Changes in premorbid brain volume predict Alzheimer's disease pathology

Beta-amyloid burden is not associated with rates of brain atrophy

OBJECTIVE

To test the hypothesis that beta-amyloid (Abeta) burden is associated with rates of brain atrophy.

METHODS

Forty-five subjects who had been prospectively studied, died, and had an autopsy diagnosis of low, intermediate, or high probability of Alzheimer's disease who had two volumetric head magnetic resonance imaging scans were identified. Compact and total (compact + diffuse) Abeta burden was measured using a computerized image analyzer with software program to detect the proportion of gray matter occupied by Abeta. Visual ratings of Abeta burden were also performed. The boundary shift integral was used to calculate change over time in whole-brain and ventricular volume. All boundary shift integral results were annualized by adjusting for scan interval. Demographics, cognitive measures, clinical diagnoses, apolipoprotein E genotype, neurofibrillary tangle (NFT) pathology, and vascular lesion burden were determined.

RESULTS

There was no correlation between compact or total Abeta burden, or visual Abeta ratings, and rates of brain loss or ventricular expansion in all subjects. However, significant correlations were observed between rates of brain loss and age, Braak NFT stage, and change over time in cognitive measures. These features also correlated with rates of ventricular expansion. The rates of brain loss and ventricular expansion were greater in demented compared with nondemented subjects.

INTERPRETATION

These findings suggest that rate of brain volume loss is not determined by the amount of insoluble Abeta in the gray matter.

A meta-analysis of hippocampal atrophy rates in Alzheimer's disease

Hippocampal atrophy rates are useful in both diagnosing and tracking Alzheimer's disease (AD). However, cohorts and methods used to determine such rates are heterogeneous, leading to differences in reported annualised rates. We performed a meta-analysis of hippocampal atrophy rates in AD patients and matched controls from studies reported in the peer-reviewed literature. Studies reporting longitudinal volume change in hippocampi in AD subjects together with controls were systematically identified and appraised. All authors were contacted either to confirm the results or to provide missing data. Meta-analysis and meta-regression were then performed on this data. Nine studies were included from seven centres, with data from a total of 595 AD and 212 matched controls. Mean (95% CIs) annualised hippocampal atrophy rates were found to be 4.66% (95% CI 3.92, 5.40) for AD subjects and 1.41% (0.52, 2.30) for controls. The difference between AD and control subject in this rate was 3.33% (1.73, 4.94).

Neuropathological basis of magnetic resonance images in aging and dementia

OBJECTIVE

Magnetic resonance (MR) imaging is used widely for assessment of patients with cognitive impairment, but the pathological correlates are unclear, especially when multiple pathologies are present.

METHODS

This report includes 93 subjects from a longitudinally followed cohort recruited for the study of Alzheimer's disease (AD) and subcortical cerebrovascular disease (CVD). MR images were analyzed to quantify cortical gray matter volume, hippocampal volume, white matter hyperintensities, and lacunes. Neuropathological examination quantified CVD parenchymal pathology, AD pathology (defined as Consortium to Establish a Registry for Alzheimer's Disease scores and Braak and Braak stage), and hippocampal sclerosis. Subjects were pathologically classified as 12 healthy control subjects, 46 AD, 14 CVD, 9 mixed AD/CVD, and 12 cognitively impaired patients without significant AD/CVD pathology. Multivariate models tested associations between magnetic resonance and pathological findings across the entire sample.

RESULTS

Pathological correlates of cortical gray matter volume were AD, subcortical vascular pathology, and arteriosclerosis. Hippocampal volume was related to AD pathology and hippocampal sclerosis, and the effects of hippocampal sclerosis were greater for subjects with low levels of AD pathology. White matter hyperintensities were related to age and to white matter pathology. Number of MRI lacunes was related to subcortical vascular pathology.

INTERPRETATION

In this clinical setting, the presence of lacunes and white matter changes provide a good signal for vascular disease. The neuropathological basis of MR defined cerebral cortical and hippocampal atrophy in aging and dementia is complex, with several pathological processes converging on similar brain structures that mediate cognitive decline.

Neuropsychological correlates of whole brain atrophy in Alzheimer's disease

Alzheimer's disease (AD) is associated with excess whole brain volume loss, and progressive cognitive impairment. We aimed to study the extent to which these two potential biomarkers of AD progression are correlated. Forty-six patients with sporadic AD were tested with a neuropsychometric battery including test of verbal and visual memory, vocabulary, arithmetic, naming, visuoperceptual skills and reasoning at two time-points, approximately 1 year apart; annualised rates of change for each test were calculated. Each subject also attended for up to twelve T1-weighted volumetric MRI scans at fixed intervals over a 2-year period. For each individual all possible scan-pairs were positionally registered, and whole brain atrophy rates were calculated using the brain boundary shift integral. Linear mixed models were used to investigate associations between atrophy rate and coincident change in each neuropsychometric score. Each model estimated the effect of a unit change in score, plus the additional effect of a fall to floor, after adjusting for baseline levels. 467 MRI scans were performed, permitting 2199 individual measures of change to be made. The model-derived mean atrophy rate was 2.23% per year with a between-subject SD of 0.99% per year. Increasing atrophy rate was significantly associated with rate of change in a number of non-memory based neuropsychological scores, with the strongest association seen with longitudinal change in matrix reasoning (p=0.004). These results provide further evidence that cerebral atrophy is a clinically relevant marker of AD progression. This methodology whereby data from patients falling to floor on a given test may be included and accounted for, rather than discarded, may find broader application in clinical studies incorporating neuropsychometric outcomes.

Taking the next steps in the diagnosis of Alzheimer's disease: the use of biomarkers

Alzheimer's disease (AD) is a progressive disorder in which neurodegeneration begins decades before clinical symptoms appear. Detecting AD during this preclinical phase presents both the enormous challenge of identifying at-risk patients prior to symptom onset and the potential reward of treating patients early enough to prevent or slow disease progression. Given that a 5-year delay in the onset of the clinical manifestations of AD could result in almost a 50% reduction in disease prevalence, early detection of AD is a major focus of clinical research. Several objective, measurable indicators of preclinical and clinical characteristics of AD are currently available or in development. These biomarkers are promising because they promote identification of individuals at risk for AD onset and disease progression; diagnostic accuracy and treatment during the early stages of AD; and the development of disease-modifying therapies that may potentially slow or prevent disease progression during the preclinical phase of AD.

11C PiB and structural MRI provide complementary information in imaging of Alzheimer's disease and amnestic mild cognitive impairment

To date, most diagnostic imaging comparisons between amyloid labelling ligands and other imaging modalities have been between the use of amyloid labelling ligand (11)C Pittsburgh Compound B (PiB) and FDG-PET. Our objectives were to compare cognitive performance and diagnostic group-wise discrimination between cognitively normal, amnestic mild cognitive impairment (MCI) and Alzheimer's disease subjects with MRI-based measures of hippocampal volume and PiB retention, and secondly to evaluate the topographic distribution of PiB retention and grey matter loss using 3D voxel-wise methods. Twenty cognitively normal, 17 amnestic MCI and 8 probable Alzheimer's disease subjects were imaged with both MRI and PiB. PiB retention was quantified as the ratio of uptake in cortical to cerebellar regions of interest (ROIs) 40-60 min post-injection. A global cortical PiB retention summary measure was derived from six cortical ROIs. Statistical parametric mapping (SPM) and voxel-based morphometry (VBM) were used to evaluate PiB retention and grey matter loss on a 3D voxel-wise basis. Alzheimer's disease subjects had high global cortical PiB retention and low hippocampal volume; most cognitively normal subjects had low PiB retention and high hippocampal volume; and on average amnestic MCI subjects were intermediate on both PiB and hippocampal volume. A target-to-cerebellar ratio of 1.5 was used to designate subjects with high or low PiB cortical retention. All Alzheimer's disease subjects fell above this ratio, as did 6 out of 20 cognitively normal subjects and 9 out of 17 MCI subjects, indicating bi-modal PiB retention in the latter two groups. Interestingly, we found no consistent differences in learning and memory performance between high versus low PiB cognitively normal or amnestic MCI subjects. The SPM/VBM voxel-wise comparisons of Alzheimer's disease versus cognitively normal subjects provided complementary information in that clear and meaningful similarities and differences in topographical distribution of amyloid deposition and grey matter loss were shown. The frontal lobes had high PiB retention with little grey matter loss, anteromedial temporal areas had low PiB retention with significant grey matter loss, whereas lateral temporoparietal association cortex displayed both significant PiB retention and grey matter loss. A voxel-wise SPM conjunction analysis revealed that subjects with high PiB retention shared a common PiB retention topographical pattern regardless of clinical category, and this matched that of amyloid plaque distribution from autopsy studies of Alzheimer's disease. Both global cortical PiB retention and hippocampal volumes demonstrated significant correlation in the expected direction with cognitive testing performance; however, correlations were stronger with MRI than PiB. Pair-wise inter-group diagnostic separation was significant for all group-wise pairs for both PiB and hippocampal volume with the exception of the comparison of cognitively normal versus amnestic MCI, which was not significant for PiB. PiB and MRI provided complementary information such that clinical diagnostic classification using both methods was superior to using either in isolation.

Transcranial magnetic stimulation and brain atrophy: a computer-based human brain model study

This paper is aimed at exploring the effect of cortical brain atrophy on the currents induced by transcranial magnetic stimulation (TMS). We compared the currents induced by various TMS conditions on several different MRI derived finite element head models of brain atrophy, incorporating both decreasing cortical volume and widened sulci. The current densities induced in the cortex were dependent upon the degree and type of cortical atrophy and were altered in magnitude, location, and orientation when compared to healthy head models. Predictive models of the degree of current density attenuation as a function of the scalp-to-cortex distance were analyzed, concluding that those which ignore the electromagnetic field-tissue interactions lead to inaccurate conclusions. Ultimately, the precise site and population of neural elements stimulated by TMS in an atrophic brain cannot be predicted based on healthy head models which ignore the effects of the altered cortex on the stimulating currents. Clinical applications of TMS should be carefully considered in light of these findings.

Structural magnetic resonance imaging-derived biomarkers for Alzheimer’s disease

The development and validation of biomarkers for prediction, diagnosis and tracking of progression of Alzheimer’s disease are both increasingly important. As potential pharmaceutical agents are developed for Alzheimer’s disease, their efficacy needs to be assessed. When medications become available, those subjects who may derive most benefit from such treatments need to be selected and their response to treatment monitored. As such, there has been much research into biomarkers in recent years, with many showing promise in all areas of biomarker utility. This review focuses on the potential of structural imaging as a biomarker in Alzheimer’s disease.

Cerebral ventricular changes associated with transitions between normal cognitive function, mild cognitive impairment, and dementia

Expansion of the cerebral ventricles may occur at an accelerated rate in subjects with dementia, but the time course of expansion during transitions between normal cognitive function, mild cognitive impairment (MCI), and dementia is not well understood. Furthermore, the effects of cardiovascular risk factors on rate of ventricular expansion are unclear. We used a fully automated segmentation technique to measure change rate in lateral ventricle-to-brain ratio (VBR) on 145 longitudinal pairs of magnetic resonance images of subjects in the Cardiovascular Health Study Cognition Study from the Pittsburgh Center. A multivariate model analyzed VBR change rate, accounting for dementia statuses at both imaging times (normal, MCI, or dementia), age, sex, education, race, magnetic resonance-defined infarcts, Center for Epidemiology Studies Depression Scale, baseline ventricular volume, and cardiovascular risk factors. VBR change was faster in subjects who were demented or transitioned from MCI to dementia, compared with subjects normal at both images and subjects who transitioned from normal to MCI or dementia. Patients with diabetes had faster VBR change. Ventricular expansion may accelerate late in the progression from normal cognitive function to dementia, and may be modulated by diabetes.

Magnetic resonance approaches to brain aging and Alzheimer disease-associated neuropathology

The noninvasive, nonradioactive, quantitative nature of magnetic resonance techniques has propelled them to the forefront of neuroscience and neuropsychiatric research. In particular, recent advances have confirmed their enormous potential in patients with Alzheimer disease (AD). Structural and functional magnetic resonance (MR) imaging have demonstrated significant correlation with clinical outcomes and underlying pathology and are used increasingly in the AD clinic. This review will highlight the role of high-resolution structural MR imaging and functional magnetic resonance imaging in the identification of atrophic and hemodynamic changes in AD and their potential as diagnostic biomarkers and surrogates of therapeutic response. Advanced MR techniques based on diffusion, perfusion, and neurochemical abnormalities in the aging brain will be presented briefly. These newer techniques continue to expand our understanding of neuropathology in the aging brain and are likely to play an important clinical role in the future.

CSF and MRI markers independently contribute to the diagnosis of Alzheimer's disease

BACKGROUND

Decreased amyloid beta (1-42) (Abeta42) and increased (phosphorylated) tau in cerebrospinal fluid (CSF) are considered to be a reflection of plaques, tangles, and neuronal degeneration in Alzheimer's disease (AD). Atrophy of the medial temporal lobe (MTA) on magnetic resonance imaging (MRI) reflects neuronal loss in this area.

OBJECTIVE

To compare diagnostic accuracy of CSF biomarkers and MTA in AD versus controls.

METHODS

Abeta42, tau and tau phosphorylated at threonine 181 (Ptau-181) were measured in CSF from 61 AD patients and 32 controls by sandwich enzyme-linked immunosorbent assay. A CSF biomarker profile for AD was constructed. MTA was rated visually on MRI.

RESULTS

When AD patients and controls were evaluated separately, no correlations were present between the CSF markers and MTA score. Both MTA and CSF biomarker profile were independently associated with the diagnosis AD (MTA: OR (95% CI)=28 (3-239); CSF biomarker profile: OR (95% CI)=57 (13-262)). Among individuals younger than 65 years old and without MTA 60% suffered AD, and the finding of an abnormal CSF biomarker profile was limited to AD patients only.

CONCLUSIONS

MTA and CSF biomarkers seem to be of incremental value for the diagnosis AD. CSF analysis is most sensitive in the absence of MTA, and especially among early-onset AD patients.

Quantitative MR imaging in Alzheimer disease

Alzheimer disease (AD) is the most common type of dementia. It currently affects approximately 4 million people in the United States. AD is a progressive neurodegenerative disorder characterized by the gradual deposition of neuritic plaques and neurofibrillary tangles in the brain, which is thought to occur decades before the onset of clinical symptoms. Identification of people at risk before the clinical appearance of dementia has become a priority due to the potential benefits of therapeutic intervention. Although atrophy of medial temporal lobe structures has been shown to correlate with progression of AD, a growing number of recent reports have indicated that such atrophy may not be specific to AD. To improve diagnostic specificity, new quantitative magnetic resonance (MR) imaging methods are being developed that exploit known pathogenic mechanisms exclusive to AD. This article reviews the MR techniques that are currently available for the diagnostic assessment of AD.

Evaluation of treatment effects in Alzheimer's and other neurodegenerative diseases by MRI and MRS

Neurodegeneration refers to a large clinically and pathologically heterogeneous disease entity associated with slowly progressive neuronal loss in different anatomical and functional systems of the brain. Neurodegenerative diseases often affect cognition, e.g. Alzheimer's disease (AD), dementia with Lewy bodies and vascular dementia, or different aspects of the motor system, e.g., amyotrophic lateral sclerosis, Parkinson's disease and ataxic disorders. Owing to increasing knowledge about the mechanisms leading to neurodegeneration, the development of treatments able to modify the neurodegenerative process becomes possible for the first time. Currently, clinical outcome measures are used to assess the efficacy of such treatments. However, most clinical outcome measures have a low test-retest reliability and thus considerable measurement variance. Therefore, large patient populations and long observation times are needed to detect treatment effects. Furthermore, clinical outcome measures cannot distinguish between symptomatic and disease-modifying treatment effects. Therefore, alternative biomarkers including neuroimaging may take on a more important role in this process. Because MR scanners are widely available and allow for non-invasive detection and quantification of changes in brain structure and metabolism, there is increasing interest in the use of MRI/MRS to monitor objectively treatment effects in clinical trials of neurodegenerative diseases. Particularly volumetric MRI has been used to measure atrophy rates in treatment trials of AD because the relationship between atrophic changes and neuron loss is well established and correlates well with clinical measures. More research is needed to determine the value of other MR modalities, i.e. diffusion, perfusion and functional MRI and MR spectroscopy, for clinical trials with neuroprotective drugs.

Amyloid load and cerebral atrophy in Alzheimer's disease: an 11C-PIB positron emission tomography study

To determine the relationship between cerebral amyloid plaque load and rates of cerebral atrophy in Alzheimer's disease. (11)C-PIB((11)C-6-OH benzothiazole)PET (positron emission tomography) findings were correlated with volumetric magnetic resonance imaging (MRI) measurements in nine subjects with mild to moderate AD. Analysis revealed a positive correlation between rates of whole brain atrophy and whole brain (p = 0.019) and regional (11)C-PIB uptake. This provides support for the central role of amyloid deposition in the pathogenesis of AD.

Acceleration of cerebral ventricular expansion in the Cardiovascular Health Study

Interactions between prevalent late-life medical conditions and expansion of the cerebral ventricles are not well understood. Thirty elderly subjects received three magnetic resonance (MR) scans each, in 1997-1999, 2002-2004, and 2003-2005. A linear expansion model of MR-measured lateral ventricle volume was estimated for each subject by fitting a line to a plot of their 1997-1999 and 2002-2004 volumes as a function of time. Acceleration in ventricular expansion was defined as the deviation between the 2003-2005 volumes measured from MR and the 2003-2005 volumes predicted by the linear expansion model. Ventricular acceleration was analyzed in a multivariate model with age, race, history of heart disease, diabetes, and hypertension as fixed effects. Ventricular acceleration was significantly higher in non-whites, diabetics, and those without heart disease (p<0.05). Ventricular acceleration was higher in subjects with a history of hypertension, but the difference was not statistically significant (p=0.08). Acceleration of ventricular expansion in the elderly may be related to demographic and cardiovascular factors.

The role of biomarkers in clinical trials for Alzheimer disease

Biomarkers are likely to be important in the study of Alzheimer disease (AD) for a variety of reasons. A clinical diagnosis of Alzheimer disease is inaccurate even among experienced investigators in about 10% to 15% of cases, and biomarkers might improve the accuracy of diagnosis. Importantly for the development of putative disease-modifying drugs for Alzheimer disease, biomarkers might also serve as indirect measures of disease severity. When used in this way, sample sizes of clinical trials might be reduced, and a change in biomarker could be considered supporting evidence of disease modification. This review summarizes a meeting of the Alzheimer's Association's Research Roundtable, during which existing and emerging biomarkers for AD were evaluated. Imaging biomarkers including volumetric magnetic resonance imaging and positron emission tomography assessing either glucose utilization or ligands binding to amyloid plaque are discussed. Additionally, biochemical biomarkers in blood or cerebrospinal fluid are assessed. Currently appropriate uses of biomarkers in the study of Alzheimer disease, and areas where additional work is needed, are discussed.

The role of quantitative structural imaging in the early diagnosis of Alzheimer's disease

The goal of this article is to review the role of structural neuroimaging in the diagnosis of Alzheimer's disease (AD). We present relevant neuroanatomy, highlight progress in the domain of AD imaging, and review the clinical characteristics of the prodromal phase of AD. We describe the history of the diagnostic issue by examining at cross-section and longitudinally the differences between patients who have AD and normal controls. We also present how subsequent works applied these characteristic traits to the early detection of the prodromal disease and to prediction of future decline. The article delineates the differences between subjects who have mild cognitive impairment and AD, which illustrate the spreading of the pathology with disease progression. The last section describes problems encountered in the differential diagnosis.

What Constitutes Clinical Evidence for Neuroprotection in Alzheimer Disease

The progression of Alzheimer disease (AD) corresponds to a prolonged course of neuronal loss in the cerebral cortex. Strategies aimed at reducing the rates of neuronal loss are therefore particularly important. The clinical measures to evaluate the disease-modifying effect of an intervention are readily confounded by any symptomatic benefit of the intervention. Thus, when testing putative neuroprotective agents that are known to have symptomatic effects, it can be difficult to separate the 2 effects. The hypothesis that cholinesterase inhibitors (ChEIs) only treat symptoms caused by cholinergic imbalances in AD is overly simplistic. Evidence has now accumulated that ChEIs have a neuroprotective, disease-modifying property. In this paper, to answer the question of what constitutes clinical evidence for neuroprotection in AD, we have reviewed clinical studies with specific designs, including "delaying end point," "withdrawal," and "randomized start" designs. We have also reviewed data on surrogate biomarkers of disease progression that may indicate a disease-modifying action. In addition, we have reviewed evidence indicating that ChEIs may protect cells in the brain of patients with AD. Among the clinical data suggesting a possible neuroprotective effect of ChEIs, the most rigorous published evidence comes from magnetic resonance imaging (MRI) hippocampal volumetric studies with donepezil.

Ventricular volume and dementia progression in the Cardiovascular Health Study

Elevated cerebral ventricular volume may be associated with dementia risk and progression. A fully-automated technique that agreed highly with radiological readings was used to estimate lateral ventricle volume on MR scans done at baseline in 1997-99 of 377 subjects in the Cardiovascular Health Study (CHS) from the Pittsburgh Center. 327 subjects were normal or diagnosed with mild cognitive impairment (MCI) at baseline and were evaluated 4 years later. Baseline ventricular volume was analyzed in multivariate models with age, gender, education level, presence and incidence of cerebral infarcts, and dementia category (normal, MCI, or dementia) at baseline and follow-up as fixed effects. Ventricular volume at baseline was significantly higher among subjects normal at baseline and demented 4 years later. Age, gender, education level, and dementia progression were significant factors affecting ventricular volume. Ventricular volume was higher in dementia compared to MCI, higher in MCI compared to controls, and higher in Possible-Alzheimer's-disease (AD) dementia compared to Probable-AD. Larger ventricles in healthy subjects may indicate susceptibility to, or progression of, dementia-related pathology.

Regional specificity of cerebrospinal fluid abnormalities in first episode schizophrenia

The timing and regional specificity of cerebrospinal fluid (CSF) enlargements have not been well described in schizophrenia. High-resolution magnetic resonance images and computational image analysis methods were used to localize cross-sectional changes in lateral ventricle and sulcal and subarachnoid CSF in first episode schizophrenia patients (51 males/21 females) and healthy subjects (37 males/41 females). Volumes were obtained for each lateral ventricle horn and regional differences identified by comparing the distances from the ventricular surfaces to the central core at anatomically matched locations. Extra-cortical CSF differences were compared by measuring the proportion of CSF voxels sampled from spatially homologous cortical surface points. Significant extra-cortical CSF enlargements were observed in first episode patients, where regional differences surrounded the temporal, anterior frontal and parietal cortices. Volume and ventricular surface analyses failed to show significant effects of diagnosis. However, interactions indicated dorsal superior horn expansions in female patients compared with same-sex controls. Since ventricular enlargements are widely reported in chronic patients, our observations at first episode suggest ventricular enlargement may progress after disease onset with early changes occurring around the dorsal superior horn. In contrast, sulcal and subarachnoid CSF increases may be manifest near or before the first episode but after brain development is complete, reflecting pronounced reductions in proximal brain tissue.

Cerebral MRI findings and cognitive functioning: the Atherosclerosis Risk in Communities study

OBJECTIVE

To examine the association between prevalent cerebral abnormalities identified on MRI and cognitive functioning in a predominantly middle-aged, population-based study cohort.

METHODS

Cerebral MRI was performed on 1,538 individuals (aged 55 to 72) from the Atherosclerosis Risk in Communities (ARIC) cohort, with no history of stroke or TIA, at study sites in Forsyth County, NC, and Jackson, MS. White matter hyperintensities (WMHs), ventricular size, and sulcal size were graded by trained neuroradiologists on a semiquantitative, 10-point scale. Cognitive functioning was assessed using the Delayed Word Recall Test (DWRT), Digit Symbol Substitution Test (DSST), and Word Fluency Test (WFT).

RESULTS

High ventricular grade was independently associated with significantly lower scores on the DWRT and DSST and greater risk (odds ratio [OR] 2.32, 95% confidence interval [CI] 1.51 to 3.56) of impaired scores (i.e., < or =10th percentile) on the DWRT. High sulcal grade was associated with a modest decrement in scores on the DWRT. The presence of coexisting high grade WMHs and silent infarcts was independently associated with lower scores on all cognitive tests and greater risk of impaired functioning on the DSST (OR 2.91, 95% CI: 1.23 to 6.89) and WFT (OR 2.28, 95% CI 1.03 to 5.08). The presence of two or more high-grade abnormalities was associated with increased risk of impaired functioning on all cognitive tests (DWRT: OR 2.23, 95% CI 1.40 to 3.55; DSST: OR 2.06, 95% CI 1.13 to 3.76; WFT: OR 2.07, 95% CI 1.23 to 3.49) independent of multiple covariates and silent infarcts.

CONCLUSION

Common changes in brain morphology are associated with diminished cognitive functioning in middle-aged and young-elderly individuals.

Recent clinical-pathologic research on the causes of dementia in late life: update from the Honolulu-Asia Aging Study

In this study, we compare neuropathological findings at autopsy with clinical dementia diagnoses, such as Alzheimer's disease and vascular dementia. Participants consisted of 363 aged Japanese-American men from the Honolulu-Asia Aging Study. Results indicated that the correspondence between clinical and neuropathologic diagnosis was not great, with 56% of patients diagnosed with probable or possible Alzheimer's disease during life but with only 19% having neuritic plaques and/or neurofibrillary tangles as the sole or dominant dementia-related lesions in the brain at autopsy. Although 16% of cases were attributed to mixed causes during life, almost 40% were found to have significant mixtures of dementia-related lesions at autopsy. Finally, both Alzheimer's disease and non-Alzheimer's disease neuropathologic lesions contributed independently to the explanation of variance on a test of overall cognitive performance. The results suggest that clinical diagnosis of dementia made during life may fail to reflect the pathogenic complexity of this condition in very elderly persons.

Neuroimaging biomarkers for clinical trials of disease-modifying therapies in Alzheimer's disease

The pathophysiologic process leading to neurodegeneration in Alzheimer's disease (AD) is thought to begin long before clinical symptoms develop. Existing therapeutics for AD improve symptoms, but increasing efforts are being directed toward the development of therapies to impede the pathologic progression of the disease. Although these medications must ultimately demonstrate efficacy in slowing clinical decline, there is a critical need for biomarkers that will indicate whether a candidate disease-modifying therapeutic agent is actually altering the underlying degenerative process. A number of in vivo neuroimaging techniques, which can reliably and noninvasively assess aspects of neuroanatomy, chemistry, physiology, and pathology, hold promise as biomarkers. These neuroimaging measures appear to relate closely to neuropathological and clinical data, such as rate of cognitive decline and risk of future decline. As this work has matured, it has become clear that neuroimaging measures may serve a variety of potential roles in clinical trials of candidate neurotherapeutic agents for AD, depending in part on the question of interest and phase of drug development. In this article, we review data related to the range of neuroimaging biomarkers of Alzheimer's disease and consider potential applications of these techniques to clinical trials, particularly with respect to the monitoring of disease progression in trials of disease-modifying therapies.

A longitudinal study of brain morphometrics using serial magnetic resonance imaging analysis in a canine model of aging

Longitudinal changes in cortical atrophy, ventricular enlargement, and lesion development in serial MRI scans collected from 47 healthy dogs from 1999 (8-11 years old) to 2002 (11-14 years old) were studied. The first method involved manual region of interest volumetric analysis to examine changes in cerebral and ventricular volume during the three years. No change in cerebral volume was detected but ventricular volume increased significantly each year in 2000, 2001, and 2002. Increased ventricular volume parallels early studies of age-dependent ventricular enlargement in the brain of aging beagle dogs. The second method involved a visual analysis of co-registered serial MRIs for each subject. Consistent with the volumetric results, there was no visible change in cortical thickness indicating no cerebral atrophy, but a significant increase in ventricular size was noted. Visual examination also revealed a significant increase in number of dogs who developed aging lesions over the last 2 years in 2001 and 2002. Additionally, a disproportionate number of lesions were recorded in the frontal cortex and caudate nucleus compared to other brain regions. These lesion findings are consistent with other studies in the aging dog that suggest that the frontal lobes may be particularly vulnerable to age-related changes.

Empirical evidence of neuroprotection by dual cholinesterase inhibition in Alzheimer??s disease

Brain grey matter density changes were quantified using voxel based morphometry in 26 patients with minimal to mild Alzheimer's disease (AD) treated with three cholinesterase inhibitors over 20 weeks. Patients whose drug treatment also inhibited butyrylcholinesterase did not show the widespread cortical atrophic changes in parietotemporal regions invariably reported in untreated AD patients, and which were detectable in the subgroups treated with selective acetylcholinesterase inhibition. This finding is the first empirical evidence that dual cholinesterase inhibition may have neuroprotective potential in AD.

Retrieval of autobiographical memory in Alzheimer's disease: Relation to volumes of medial temporal lobe and other structures

The representation of autobiographical memory is distributed over a network of brain structures, with the medial temporal lobe (MTL) at its epicenter. Some believe that, over time, all memories become independent of their MTL component ("consolidation theories"). Others have suggested that this is true only of semantic memory, while episodic aspects of autobiographical memories are dependent on the MTL for as long as they exist, such as multiple trace theory (MTT). In the present study, the volumes of 28 brain regions, including the MTL, and their relation to autobiographical memory were investigated in a group of patients with Alzheimer's disease with varying degrees of retrograde memory loss as assessed by the Autobiographical Memory Interview (AMI). We used the multivariate analysis method of partial least squares (PLS) to assess patterns of atrophy that can lead to retrograde amnesia. We found that different aspects of autobiographical memory were associated with different patterns of tissue loss. Personal semantics were related to a pattern of bilateral anterior and posterior lateral temporal cortex degeneration, more pronounced on the left, as well as right frontal degeneration. Autobiographical event memory ("episodic") was associated with combined atrophy in bilateral MTL and anterior lateral temporal neocortex, more pronounced on the right. This pattern was invariant for memories from childhood, early adulthood, and recent memories, in line with the predictions of MTT, suggesting that MTL tissue is crucial for retrieval of episodic memories regardless of their age.

Quantitative magnetic resonance techniques as surrogate markers of Alzheimer's disease

Recent advances in understanding the molecular biology of Alzheimer's disease (AD) offer the promise of useful therapeutic intervention in the foreseeable future. Hence, improved methods for early diagnosis and noninvasive surrogates of disease severity in AD have become more imperative. Various quantitative magnetic resonance (MR) techniques that measure the anatomic, biochemical, microstructural, functional, and blood-flow changes are being evaluated as possible surrogate measures of disease progression. Cross-sectional and longitudinal studies indicate that MR-based volume measurements are potential surrogates of disease progression in AD, starting from the preclinical stages. The validity of MR-based volumetry as a surrogate marker for therapeutic efficacy in AD remains to be tested in a positive disease-modifying drug trial. Recent development of amyloid imaging tracers for positron emission tomography has been a major breakthrough in the field of imaging markers for AD. Efforts to image plaques are also underway in MR imaging. As with indirect MR measures, these approaches of directly imaging the pathological substrate will need to undergo a validation process with longitudinal studies to prove their usefulness as surrogate markers in AD.

Imaging cerebral atrophy: normal ageing to Alzheimer's disease

CONTEXT

With ageing populations, the prevalence of dementia, especially Alzheimer's disease, is set to soar. Alzheimer's disease is associated with progressive cerebral atrophy, which can be seen on MRI with high resolution. Longitudinal MRI could track disease progression and detect neurodegenerative diseases earlier to allow prompt and specific treatment. Such use of MRI requires accurate understanding of how brain changes in normal ageing differ from those in dementia.

STARTING POINT

Recently, Henry Rusinek and colleagues, in a 6-year longitudinal MRI study of initially healthy elderly subjects, showed that an increased rate of atrophy in the medial temporal lobe predicted future cognitive decline with a specificity of 91% and sensitivity of 89% (Radiology 2003; 229: 691-96). WHERE NEXT? As understanding of neurodegenerative diseases increases, specific disease-modifying treatments might become available. Serial MRI could help to determine the efficacy of such treatments, which would be expected to slow the rate of atrophy towards that of normal ageing, and might also detect the onset of neurodegeneration. The amount and pattern of excess atrophy might help to predict the underlying pathological process, allowing specific therapies to be started. As the precision of imaging improves, the ability to distinguish healthy ageing from degenerative dementia should improve.