factor achieving nuclear DNA localization. J. Control. Release108 (2), 513–528. 10.1016/j.jconrel.2005.08.025

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 62

  Duvshani-EshetM.BaruchL.KesselmanE.ShimoniE.MachlufM. (2006). Therapeutic ultrasound-mediated DNA to cell and nucleus: bioeffects revealed by confocal and atomic force microscopy. Gene Ther.13 (2), 163–172.

  • Pubmed Abstract
  • Google Scholar

• 63

  EaK.TaulierN.Contino-PépinC.UrbachW.DesgrangesS.BlascoH.et al (2025). Intracerebral drug delivery using microbubble/nanodroplet-assisted ultrasound to address neurodegenerative diseases. J. Clin. Transl. Res.00061. 10.36922/jctr.24.00061

  • CrossRef
  • Google Scholar

• 64

  EckersleyR. J.ChinC. T.BurnsP. N. (2005). Optimising phase and amplitude modulation schemes for imaging microbubble contrast agents at low acoustic power. Ultrasound Med. Biol.31 (2), 213–219. 10.1016/j.ultrasmedbio.2004.10.004

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 65

  EdwardsI. A.De CarloF.SittaJ.VarnerW.HowardC. M.ClaudioP. P. (2023). Enhancing targeted therapy in breast cancer by ultrasound-responsive nanocarriers. Int. J. Mol. Sci.24 (6), 5474. 10.3390/ijms24065474

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 66

  EisenbreyJ. R.GabrielH.SavsaniE.LyshchikA. (2021). Contrast-enhanced ultrasound (CEUS) in HCC diagnosis and assessment of tumor response to locoregional therapies. Abdom. Radiol.46, 3579–3595. 10.1007/s00261-021-03059-y

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 67

  EntzianK.AignerA. (2021). Drug delivery by ultrasound-responsive nanocarriers for cancer treatment. Pharmaceutics13 (8), 1135. 10.3390/pharmaceutics13081135

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 68

  EscoffreJ. M.CampomanesP.TarekM.BouakazA. (2020). New insights on the role of ROS in the mechanisms of sonoporation-mediated gene delivery. Ultrason. Sonochem64, 104998. 10.1016/j.ultsonch.2020.104998

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 69

  FanZ.KumonR. E.ParkJ.DengC. X. (2010). Intracellular delivery and calcium transients generated in sonoporation facilitated by microbubbles. J. Control. Release142 (1), 31–39. 10.1016/j.jconrel.2009.09.031

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 70

  FanZ.LiuH.MayerM.DengC. X. (2012). Spatiotemporally controlled single cell sonoporation. Proc. Natl. Acad. Sci. U. S. A.109 (41), 16486–16491. 10.1073/pnas.1208198109

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 71

  FanZ.SunY.DiC.TayD.ChenW.DengC. X.et al (2013). Acoustic tweezing cytometry for live-cell subcellular modulation of intracellular cytoskeleton contractility. Sci. Rep.3 (1), 2176. 10.1038/srep02176

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 72

  FanZ.KumonR. E.DengC. X. (2014). Mechanisms of microbubble-facilitated sonoporation for drug and gene delivery. Ther. Deliv.5 (4), 467–486. 10.4155/tde.14.10

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 73

  FanC.-H.HoY.-J.LinC.-W.WuN.ChiangP.-H.YehC.-K. (2022). State-of-the-art of ultrasound-triggered drug delivery from ultrasound-responsive drug carriers. Expert Opin. drug Deliv.19 (8), 997–1009. 10.1080/17425247.2022.2110585

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 74

  FerranteE. A.PickardJ. E.RychakJ.KlibanovA.LeyK. (2009). Dual targeting improves microbubble contrast agent adhesion to VCAM-1 and P-selectin under flow. J. Control Release140 (2), 100–107. 10.1016/j.jconrel.2009.08.001

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 75

  FilippouA.DrakosT.GiannakouM.EvripidouN.DamianouC. (2021). Experimental evaluation of the near-field and far-field heating of focused ultrasound using the thermal dose concept. Ultrasonics116, 106513. 10.1016/j.ultras.2021.106513

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 76

  FleuryG.BerrietR.ChapelonJ. Y.ter HaarG.LafonC.Le BaronO. (2005). “Safety issues for HIFU transducer design,” AIP Conf. Proc. (Kyoto, Japan: American Institute of Physics). 754, 233–241.

  • Google Scholar

• 77

  FolkmanJ. (2006). Angiogenesis. Annu. Rev. Med.57, 1–18. 10.1146/annurev.med.57.121304.131306

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 78

  ForbesM. M.SteinbergR. L.O'BrienW. D.Jr (2008). Examination of inertial cavitation of optison in producing sonoporation of Chinese hamster ovary cells. Ultrasound Med. Biol.34 (12), 2009–2018. 10.1016/j.ultrasmedbio.2008.05.003

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 79

  ForsbergF.ShiW. T.GoldbergB. B. (2000). Subharmonic imaging of contrast agents. Ultrasonics38 (1-8), 93–98. 10.1016/s0041-624x(99)00148-1

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 80

  FowlkesJ. B. (2008). American institute of ultrasound in medicine consensus report on potential bioeffects of diagnostic ultrasound: executive summary. J. Ultrasound Med.27 (4), 503–513. 10.1177/8756479310394986

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 81

  FriendJ.YeoL. Y. (2011). Microscale acoustofluidics: microfluidics driven via acoustics and ultrasonics. Rev. Mod. Phys.83 (2), 647–704. 10.1103/revmodphys.83.647

  • CrossRef
  • Google Scholar

• 82

  FuY.ZhouJ.LiJ. (2024). Diagnostic performance of ultrasound-based artificial intelligence for predicting key molecular markers in breast cancer: a systematic review and meta-analysis. Plos One19 (5), e0303669. 10.1371/journal.pone.0303669

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 83

  FurusawaY.HassanM. A.ZhaoQ.-L.OgawaR.TabuchiY.KondoT. (2014). Effects of therapeutic ultrasound on the nucleus and genomic DNA. Ultrason. Sonochem.21 (6), 2061–2068. 10.1016/j.ultsonch.2014.02.028

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 84

  GargalionisA. N.PapavassiliouK. A.PapavassiliouA. G. (2024). Mechanotransduction circuits in human pathobiology. Int. J. Mol. Sci.25 (7), 3816. 10.3390/ijms25073816

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 85

  GaroffoloG.PesceM. (2019). Mechanotransduction in the cardiovascular system: from developmental origins to homeostasis and pathology. Cells8 (12), 1607. 10.3390/cells8121607

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 86

  GedgeM.HillM. (2012). Acoustofluidics 17: theory and applications of surface acoustic wave devices for particle manipulation. Lab a Chip12 (17), 2998–3007. 10.1039/c2lc40565b

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 87

  GheorgheE. C.NicolauC.KamalA.UdristoiuA.GruionuL.SaftoiuA. (2023). Artificial intelligence (AI)-enhanced ultrasound techniques used in non-alcoholic fatty liver disease: are they ready for prime time?Appl. Sci.13 (8), 5080. 10.3390/app13085080

  • CrossRef
  • Google Scholar

• 88

  GliklichR. E.WhiteW. M.SlaytonM. H.BartheP. G.MakinI. R. (2007). Clinical pilot study of intense ultrasound therapy to deep dermal facial skin and subcutaneous tissues. Arch. Facial Plast. Surg.9 (2), 88–95. 10.1001/archfaci.9.2.88

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 89

  GoldbergB. B.LiuJ.-B.ForsbergF. (1994). Ultrasound contrast agents: a review. Ultrasound Med. Biol.20 (4), 319–333. 10.1016/0301-5629(94)90001-9

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 90

  GornyK.TradupD.HangiandreouN. (2005). Implementation and validation of three automated methods for measuring ultrasound maximum depth of penetration: application to ultrasound quality control. Med. Phys.32 (8), 2615–2628. 10.1118/1.1951095

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 91

  GoudarziS.JonesR. M.LeeY. H. W.HynynenK. (2024). Transducer module apodization to reduce bone heating during focused ultrasound uterine fibroid ablation with phased arrays: a numerical study. Med. Phys.51 (12), 8670–8687. 10.1002/mp.17427

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 92

  GourlayC. W.AyscoughK. R. (2005). The actin cytoskeleton: a key regulator of apoptosis and ageing?Nat. Rev. Mol. Cell Biol.6 (7), 583–589. 10.1038/nrm1682

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 93

  GuzmánH. R.NguyenD. X.KhanS.PrausnitzM. R. (2001). Ultrasound-mediated disruption of cell membranes. I. Quantification of molecular uptake and cell viability. J. Acoust. Soc. Am.110 (1), 588–596. 10.1121/1.1376131

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 94

  HamiltonM. F.BlackstockD. T. (2024). Nonlinear acoustics. Switzerland: Springer Nature.

  • Google Scholar

• 95

  HanahanD.WeinbergR. A. (2000). The hallmarks of cancer. Cell100 (1), 57–70. 10.1016/s0092-8674(00)81683-9

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 96

  HarrisonA.AltV. (2021). Low-intensity pulsed ultrasound (LIPUS) for stimulation of bone healing–A narrative review. Injury52, S91–S96. 10.1016/j.injury.2021.05.002

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 97

  HassanM. A.BuldakovM. A.OgawaR.ZhaoQ. L.FurusawaY.KudoN.et al (2010a). Modulation control over ultrasound-mediated gene delivery: evaluating the importance of standing waves. J. Control Release141 (1), 70–76. 10.1016/j.jconrel.2009.08.020

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 98

  HassanM. A.CampbellP.KondoT. (2010b). The role of Ca2+ in ultrasound-elicited bioeffects: progress, perspectives and prospects. Drug Discov. Today15 (21-22), 892–906. 10.1016/j.drudis.2010.08.005

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 99

  HauserJ.HauserM.MuhrG.EsenweinS. (2009). Ultrasound-induced modifications of cytoskeletal components in osteoblast-like SAOS-2 cells. J. Orthop. Res.27 (3), 286–294. 10.1002/jor.20741

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 100

  HelfieldB.ChenX.WatkinsS. C.VillanuevaF. S. (2016). Biophysical insight into mechanisms of sonoporation. Proc. Natl. Acad. Sci. U. S. A.113 (36), 9983–9988. 10.1073/pnas.1606915113

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 101

  HondaH.KondoT.ZhaoQ.-L.FerilL. B.JrKitagawaH. (2004). Role of intracellular calcium ions and reactive oxygen species in apoptosis induced by ultrasound. Ultrasound Med. Biol.30 (5), 683–692. 10.1016/j.ultrasmedbio.2004.02.008

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 102

  HuY.WanJ. M. F.YuA. C. H. (2013). Membrane perforation and recovery dynamics in microbubble-mediated sonoporation. Ultrasound Med. Biol.39 (12), 2393–2405. 10.1016/j.ultrasmedbio.2013.08.003

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 103

  HuY.HuangH.ChenM.ShenY. (2019). Non-localized increase in lipid content and striation pattern formation characterize the sonoporated plasma membrane. Ultrasound Med. Biol.45 (11), 3005–3017. 10.1016/j.ultrasmedbio.2019.07.411

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 104

  HuangY.DasP. K.BhethanabotlaV. R. (2021). Surface acoustic waves in biosensing applications. Sensors Actuators Rep.3, 100041. 10.1016/j.snr.2021.100041

  • CrossRef
  • Google Scholar

• 105

  HundtW.YuhE. L.BednarskiM. D.GuccioneS. (2007). Gene expression profiles, histologic analysis, and imaging of squamous cell carcinoma model treated with focused ultrasound beams. AJR Am. J. Roentgenol.189 (3), 726–736. 10.2214/ajr.07.2371

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 106

  IngberD. (2003). Mechanobiology and diseases of mechanotransduction. Ann. Med.35 (8), 564–577. 10.1080/07853890310016333

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 107

  IngberD. E. (2006). Cellular mechanotransduction: putting all the pieces together again. FASEB J.20 (7), 811–827. 10.1096/fj.05-5424rev

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 108

  IzadifarZ.BabynP.ChapmanD. (2019). Ultrasound cavitation/microbubble detection and medical applications. J. Med. Biol. Eng.39, 259–276. 10.1007/s40846-018-0391-0

  • CrossRef
  • Google Scholar

• 109

  JacobsE.RubinskyB.DavalosR. (2025). Pulsed field ablation in medicine: irreversible electroporation and electropermeabilization theory and applications. Radiol. Oncol.59 (1), 1–22. 10.2478/raon-2025-0011

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 110

  JawadN.ParkerP.LakshminarayanR. (2016). The role of contrast-enhanced ultrasound imaging in the follow-up of patients post-endovascular aneurysm repair. Ultrasound24 (1), 50–59. 10.1177/1742271x15627303

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 111

  JensenJ. A.NikolovS. I.GammelmarkK. L.PedersenM. H. (2006). Synthetic aperture ultrasound imaging. Ultrasonics44, e5–e15. 10.1016/j.ultras.2006.07.017

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 112

  JiaY.YuanW.ZhangK.WangJ.WangP.LiuQ.et al (2015). Comparison of cell membrane damage induced by the therapeutic ultrasound on human breast cancer MCF-7 and MCF-7/ADR cells. Ultrason. Sonochem26, 128–135. 10.1016/j.ultsonch.2015.03.001

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 113

  JiaC.ShiJ.HanT.YuA. C.QinP. (2022). Spatiotemporal dynamics and mechanisms of actin cytoskeletal re-modeling in cells perforated by ultrasound-driven microbubbles. Ultrasound Med. Biol.48 (5), 760–777. 10.1016/j.ultrasmedbio.2021.12.014

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 114

  JiangZ.SalcudeanS. E.NavabN. (2023). Robotic ultrasound imaging: state-of-the-art and future perspectives. Med. image Anal.89, 102878. 10.1016/j.media.2023.102878

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 115

  JuffermansL. J. M.van DijkA.JongenelenC. A. M.DrukarchB.ReijerkerkA.de VriesH. E.et al (2009). Ultrasound and microbubble-induced Intra- and intercellular bioeffects in primary endothelial cells. Ultrasound Med. Biol.35 (11), 1917–1927. 10.1016/j.ultrasmedbio.2009.06.1091

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 116

  JugniotN.BamR.MeuilletE. J.UngerE. C.PaulmuruganR. (2021). Current status of targeted microbubbles in diagnostic molecular imaging of pancreatic cancer. Bioeng. Transl. Med.6 (1), e10183. 10.1002/btm2.10183

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 117

  JungeL.OhlC. D.WolfrumB.AroraM.IkinkR. (2003). Cell detachment method using shock-wave-induced cavitation. Ultrasound Med. Biol.29 (12), 1769–1776. 10.1016/j.ultrasmedbio.2003.08.010

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 118

  KamenacA.SchilberthF. L.WagnerE.WixforthA.LächeltU.WesterhausenC. (2021). Transient permeabilization of living cells: combining shear flow and acoustofluidic trapping for the facilitated uptake of molecules. Processes9 (6), 913. 10.3390/pr9060913

  • CrossRef
  • Google Scholar

• 119

  KanekoO. F.WillmannJ. K. (2012). Ultrasound for molecular imaging and therapy in cancer. Quantitative Imaging Med. Surg.2 (2), 87–97. 10.3978/j.issn.2223-4292.2012.06.06

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 120

  KaufmannB. A.SandersJ. M.DavisC.XieA.AldredP.SarembockI. J.et al (2007a). Molecular imaging of inflammation in atherosclerosis with targeted ultrasound detection of vascular cell adhesion molecule-1. Circulation116 (3), 276–284. 10.1161/circulationaha.106.684738

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 121

  KaufmannB. A.LewisC.XieA.Mirza-MohdA.LindnerJ. R. (2007b). Detection of recent myocardial ischaemia by molecular imaging of P-selectin with targeted contrast echocardiography. Eur. Heart J.28 (16), 2011–2017. 10.1093/eurheartj/ehm176

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 122

  KidaH.TachibanaK. (2023). “Application of ultrasound‐responsive reagents for drug delivery systems,” Hoboken, NJ, United States: Acoustic technologies in biology and medicine, 181–215.

  • Google Scholar

• 123

  KierskiT. M. (2022). Improving ultrasound microvascular imaging with superharmonic imaging and machine learning. NC, United States: The University of North Carolina at Chapel Hill.

  • Google Scholar

• 124

  KimS.MoonS.RhoS.YoonS. (2021). Measurements of acoustic radiation force of ultrahigh frequency ultrasonic transducers using model-based approach. Appl. Phys. Lett.118 (18), 184102. 10.1063/5.0044512

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 125

  KlothC.KratzerW.SchmidbergerJ.BeerM.ClevertD. A.GraeterT. (2021). “Ultrasound 2020–diagnostics and therapy: on the way to multimodal ultrasound: contrast-enhanced ultrasound (ceus), microvascular doppler techniques, fusion imaging, sonoelastography, interventional sonography,” Rofo.193 (01), 23–32. 10.1055/a-1217-7400

  • CrossRef
  • Google Scholar

• 126

  KooimanK.VosH. J.VersluisM.de JongN. (2014). Acoustic behavior of microbubbles and implications for drug delivery. Adv. Drug Deliv. Rev.72, 28–48. 10.1016/j.addr.2014.03.003

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 127

  KooimanK.RooversS.LangeveldS. A.KlevenR. T.DewitteH.O'ReillyM. A.et al (2020). Ultrasound-responsive cavitation nuclei for therapy and drug delivery. Ultrasound Med. Biol.46 (6), 1296–1325. 10.1016/j.ultrasmedbio.2020.01.002

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 128

  KorpantyG.CarbonJ. G.GrayburnP. A.FlemingJ. B.BrekkenR. A. (2007). Monitoring response to anticancer therapy by targeting microbubbles to tumor vasculature. Clin. Cancer Res.13 (1), 323–330. 10.1158/1078-0432.ccr-06-1313

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 129

  KremkauF. W. (1979). Cancer therapy with ultrasound: a historical review. J. Clin. Ultrasound7 (4), 287–300. 10.1002/jcu.1870070410

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 130

  KrutZ.GazitD.GazitZ.PelledG. (2022). Applications of ultrasound-mediated gene delivery in regenerative medicine. Bioengineering9 (5), 190. 10.3390/bioengineering9050190

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 131

  KuehlmannB.BonhamC. A.ZucalI.PrantlL.GurtnerG. C. (2020). Mechanotransduction in wound healing and fibrosis. J. Clin. Med.9 (5), 1423. 10.3390/jcm9051423

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 132

  KunkelE. J.ButcherE. C. (2003). Plasma-cell homing. Nat. Rev. Immunol.3 (10), 822–829. 10.1038/nri1203

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 133

  LaganàF.PratticoD.De CarloD.OlivaG.PullanoS. A.CalcagnoS. (2024). Engineering biomedical problems to detect carcinomas: a tomographic impedance approach. Eng5 (3), 1594–1614. 10.3390/eng5030084

  • CrossRef
  • Google Scholar

• 134

  LaghiF. A.SaadM.ShaikhH. (2021). Ultrasound and non-ultrasound imaging techniques in the assessment of diaphragmatic dysfunction. BMC Pulm. Med.21, 85–29. 10.1186/s12890-021-01441-6

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 135

  LaiC. Y.WuC. H.ChenC. C.LiP. C. (2006). Quantitative relations of acoustic inertial cavitation with sonoporation and cell viability. Ultrasound Med. Biol.32 (12), 1931–1941. 10.1016/j.ultrasmedbio.2006.06.020

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 136

  LammerdingJ. A. N.KammR. D.LeeR. T. (2004). Mechanotransduction in cardiac myocytes. Ann. N. Y. Acad. Sci.1015 (1), 53–70. 10.1196/annals.1302.005

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 137

  LangeveldS. A.MeijlinkB.KooimanK. (2021). Phospholipid-coated targeted microbubbles for ultrasound molecular imaging and therapy. Curr. Opin. Chem. Biol.63, 171–179. 10.1016/j.cbpa.2021.04.013

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 138

  LeeD. J.LyshchikA.HuamaniJ.HallahanD. E.FleischerA. C. (2008). Relationship between retention of a vascular endothelial growth factor receptor 2 (VEGFR2)-targeted ultrasonographic contrast agent and the level of VEGFR2 expression in an in vivo breast cancer model. J. Ultrasound Med.27 (6), 855–866. 10.7863/jum.2008.27.6.855

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 139

  LeightonT. (2012). The acoustic bubble. Cambridge, MA, United States: Academic Press.

  • Google Scholar

• 140

  LentackerI.De CockI.DeckersR.De SmedtS. C.MoonenC. T. (2014). Understanding ultrasound induced sonoporation: definitions and underlying mechanisms. Adv. Drug Deliv. Rev.72, 49–64. 10.1016/j.addr.2013.11.008

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 141

  LeowR. S.WanJ. M. F.YuA. C. H. (2015). Membrane blebbing as a recovery manoeuvre in site-specific sonoporation mediated by targeted microbubbles. J. R. Soc. Interface12 (105), 20150029. 10.1098/rsif.2015.0029

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 142

  LiY.ZafarM. I.WangX.DingX.LiH. (2020). Heat stress and pulsed unfocused ultrasound: the viability of these physical approaches for drug delivery into testicular seminiferous tubules. Curr. Drug Deliv.17 (5), 438–446. 10.2174/1567201817666200514080811

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 143

  LiR.FengD.HanS.ZhaiX.YuX.FuY.et al (2023). Macrophages and fibroblasts in foreign body reactions: how mechanical cues drive cell functions?Mater. Today Bio22, 100783. 10.1016/j.mtbio.2023.100783

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 144

  LiX.PengX.ZoulikhaM.BoafoG. F.MagarK. T.JuY.et al (2024a). Multifunctional nanoparticle-mediated combining therapy for human diseases. Signal Transduct. Target. Ther.9 (1), 1. 10.1038/s41392-023-01668-1

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 145

  LiH.XuH.LiY.LiX. (2024b). Application of artificial intelligence (AI)-enhanced biochemical sensing in molecular diagnosis and imaging analysis: advancing and challenges. TrAC Trends Anal. Chem.174, 117700. 10.1016/j.trac.2024.117700

  • CrossRef
  • Google Scholar

• 146

  LindnerJ. R.SongJ.XuF.KlibanovA. L.SingbartlK.LeyK.et al (2000). Noninvasive ultrasound imaging of inflammation using microbubbles targeted to activated leukocytes. Circulation102 (22), 2745–2750. 10.1161/01.cir.102.22.2745

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 147

  LiuY.ChoC.-W.YanX.HenthornT. K.LilleheiK. O.CobbW. N.et al (2001). Ultrasound-induced hyperthermia increases cellular uptake and cytotoxicity of P-glycoprotein substrates in multi-drug resistant cells. Pharm. Res.18, 1255–1261. 10.1023/a:1013025625156

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 148

  LiuS.YangY.NiZ.GuoX.LuoL.TuJ.et al (2017). Investigation into the effect of acoustic radiation force and acoustic streaming on particle patterning in acoustic standing wave fields. Sensors17 (7), 1664. 10.3390/s17071664

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 149

  LiuJ.WangC.QiuS.SunW.YangG.YuanL. (2024). Toward ultrasound molecular imaging of endothelial dysfunction in diabetes: targets, strategies, and challenges. ACS Appl. Bio Mater.7 (3), 1416–1428. 10.1021/acsabm.4c00053

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 150

  LohseD.ZhangX. (2015). Surface nanobubbles and nanodroplets. Rev. Mod. Phys.87 (3), 981–1035. 10.1103/revmodphys.87.981

  • CrossRef
  • Google Scholar

• 151

  LopezW.NguyenN.CaoJ.EddowC.ShungK. K.LeeN. S.et al (2021). Ultrasound therapy, chemotherapy and their combination for prostate cancer. Technol. Cancer Res. Treat.20, 15330338211011965. 10.1177/15330338211011965

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 152

  LuS.-s.YangL.-l.YangW.WangJ.ZhangX.-L.YangL.et al (2024). Complications and adverse events of high-intensity focused ultrasound in its application to gynecological field-a systematic review and meta-analysis. Int. J. Hyperth.41 (1), 2370969. 10.1080/02656736.2024.2370969

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 153

  MaP.LaiX.LuoZ.ChenY.LohX. J.YeE.et al (2022). Recent advances in mechanical force-responsive drug delivery systems. Nanoscale Adv.4 (17), 3462–3478. 10.1039/d2na00420h

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 154

  Mahnič-KalamizaS.MiklavčičD. (2022). The Phenomenon of Electroporation. In: Editors: Raso, J., Heinz, V., Alvarez, I., Toepfl, S. Pulsed Electric Fields Technology for the Food Industry. Springer, Cham: Food Engineering Series. 10.1007/978-3-030-70586-2_3

  • CrossRef
  • Google Scholar

• 155

  McNeilP. L.SteinhardtR. A. (2003). Plasma membrane disruption: repair, prevention, adaptation. Annu. Rev. Cell Dev. Biol.19, 697–731. 10.1146/annurev.cellbio.19.111301.140101

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 156

  Mehier-HumbertS.BettingerT.YanF.GuyR. H. (2005). Plasma membrane poration induced by ultrasound exposure: implication for drug delivery. J. Control Release104 (1), 213–222. 10.1016/j.jconrel.2005.01.007

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 157

  MengY.PopleC. B.SuppiahS.LlinasM.HuangY.SahgalA.et al (2021). MR-guided focused ultrasound liquid biopsy enriches circulating biomarkers in patients with brain tumors. Neuro-Oncol.23 (10), 1789–1797. 10.1093/neuonc/noab057

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 158

  MillerD. L. (2007). Overview of experimental studies of biological effects of medical ultrasound caused by gas body activation and inertial cavitation. Prog. Biophys. Mol. Biol.93 (1-3), 314–330. 10.1016/j.pbiomolbio.2006.07.027

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 159

  MillerD. L.SmithN. B.BaileyM. R.CzarnotaG. J.HynynenK.MakinI. R. (2012). Overview of therapeutic ultrasound applications and safety considerations. J. Ultrasound Med.31 (4), 623–634. 10.7863/jum.2012.31.4.623

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 160

  MishraA.PayneC.Carrascal-MininoA.HalbherrS.PouliopoulosA.de RosalesR. T. (2025). PET imaging for non-invasive monitoring of 89Zr-Talidox delivery to the brain following focused ultrasound-mediated blood-brain barrier opening. bioRxiv2025, 10.1101/2025.06.16.659954

  • CrossRef
  • Google Scholar

• 161

  MoreelL.BetrainsA.DoumenM.MolenberghsG.VanderschuerenS.BlockmansD. (2023). Diagnostic yield of combined cranial and large vessel PET/CT, ultrasound and MRI in giant cell arteritis: a systematic review and meta-analysis. Autoimmun. Rev.22 (7), 103355. 10.1016/j.autrev.2023.103355

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 162

  MuratoreR.LaMannaJ.SzulmanE.KaliszM. A.LamprechtM.SimonM. M. (2009). Bioeffective ultrasound at very low doses: reversible manipulation of neuronal cell morphology and function in vitro, AIP Conf. Proc.1113, 25–29. 10.1063/1.3131426

  • CrossRef
  • Google Scholar

• 163

  NewmanC.BettingerT. (2007). Gene therapy progress and prospects: ultrasound for gene transfer. Gene Ther.14 (6), 465–475. 10.1038/sj.gt.3302925

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 164

  NewmanC. M.LawrieA.BriskenA. F.CumberlandD. C. (2001). Ultrasound gene therapy: on the road from concept to reality. Echocardiography18 (4), 339–347. 10.1046/j.1540-8175.2001.00339.x

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 165

  NewsonA. J. (2008). Ethical aspects arising from non-invasive fetal. Semin Fetal Neonatal Med.13 (2), 103–108. 10.1016/j.siny.2007.12.004

  • CrossRef
  • Google Scholar

• 166

  NinetJ.RoquesX.SeitelbergerR.DevilleC.PomarJ. L.RobinJ.et al (2005). Surgical ablation of atrial fibrillation with off-pump, epicardial, high-intensity focused ultrasound: results of a multicenter trial. J. Thorac. Cardiovasc Surg.130 (3), 803.e1–803.e8. 10.1016/j.jtcvs.2005.05.014

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 167

  NyborgW.CarsonP.DunnF.MillerD.MillerM.ZiskinM.et al (1985). Biological effects of ultrasound: mechanisms and clinical implications, J. Acoust. Soc. Am.77, 1628, 10.1121/1.391973

  • CrossRef
  • Google Scholar

• 168

  NyborgW.CarsonP.CarstensenE.DunnF.MillerM.MillerD.et al (2002). “Exposure criteria for medical diagnostic ultrasound: II,” in Criteria based on all known mechanisms. Bethesda, MD: National Council on Radiation Protection and Measurements.

  • Google Scholar

• 169

  O'BrienW. D.Jr (2007). Ultrasound-biophysics mechanisms. Prog. Biophys. Mol. Biol.93 (1-3), 212–255. 10.1016/j.pbiomolbio.2006.07.010

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 170

  OgawaK.TachibanaK.UchidaT.TaiT.YamashitaN.TsujitaN.et al (2001). High-resolution scanning electron microscopic evaluation of cell-membrane porosity by ultrasound. Med. Electron Microsc.34 (4), 249–253. 10.1007/s007950100022

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 171

  OhashiK.KunitomiA.ChibaS.MizunoK. (2024). Roles of the Dbl family of RhoGEFs in mechanotransduction – a review. Front. Cell Dev. Biol.12, 1485725. 10.3389/fcell.2024.1485725

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 172

  OhlC.-D.WolfrumB. (2003). Detachment and sonoporation of adherent HeLa-cells by shock wave-induced cavitation. Biochimica Biophysica Acta (BBA)-General Subj.1624 (1-3), 131–138. 10.1016/j.bbagen.2003.10.005

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 173

  OkadaK.KudoN.HassanM. A.KondoT.YamamotoK. (2009). Threshold curves obtained under various gaseous conditions for free radical generation by burst ultrasound - effects of dissolved gas, microbubbles and gas transport from the air. Ultrason. Sonochem16 (4), 512–518. 10.1016/j.ultsonch.2008.11.010

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 174

  PalmowskiM.HuppertJ.LadewigG.HauffP.ReinhardtM.MuellerM. M.et al (2008). Molecular profiling of angiogenesis with targeted ultrasound imaging: early assessment of antiangiogenic therapy effects. Mol. Cancer Ther.7 (1), 101–109. 10.1158/1535-7163.mct-07-0409

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 175

  ParkJ.FanZ.KumonR. E.El-SayedM. E.DengC. X. (2010). Modulation of intracellular Ca2+ concentration in brain microvascular endothelial cells in vitro by acoustic cavitation. Ultrasound Med. Biol.36 (7), 1176–1187. 10.1016/j.ultrasmedbio.2010.04.006

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 176

  ParkJ.FanZ.DengC. X. (2011). Effects of shear stress cultivation on cell membrane disruption and intracellular calcium concentration in sonoporation of endothelial cells. J. Biomech.44 (1), 164–169. 10.1016/j.jbiomech.2010.09.003

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 177

  ParkD.LeeS. J.ParkJ.-W. (2024). Aptamer-based smart targeting and spatial trigger–response drug-delivery systems for anticancer therapy. Biomedicines12 (1), 187. 10.3390/biomedicines12010187

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 178

  ParsonsJ. E.CainC. A.AbramsG. D.FowlkesJ. B. (2006). Pulsed cavitational ultrasound therapy for controlled tissue homogenization. Ultrasound Med. Biol.32 (1), 115–129. 10.1016/j.ultrasmedbio.2005.09.005

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 179

  PhillipsP. (2001). “Contrast pulse sequences (CPS): imaging nonlinear microbubbles,” 2001 IEEE ultrasonics symposium proceedings an international symposium (Cat No 01CH37263) (Atlanta, GA, United States: IEEE).

  • Google Scholar

• 180

  PolatB. E.HartD.LangerR.BlankschteinD. (2011). Ultrasound-mediated transdermal drug delivery: mechanisms, scope, and emerging trends. J. Control. Release152 (3), 330–348. 10.1016/j.jconrel.2011.01.006

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 181

  PonomarchukE. M.HunterC.SongM.KhokhlovaV. A.SapozhnikovO. A.YuldashevP. V.et al (2022). Mechanical damage thresholds for hematomas near gas-containing bodies in pulsed HIFU fields. Phys. Med. Biol.67 (21), 215007. 10.1088/1361-6560/ac96c7

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 182

  PostemaM.KotopoulisS.DelalandeA.GiljaO. H. (2012). Sonoporation: why microbubbles create pores. Ultraschall der Medizin33 (1), 97–98. 10.1055/s-0031-1274749

  • CrossRef
  • Google Scholar

• 183

  Prado-CostaR.RebeloJ.Monteiro-BarrosoJ.PretoA. S. (2018). Ultrasound elastography: compression elastography and shear-wave elastography in the assessment of tendon injury. Insights Imaging9, 791–814. 10.1007/s13244-018-0642-1

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 184

  PrantsS. (2009). Proliferation of atomic wave packets at the nodes of a standing light wave. J. Exp. Theor. Phys.109, 751–761. 10.1134/s1063776109110041

  • CrossRef
  • Google Scholar

• 185

  PrzystupskiD.UssowiczM. (2022). Landscape of cellular bioeffects triggered by ultrasound-induced sonoporation. Int. J. Mol. Sci.23 (19), 11222. 10.3390/ijms231911222

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 186

  PyszM. A.FoygelK.RosenbergJ.GambhirS. S.SchneiderM.WillmannJ. K. (2010). Antiangiogenic cancer therapy: monitoring with molecular US and a clinically translatable contrast agent (BR55). Radiology256 (2), 519–527. 10.1148/radiol.10091858

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 187

  QinD.ZhangL.ChangN.NiP.ZongY.BouakazA.et al (2018). In situ observation of single cell response to acoustic droplet vaporization: membrane deformation, permeabilization, and blebbing. Ultrason. Sonochem47, 141–150. 10.1016/j.ultsonch.2018.02.004

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 188

  QuaiaE. (2007). Microbubble ultrasound contrast agents: an update. Eur. Radiol.17, 1995–2008. 10.1007/s00330-007-0623-0

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 189

  QuaratoC. M. I.LacedoniaD.SalveminiM.TuccariG.MastrodonatoG.VillaniR.et al (2023). A review on biological effects of ultrasounds: key messages for clinicians. Diagnostics13 (5), 855. 10.3390/diagnostics13050855

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 190

  QuaziS. (2022). RETRACTED ARTICLE: artificial intelligence and machine learning in precision and genomic medicine. Med. Oncol.39 (8), 120. 10.1007/s12032-022-01711-1

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 191

  RamesanS.RezkA. R.CevaalP. M.Cortez-JugoC.SymonsJ.YeoL. Y. (2021). Acoustofection: high-frequency vibrational membrane permeabilization for intracellular siRNA delivery into nonadherent cells. ACS Appl. Bio Mater4 (3), 2781–2789. 10.1021/acsabm.1c00003

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 192

  RevenuC.AthmanR.RobineS.LouvardD. (2004). The co-workers of actin filaments: from cell structures to signals. Nat. Rev. Mol. Cell Biol.5 (8), 635–646. 10.1038/nrm1437

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 193

  RichJ.TianZ.HuangT. J. (2022). Sonoporation: past, present, and future. Adv. Mater. Technol.7 (1), 2100885. 10.1002/admt.202100885

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 194

  Rincon-TorroellaJ.KhelaH.BettegowdaA.BettegowdaC. (2022). Biomarkers and focused ultrasound: the future of liquid biopsy for brain tumor patients. J. Neuro-Oncol.156, 33–48. 10.1007/s11060-021-03837-0

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 195

  RobertsonV. J.BakerK. G. (2001). A review of therapeutic ultrasound: effectiveness studies. Phys. Ther.81 (7), 1339–1350. 10.1093/ptj/81.7.1339

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 196

  RoozeJ.RebrovE. V.SchoutenJ. C.KeurentjesJ. T. (2013). Dissolved gas and ultrasonic cavitation–a review. Ultrason. Sonochem.20 (1), 1–11. 10.1016/j.ultsonch.2012.04.013

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 197

  RosenthalI.SostaricJ. Z.RieszP. (2004). Sonodynamic therapy–a review of the synergistic effects of drugs and ultrasound. Ultrason. Sonochem.11 (6), 349–363. 10.1016/j.ultsonch.2004.03.004

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 198

  RubinskyB. (2007). Irreversible electroporation in medicine. Technol. Cancer Res. Treat.6 (4), 255–259. 10.1177/153303460700600401

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 199

  SabaL.MaindarkarM.JohriA. M.MantellaL.LairdJ. R.KhannaN. N.et al (2024). UltraAIGenomics: artificial intelligence-based cardiovascular disease risk assessment by fusion of ultrasound-based radiomics and genomics features for preventive, personalized and precision medicine: a narrative review. Rev. Cardiovasc. Med.25 (5), 184. 10.31083/j.rcm2505184

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 200

  SabaL.PinnaA.FaaG.BalestrieriA.PolitiC.CogheF.et al (2025). The evolution from qualitative to quantitative analysis in medical sciences: a historical perspective and the impact of AI, Imaging, 17(1), 15–25.

  • Google Scholar

• 201

  SanlıC.LohseD.van der MeerD. (2014). From antinode clusters to node clusters: the concentration-dependent transition of floaters on a standing Faraday wave. Phys. Rev. E89 (5), 053011. 10.1103/physreve.89.053011

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 202

  SanwalR.JoshiK.DitmansM.TsaiS. S.LeeW. L. (2021). Ultrasound and microbubbles for targeted drug delivery to the lung endothelium in ARDS: cellular mechanisms and therapeutic opportunities. Biomedicines9 (7), 803. 10.3390/biomedicines9070803

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 203

  SaparetoS. A.DeweyW. C. (1984). Thermal dose determination in cancer therapy. Int. J. Radiat. Oncol. Biol. Phys.10 (6), 787–800. 10.1016/0360-3016(84)90379-1

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 204

  SchlicherR. K.RadhakrishnaH.TolentinoT. P.ApkarianR. P.ZarnitsynV.PrausnitzM. R. (2006). Mechanism of intracellular delivery by acoustic cavitation. Ultrasound Med. Biol.32 (6), 915–924. 10.1016/j.ultrasmedbio.2006.02.1416

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 205

  SchlicherR. K.HutchesonJ. D.RadhakrishnaH.ApkarianR. P.PrausnitzM. R. (2010). Changes in cell morphology due to plasma membrane wounding by acoustic cavitation. Ultrasound Med. Biol.36 (4), 677–692. 10.1016/j.ultrasmedbio.2010.01.010

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 206

  SchmidF.SchindeleD.MortezaviA.SpitznagelT.SulserT.SchostakM. (2020). Prospective multicentre study using high intensity focused ultrasound (HIFU) for the focal treatment of prostate cancer: safety outcomes and complications. Urol. Oncol-Semin. Orig. Investig.38 (4), 225–230. 10.1016/j.urolonc.2019.09.001

  • CrossRef
  • Google Scholar

• 207

  SchumannP. A.ChristiansenJ. P.QuigleyR. M.McCreeryT. P.SweitzerR. H.UngerE. C.et al (2002). Targeted-microbubble binding selectively to GPIIb IIIa receptors of platelet thrombi. Invest. Radiol.37 (11), 587–593. 10.1097/00004424-200211000-00001

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 208

  ScorerR. (1967). “Causes and consequences of standing waves,” Fort Collins, CO, United States: American Meteorological Society (AMS).

  • Google Scholar

• 209

  ShamoutF. E.PouliopoulosA. N.LeeP.BonaccorsiS.TowhidiL.KramsR.et al (2015). Enhancement of non-invasive trans-membrane drug delivery using ultrasound and microbubbles during physiologically relevant flow. Ultrasound Med. Biol.41 (9), 2435–2448. 10.1016/j.ultrasmedbio.2015.05.003

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 210

  ShawA.HodnettM. (2008). Calibration and measurement issues for therapeutic ultrasound. Ultrasonics48 (4), 234–252. 10.1016/j.ultras.2007.10.010

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 211

  ShawA.ter HaarG.HallerJ.WilkensV. (2015). Towards a dosimetric framework for therapeutic ultrasound. Int. J. Hyperth.31 (2), 182–192. 10.3109/02656736.2014.997311

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 212

  ShinC. S.KimJ. I. (2024). High-intensity focused ultrasound in the treatment of varicose veins: a comprehensive review. Ann. Phlebol.22 (2), 57–60. 10.37923/phle.2024.22.2.57

  • CrossRef
  • Google Scholar

• 213

  ShungK. K. (2011). Diagnostic ultrasound: past, present, and future. J. Med. Biol. Eng.31 (6), 371–374. 10.5405/jmbe.871

  • CrossRef
  • Google Scholar

• 214

  SilbersteinJ.LakinC. M.Kellogg ParsonsJ. (2008). Shock wave lithotripsy and renal hemorrhage. Rev. Urol.10 (3), 236–241.

  • Pubmed Abstract
  • Google Scholar

• 215

  SimpsonD. H.BurnsP. N.AverkiouM. A. (2001). Techniques for perfusion imaging with microbubble contrast agents. IEEE Trans. Ultrason. Ferroelectr. Freq. Control48 (6), 1483–1494. 10.1109/58.971698

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 216

  SittaJ.HowardC. M. (2021). Applications of ultrasound-mediated drug delivery and gene therapy. Int. J. Mol. Sci.22 (21), 11491. 10.3390/ijms222111491

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 217

  SnipstadS.SulheimE.de Lange DaviesC.MoonenC.StormG.KiesslingF.et al (2018). Sonopermeation to improve drug delivery to tumors: from fundamental understanding to clinical translation. Expert Opin. drug Deliv.15 (12), 1249–1261. 10.1080/17425247.2018.1547279

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 218

  SongJ.PulkkinenA.HuangY.HynynenK. (2011). Investigation of standing-wave formation in a human skull for a clinical prototype of a large-aperture, transcranial MR-guided focused ultrasound (MRgFUS) phased array: an experimental and simulation study. IEEE Trans. Biomed. Eng.59 (2), 435–444. 10.1109/TBME.2011.2174057

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 219

  SongJ.HuangY.HynynenK. (2010). “Investigation of standing wave formation in a human calvarium using a large scale, transcranial MR guided focused ultrasound phased-array.” San Diego, CA, United States: 2010 IEEE international ultrasonics symposium (IEEE).

  • Google Scholar

• 220

  SridharanA.EisenbreyJ. R.ForsbergF.LorenzN.SteffgenL.NtouliaA. (2021). Ultrasound contrast agents: microbubbles made simple for the pediatric radiologist. Pediatr. Radiol.51 (12), 2117–2127. 10.1007/s00247-021-05080-1

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 221

  SteinlD. C.XuL.KhanichehE.EllertsdottirE.Ochoa-EspinosaA.MitterhuberM.et al (2016). Noninvasive contrast-enhanced ultrasound molecular imaging detects myocardial inflammatory response in autoimmune myocarditis. Autoimmune Myocarditis. Circ. Cardiovasc. Imaging9 (8), e004720. 10.1161/circimaging.116.004720

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 222

  SunM. K. (1999). Hypoxia, ischemic stroke, and memory deficits: prospects for therapy. Iubmb Life.48 (4), 373–378. 10.1080/152165499306720

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 223

  SunS.TangQ.SunL.ZhangJ.ZhangL.XuM.et al (2022a). Ultrasound-mediated immune regulation in tumor immunotherapy. Mater. Today Adv.14, 100248. 10.1016/j.mtadv.2022.100248

  • CrossRef
  • Google Scholar

• 224

  SunM.YueT.WangC.FanZ.GazitE.DuJ. (2022b). Ultrasound-responsive peptide nanogels to balance conflicting requirements for deep tumor penetration and prolonged blood circulation. ACS Nano.16 (6), 9183–9194. 10.1021/acsnano.2c01407

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 225

  TachibanaK.UchidaT.OgawaK.YamashitaN.TamuraK. (1999). Induction of cell-membrane porosity by ultrasound. Lancet353 (9162), 1409. 10.1016/s0140-6736(99)01244-1

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 226

  TaegtmeyerH.DilsizianV. (2008). Imaging myocardial metabolism and ischemic memory. Nat. Clin. Pract. Cardiovasc. Med.5 (Suppl. 2), S42–S48. 10.1038/ncpcardio1186

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 227

  TaniyamaY.TachibanaK.HiraokaK.AokiM.YamamotoS.MatsumotoK.et al (2002). Development of safe and efficient novel nonviral gene transfer using ultrasound: enhancement of transfection efficiency of naked plasmid DNA in skeletal muscle. Gene Ther.9 (6), 372–380. 10.1038/sj.gt.3301678

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 228

  TaranF. A.TempanyC. M.ReganL.InbarY.RevelA.StewartE. A. (2009). Magnetic resonance-guided focused ultrasound (MRgFUS) compared with abdominal hysterectomy for treatment of uterine leiomyomas. Ultrasound Obstet. Gynecol.34 (5), 572–578. 10.1002/uog.7435

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 229

  TerH. G. (2016). HIFU tissue ablation: concept and devices. Adv. Exp. Med. Biol.880, 3–20. 10.1007/978-3-319-22536-4_1

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 230

  TrachoothamD.AlexandreJ.HuangP. (2009). Targeting cancer cells by ROS-mediated mechanisms: a radical therapeutic approach?Nat. Rev. Drug Discov.8 (7), 579–591. 10.1038/nrd2803

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 231

  TranT. A.RogerS.Le GuennecJ. Y.TranquartF.BouakazA. (2007). Effect of ultrasound-activated microbubbles on the cell electrophysiological properties. Ultrasound Med. Biol.33 (1), 158–163. 10.1016/j.ultrasmedbio.2006.07.029

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 232

  TranT. A.Le GuennecJ. Y.BougnouxP.TranquartF.BouakazA. (2008). Characterization of cell membrane response to ultrasound activated microbubbles. IEEE Trans. Ultrason. Ferroelectr. Freq. Control55 (1), 43–49. 10.1109/TUFFC.2008.615

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 233

  TsirkinS.GoldbartR.TraitelT.KostJ. (2021). Tailor-made single-core PLGA microbubbles as acoustic cavitation enhancers for therapeutic applications. ACS Appl. Mater. Interfaces13 (22), 25748–25758. 10.1021/acsami.1c04770

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 234

  UddinS. M.KomatsuD. E.MotykaT.PettersonS. (2021). Low-intensity continuous ultrasound therapies—a systematic review of current state-of-the-art and future perspectives. J. Clin. Med.10 (12), 2698. 10.3390/jcm10122698

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 235

  UngaJ.HashidaM. (2014). Ultrasound induced cancer immunotherapy. Adv. drug Deliv. Rev.72, 144–153. 10.1016/j.addr.2014.03.004

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 236

  UyyalaS. (2023). The development of new treatments for neurological disorders: insights, innovations, and ethical foundations. Indus J. Med. Health Sci.1 (01), 45–55.

  • Google Scholar

• 237

  van RooijT.SkachkovI.BeekersI.LattweinK. R.VoorneveldJ. D.KokhuisT. J. A.et al (2016). Viability of endothelial cells after ultrasound-mediated sonoporation: influence of targeting, oscillation, and displacement of microbubbles. J. Control Release238, 197–211. 10.1016/j.jconrel.2016.07.037

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 238

  van WamelA.KooimanK.HarteveldM.EmmerM.ten CateF. J.VersluisM.et al (2006). Vibrating microbubbles poking individual cells: drug transfer into cells via sonoporation. J. Control. Release112 (2), 149–155. 10.1016/j.jconrel.2006.02.007

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 239

  VermaJ.WarsameC.SeenivasagamR. K.KatiyarN. K.AleemE.GoelS. (2023). Nanoparticle-mediated cancer cell therapy: basic science to clinical applications. Cancer Metastasis Rev.42 (3), 601–627. 10.1007/s10555-023-10086-2

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 240

  VillanuevaF. S.LuE.BowryS.KilicS.TomE.WangJ.et al (2007). Myocardial ischemic memory imaging with molecular echocardiography. Circulation115 (3), 345–352. 10.1161/circulationaha.106.633917

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 241

  WangN. (2017). Review of cellular mechanotransduction. J. Phys. D Appl. Phys.50 (23), 233002. 10.1088/1361-6463/aa6e18

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 242

  WangB.ZangW. J.WangM.AiH.WangY. W.LiY. P.et al (2006). Prolonging the ultrasound signal enhancement from thrombi using targeted microbubbles based on sulfur-hexafluoride-filled gas. Acad. Radiol.13 (4), 428–433. 10.1016/j.acra.2005.11.035

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 243

  WangD.LuoW.WenG.YangL.HongS.ZhangS.et al (2017). Synergistic effects of negative-charged nanoparticles assisted by ultrasound on the reversal multidrug resistance phenotype in breast cancer cells. Ultrason. Sonochem34, 448–457. 10.1016/j.ultsonch.2016.06.012

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 244

  WangM.ZhangY.CaiC.TuJ.GuoX.ZhangD. (2018). Sonoporation-induced cell membrane permeabilization and cytoskeleton disassembly at varied acoustic and microbubble-cell parameters. Sci. Rep.8 (1), 3885. 10.1038/s41598-018-22056-8

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 245

  WangY.GeX.MaH.QiS.ZhangG.YaoY. (2021). Deep learning in medical ultrasound image analysis: a review. Ieee Access9, 54310–54324. 10.1109/access.2021.3071301

  • CrossRef
  • Google Scholar

• 246

  WangN.LuY.RothrauffB. B.ZhengA.LambA.YanY.et al (2023). Mechanotransduction pathways in articular chondrocytes and the emerging role of estrogen receptor-α. Bone Res.11 (1), 13. 10.1038/s41413-023-00248-x

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 247

  WellsP. N.LiangH.-D. (2011). Medical ultrasound: imaging of soft tissue strain and elasticity. J. R. Soc. Interface8 (64), 1521–1549. 10.1098/rsif.2011.0054

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 248

  WenZ.LiuC.TengZ.JinQ.LiaoZ.ZhuX.et al (2023). Ultrasound meets the cell membrane: for enhanced endocytosis and drug delivery. Nanoscale15 (33), 13532–13545. 10.1039/d3nr02562d

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 249

  WillmannJ. K.LutzA. M.PaulmuruganR.PatelM. R.ChuP.RosenbergJ.et al (2008). Dual-targeted contrast agent for US assessment of tumor angiogenesis in vivo. Radiology248 (3), 936–944. 10.1148/radiol.2483072231

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 250

  WuA.JiangL.XiaC.XuQ.ZhouB.JinZ.et al (2023). Ultrasound‐driven piezoelectrocatalytic immunoactivation of deep tumor. Adv. Sci.10 (28), 2303016. 10.1002/advs.202303016

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 251

  XiaoD.De la TorreP.AlfredC. (2024). Real-time speed-of-sound estimation in vivo via steered plane wave ultrasound. IEEE Trans. Ultrasonics, Ferroelectr. Freq. Control71, 673–686. 10.1109/tuffc.2024.3395490

  • CrossRef
  • Google Scholar

• 252

  XieN.XiaoC.ShuQ.ChengB.WangZ.XueR.et al (2023). Cell response to mechanical microenvironment cues via rho signaling: from mechanobiology to mechanomedicine. Acta Biomater.159, 1–20. 10.1016/j.actbio.2023.01.039

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 253

  XuZ.FanZ.HallT. L.WinterrothF.FowlkesJ. B.CainC. A. (2009). Size measurement of tissue debris particles generated from pulsed ultrasound cavitational therapy–histotripsy. Ultrasound Med. Biol.35 (2), 245–255. 10.1016/j.ultrasmedbio.2008.09.002

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 254

  YangF.GuN.ChenD.XiX.ZhangD.LiY.et al (2008). Experimental study on cell self-sealing during sonoporation. J. Control. Release131 (3), 205–210. 10.1016/j.jconrel.2008.07.038

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 255

  YangY.LiQ.GuoX.TuJ.ZhangD. (2020). Mechanisms underlying sonoporation: interaction between microbubbles and cells. Ultrason. Sonochem.67, 105096. 10.1016/j.ultsonch.2020.105096

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 256

  YangY.ChengY.ChengL. (2024). The emergence of cancer sono-immunotherapy. Trends Immunol.45 (7), 549–563. 10.1016/j.it.2024.06.001

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 257

  YoonS.WangY.ShungK. K. (2016). Optimization of input parameters of acoustic-transfection for the intracellular delivery of macromolecules using FRET-based biosensors. Reporters, markers, dyes, nanoparticles (San Francisco, CA, United States: SPIE: Molecular Probes for Biomedical Applications VIII).

  • Google Scholar

• 258

  YoonS.WangP.PengQ.WangY.ShungK. K. (2017). Acoustic-transfection for genomic manipulation of single-cells using high frequency ultrasound. Sci. Rep.7 (1), 5275. 10.1038/s41598-017-05722-1

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 259

  YoungJ. L.DeanD. A. (2015). Electroporation-mediated gene delivery. Adv. Genet.89, 49–88. 10.1016/bs.adgen.2014.10.003

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 260

  YuH.XuL. (2014). Cell experimental studies on sonoporation: state of the art and remaining problems. J. Control Release174, 151–160. 10.1016/j.jconrel.2013.11.010

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 261

  YuT.WangZ.MasonT. J. (2004). A review of research into the uses of low level ultrasound in cancer therapy. Ultrason. Sonochem.11 (2), 95–103. 10.1016/s1350-4177(03)00157-3

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 262

  YuT.LiS.ZhaoJ.MasonT. J. (2006). Ultrasound: a chemotherapy sensitizer. Technol. cancer Res. Treat.5 (1), 51–60. 10.1177/153303460600500107

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 263

  YuH.LinZ.XuL.LiuD.ShenY. (2015). Theoretical study of microbubble dynamics in sonoporation. Ultrasonics61, 136–144. 10.1016/j.ultras.2015.04.008

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 264

  ZarnitsynV. G.MeachamJ. M.VaradyM. J.HaoC.DegertekinF. L.FedorovA. G. (2008a). Electrosonic ejector microarray for drug and gene delivery. Biomed. Microdev.10 (2), 299–308. 10.1007/s10544-007-9137-4

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 265

  ZarnitsynV.RostadC. A.PrausnitzM. R. (2008b). Modeling transmembrane transport through cell membrane wounds created by acoustic cavitation. Biophys. J.95 (9), 4124–4138. 10.1529/biophysj.108.131664

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 266

  ZeghimiA.EscoffreJ. M.BouakazA. (2015). Role of endocytosis in sonoporation-mediated membrane permeabilization and uptake of small molecules: a electron microscopy study. Phys. Biol.12 (6), 066007. 10.1088/1478-3975/12/6/066007

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 267

  ZhangB.PintonG. F.DengY.NightingaleK. R. (2021). Quantifying the effect of abdominal body Wall on in situ peak rarefaction pressure during diagnostic ultrasound imaging. Ultrasound Med. Biol.47 (6), 1548–1558. 10.1016/j.ultrasmedbio.2021.01.028

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 268

  ZhaoY. Z.LuoY. K.LuC. T.XuJ. F.TangJ.ZhangM.et al (2008). Phospholipids-based microbubbles sonoporation pore size and reseal of cell membrane cultured in vitro. J. Drug Target16 (1), 18–25. 10.1080/10611860701637792

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 269

  ZhongW.SitW. H.WanJ. M.YuA. C. (2011). Sonoporation induces apoptosis and cell cycle arrest in human promyelocytic leukemia cells. Ultrasound Med. Biol.37 (12), 2149–2159. 10.1016/j.ultrasmedbio.2011.09.012

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 270

  ZhongJ.SuM.JiangY.HuangL.ChenY.HuangZ.et al (2023). VEGFR2 targeted microbubble-based ultrasound molecular imaging improving the diagnostic sensitivity of microinvasive cervical cancer. J. Nanobiotechnol.21 (1), 220. 10.1186/s12951-023-01984-2

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 271

  ZhouY.-F. (2011). High intensity focused ultrasound in clinical tumor ablation. World J. Clin. Oncol.2 (1), 8. 10.5306/wjco.v2.i1.8

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 272

  ZhouY.KumonR. E.CuiJ.DengC. X. (2009). The size of sonoporation pores on the cell membrane. Ultrasound Med. Biol.35 (10), 1756–1760. 10.1016/j.ultrasmedbio.2009.05.012

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 273

  ZhouY.YangK.CuiJ.YeJ. Y.DengC. X. (2012). Controlled permeation of cell membrane by single bubble acoustic cavitation. J. Control. Release157 (1), 103–111. 10.1016/j.jconrel.2011.09.068

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 274

  ZhuQ.LiuY.YueD. K. (2003). Three-dimensional instability of standing waves. J. Fluid Mech.496, 213–242. 10.1017/s0022112003006347

  • CrossRef
  • Google Scholar

• 275

  ZiniC.HippE.ThomasS.NapoliA.CatalanoC.OtoA. (2012). Ultrasound- and MR-guided focused ultrasound surgery for prostate cancer. World J. Radiol.4 (6), 247–252. 10.4329/wjr.v4.i6.247

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 276

  ZylberbergC.MatosevicS. (2016). Pharmaceutical liposomal drug delivery: a review of new delivery systems and a look at the regulatory landscape. Drug Deliv.23 (9), 3319–3329. 10.1080/10717544.2016.1177136

  • Pubmed Abstract
  • CrossRef
  • Google Scholar