Molecular imaging of neuroinflammation in Alzheimer’s disease

Have (R)-[11C]PK11195 challengers fulfilled the promise? A scoping review of clinical TSPO PET studies

PURPOSE

The prototypical TSPO radiotracer (R)-[11C]PK11195 has been used in humans for more than thirty years to visualize neuroinflammation in several pathologies. Alternative radiotracers have been developed to improve signal-to-noise ratio and started to be tested clinically in 2008. Here we examined the scientific value of these "(R)-[11C]PK11195 challengers" in clinical research to determine if they could supersede (R)-[11C]PK11195.

METHODS

A systematic MEDLINE (PubMed) search was performed (up to end of year 2020) to extract publications reporting TSPO PET in patients with identified pathologies, excluding studies in healthy subjects and methodological studies.

RESULTS

Of the 288 publications selected, 152 used 13 challengers, and 142 used (R)-[11C]PK11195. Over the last 20 years, the number of (R)-[11C]PK11195 studies remained stable (6 ± 3 per year), but was surpassed by the total number of challenger studies for the last 6 years. In total, 3914 patients underwent a TSPO PET scan, and 47% (1851 patients) received (R)-[11C]PK11195. The 2 main challengers were [11C]PBR28 (24%-938 patients) and [18F]FEPPA (11%-429 patients). Only one-in-ten patients (11%-447) underwent 2 TSPO scans, among whom 40 (1%) were scanned with 2 different TSPO radiotracers.

CONCLUSIONS

Generally, challengers confirmed disease-specific initial (R)-[11C]PK11195 findings. However, while their better signal-to-noise ratio seems particularly useful in diseases with moderate and widespread neuroinflammation, most challengers present an allelic-dependent (Ala147Thr polymorphism) TSPO binding and genetic stratification is hindering their clinical implementation. As new challengers, insensitive to TSPO human polymorphism, are about to enter clinical evaluation, we propose this systematic review to be regularly updated (living review).

Cortical microstructural correlates of astrocytosis in autosomal-dominant Alzheimer disease

OBJECTIVE

To study the macrostructural and microstructural MRI correlates of brain astrocytosis, measured with ¹¹C-deuterium-L-deprenyl (¹¹C-DED)-PET, in familial autosomal-dominant Alzheimer disease (ADAD).

METHODS

The total sample (n = 31) comprised ADAD mutation carriers (n = 10 presymptomatic, 39.2 ± 10.6 years old; n = 3 symptomatic, 55.5 ± 2.0 years old) and noncarriers (n = 18, 44.0 ± 13.7 years old) belonging to families with mutations in either the presenilin-1 or amyloid precursor protein genes. All participants underwent structural and diffusion MRI and neuropsychological assessment, and 20 participants (6 presymptomatic and 3 symptomatic mutation carriers and 11 noncarriers) also underwent ¹¹C-DED-PET.

RESULTS

Vertex-wise interaction analyses revealed a differential relationship between carriers and noncarriers in the association between ¹¹C-DED binding and estimated years to onset (EYO) and between cortical mean diffusivity (MD) and EYO. These differences were due to higher ¹¹C-DED binding in presymptomatic carriers, with lower binding in symptomatic carriers compared to noncarriers, and to lower cortical MD in presymptomatic carriers, with higher MD in symptomatic carriers compared to noncarriers. Using a vertex-wise local correlation approach, ¹¹C-DED binding was negatively correlated with cortical MD and positively correlated with cortical thickness.

CONCLUSIONS

Our proof-of-concept study is the first to show that microstructural and macrostructural changes can reflect underlying neuroinflammatory mechanisms in early stages of Alzheimer disease (AD). The findings support a role for neuroinflammation in AD pathogenesis, with potential implications for the correct interpretation of neuroimaging biomarkers as surrogate endpoints in clinical trials.

A new perspective for advanced positron emission tomography-based molecular imaging in neurodegenerative proteinopathies

Recent studies in neurodegenerative conditions have increasingly highlighted that the same neuropathology can trigger different clinical phenotypes or, vice-versa, that similar phenotypes can be triggered by different neuropathologies. This evidence has called for the adoption of a pathology spectrum-based approach to study neurodegenerative proteinopathies. These conditions share brain deposition of abnormal protein aggregates, leading to aberrant biochemical, metabolic, functional, and structural changes. Positron emission tomography (PET) is a well-recognized and unique tool for the in vivo assessment of brain neuropathology, and novel PET techniques are emerging for the study of specific protein species. Today, key applications of PET range from early research and clinical diagnostic tools to their use in clinical trials for both participants screening and outcome evaluation. This position article critically reviews the role of distinct PET molecular tracers for different neurodegenerative proteinopathies, highlighting their strengths, weaknesses, and opportunities, with special emphasis on methodological challenges and future applications.

A Review and Hypothesized Model of the Mechanisms That Underpin the Relationship Between Inflammation and Cognition in the Elderly

Age is associated with increased risk for several disorders including dementias, cardiovascular disease, atherosclerosis, obesity, and diabetes. Age is also associated with cognitive decline particularly in cognitive domains associated with memory and processing speed. With increasing life expectancies in many countries, the number of people experiencing age-associated cognitive impairment is increasing and therefore from both economic and social terms the amelioration or slowing of cognitive aging is an important target for future research. However, the biological causes of age associated cognitive decline are not yet, well understood. In the current review, we outline the role of inflammation in cognitive aging and describe the role of several inflammatory processes, including inflamm-aging, vascular inflammation, and neuroinflammation which have both direct effect on brain function and indirect effects on brain function via changes in cardiovascular function.

In vivo molecular imaging of neuroinflammation in Alzheimer's disease

It has become increasingly evident that neuroinflammation plays a critical role in the pathophysiology of Alzheimer's disease (AD) and other neurodegenerative disorders. Increased glial cell activation is consistently reported in both rodent models of AD and in AD patients. Moreover, recent genome wide association studies have revealed multiple genes associated with inflammation and immunity are significantly associated with an increased risk of AD development (e.g. TREM2). Non‐invasive in vivo detection and tracking of neuroinflammation is necessary to enhance our understanding of the contribution of neuroinflammation to the initiation and progression of AD. Importantly, accurate methods of quantifying neuroinflammation may aid early diagnosis and serve as an output for therapeutic monitoring and disease management. This review details current in vivo imaging biomarkers of neuroinflammation being explored and summarizes both pre‐clinical and clinical results from molecular imaging studies investigating the role of neuroinflammation in AD, with a focus on positron emission tomography and magnetic resonance spectroscopy (MRS).

Molecular imaging of neuroinflammation in Alzheimer's disease and mild cognitive impairment

Neuroinflammatory changes have been demonstrated to be an important feature of Alzheimer's disease (AD); however, the exact role of neuroinflammation and its progression during disease is still not well understood. One of the main drivers of the neuroinflammatory process are microglial cells. Positron Emission Tomography allows for the quantification of microglial activation by labelling the Translocator Protein 18kDa (TSPO), which becomes overexpressed upon activation of microglial cells. Several radioligands have been designed to target TSPO and have been studied in-vivo in AD populations. While most studies have shown important increases in TSPO binding in AD populations compared to healthy volunteers, whether the neuroinflammatory progress occurs early on or later during disease is still unclear. In order to investigate the early changes in neuroinflammation, studies have sought to investigate microglial activation in patients with mild cognitive impairment (MCI), which is defined as a transitional stage between normal aging and dementia. In this prodromal population, conflicting results have been reported with some studies reporting increased binding in MCI, while others demonstrate no differences from controls. Here we review the TSPO PET studies in AD and MCI populations and discuss the important methodological considerations of imaging microglial activation.

Imaging Neuroinflammation: Quantification of Astrocytosis in a Multitracer PET Approach

The recent progress in the development of in vivo biomarkers is rapidly changing how neurodegenerative diseases are conceptualized and diagnosed, and how clinical trials are designed today. Alzheimer's disease (AD)-the most common neurodegenerative disorder-is characterized by a complex neuropathology involving the deposition of extracellular amyloid-β (Aβ) plaques and intracellular neurofibrillary tangles (NFT) of hyperphosphorylated tau proteins, accompanied by the activation of glial cells-astrocytes and microglia-and neuroinflammatory responses, leading to neurodegeneration and cognitive dysfunction. An increasing diversity of positron emission tomography (PET) imaging radiotracers are available to selectively target the different pathophysiological processes of AD. Along with the success of Aβ PET and the more recent tau PET imaging, there is also a great interest to develop PET tracers to image glial activation and neuroinflammation. While most research to date has focused on imaging microgliosis, recent studies using ¹¹C-deuterium-L-deprenyl (¹¹C-DED) PET imaging suggest that astrocytosis may be present from very early stages of disease development in AD. This chapter provides a detailed description of the practical approach used for the analysis of ¹¹C-DED PET imaging data in a multitracer PET paradigm including ¹¹C-Pittsburgh compound B (¹¹C-PiB) and ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG). The multitracer PET approach allows investigating the comparative regional and temporal patterns of in vivo brain astrocytosis, fibrillar Aβ deposition, and glucose metabolism in patients at different stages of disease progression. This chapter attempts to stimulate further research in the field, including the development of novel PET tracers that may allow visualizing different aspects of the complex astrocytic and microglial responses in neurodegenerative diseases. Progress in the field will contribute to the incorporation of PET imaging of glial activation and neuroinflammation as biomarkers with clinical application, and motivate further investigation on glial cells as therapeutic targets in AD and other neurodegenerative diseases.

Comparative Evaluation of Three TSPO PET Radiotracers in a LPS-Induced Model of Mild Neuroinflammation in Rats

Purpose

Over the past 20 years, neuroinflammation (NI) has increasingly been recognised as having an important role in  many neurodegenerative diseases, including Alzheimer’s disease. As such, being able to image NI non-invasively in patients is critical to monitor pathological processes and potential therapies targeting neuroinflammation. The translocator protein (TSPO) has proven a reliable NI biomarker for positron emission tomography (PET) imaging. However, if TSPO imaging in acute conditions such as stroke provides strong and reliable signals, TSPO imaging in neurodegenerative diseases has proven more challenging. Here, we report results comparing the recently developed TSPO tracers [¹⁸F]GE-180 and [¹⁸F]DPA-714 with (R)-[¹¹C]PK11195 in a rodent model of subtle focal inflammation.

Procedures

Adult male Wistar rats were stereotactically injected with 1 μg lipopolysaccharide in the right striatum. Three days later, animals underwent a 60-min PET scan with (R)-[¹¹C]PK11195 and [¹⁸F]GE-180 (n = 6) or [¹⁸F]DPA-714 (n = 6). Ten animals were scanned with either [¹⁸F]GE-180 (n = 5) or [¹⁸F]DPA-714 (n = 5) only. Kinetic analysis of PET data was performed using the simplified reference tissue model (SRTM) with a contralateral reference region or a novel data-driven input to estimate binding potential BP_ND. Autoradiography and immunohistochemistry were performed to confirm in vivo results.

Results

At 40–60 min post-injection, [¹⁸F]GE-180 dual-scanned animals showed a significantly increased core/contralateral uptake ratio vs. the same animals scanned with (R)-[¹¹C]PK11195 (3.41 ± 1.09 vs. 2.43 ± 0.39, p = 0.03); [¹⁸]DPA-714 did not (2.80 ± 0.69 vs. 2.26 ± 0.41). Kinetic modelling with a contralateral reference region identified significantly higher binding potential (BP_ND) in the core of the LPS injection site with [¹⁸F]GE-180 but not with [¹⁸F]DPA-714 vs. (R)-[¹¹C]PK11195. A cerebellar reference region and novel data-driven input to the SRTM were unable to distinguish differences in tracer BP_ND.

Conclusions

Second-generation TSPO-PET tracers are able to accurately detect mild-level NI. In this model, [¹⁸F]GE-180 shows a higher core/contralateral ratio and BP_ND when compared to (R)-[¹¹C]PK11195, while [¹⁸F]DPA-714 did not.

Electronic supplementary material

The online version of this article (doi:10.1007/s11307-016-0984-3) contains supplementary material, which is available to authorized users.

Increased White Matter Inflammation in Aging- and Alzheimer's Disease Brain

Chronic neuroinflammation, which is primarily mediated by microglia, plays an essential role in aging and neurodegeneration. It is still unclear whether this microglia-induced neuroinflammation occurs globally or is confined to distinct brain regions. In this study, we investigated microglia activity in various brain regions upon healthy aging and Alzheimer's disease (AD)-related pathology in both human and mouse samples. In purified microglia isolated from aging mouse brains, we found a profound gene expression pattern related to pro-inflammatory processes, phagocytosis, and lipid homeostasis. Particularly in white matter microglia of 24-month-old mice, abundant expression of phagocytic markers including Mac-2, Axl, CD16/32, Dectin1, CD11c, and CD36 was detected. Interestingly, in white matter of human brain tissue the first signs of inflammatory activity were already detected during middle age. Thus quantification of microglial proteins, such as CD68 (commonly associated with phagocytosis) and HLA-DR (associated with antigen presentation), in postmortem human white matter brain tissue showed an age-dependent increase in immunoreactivity already in middle-aged people (53.2 ± 2.0 years). This early inflammation was also detectable by non-invasive positron emission tomography imaging using [¹¹C]-(R)-PK11195, a ligand that binds to activated microglia. Increased microglia activity was also prominently present in the white matter of human postmortem early-onset AD (EOAD) brain tissue. Interestingly, microglia activity in the white matter of late-onset AD (LOAD) CNS was similar to that of the aged clinically silent AD cases. These data indicate that microglia-induced neuroinflammation is predominant in the white matter of aging mice and humans as well as in EOAD brains. This white matter inflammation may contribute to the progression of neurodegeneration, and have prognostic value for detecting the onset and progression of aging and neurodegeneration.