Future Imaging in Dementia

Primary progressive aphasia: six questions in search of an answer

Here, we review recent progress in the diagnosis and management of primary progressive aphasia-the language-led dementias. We pose six key unanswered questions that challenge current assumptions and highlight the unresolved difficulties that surround these diseases. How many syndromes of primary progressive aphasia are there-and is syndromic diagnosis even useful? Are these truly 'language-led' dementias? How can we diagnose (and track) primary progressive aphasia better? Can brain pathology be predicted in these diseases? What is their core pathophysiology? In addition, how can primary progressive aphasia best be treated? We propose that pathophysiological mechanisms linking proteinopathies to phenotypes may help resolve the clinical complexity of primary progressive aphasia, and may suggest novel diagnostic tools and markers and guide the deployment of effective therapies.

High-Resolution Silicon Photomultiplier Time-of-Flight Dedicated Head PET System for Clinical Brain Studies

We acquired brain ¹⁸F-FDG and ¹⁸F-flutemetamol PET images using a time-of-flight system dedicated to the head (dhPET) and a conventional whole-body PET/CT (wbPET) system and evaluated the clinical superiority of dhPET over wbPET. Methods: There were 18 subjects for the ¹⁸F-FDG PET study and 17 subjects for the ¹⁸F-flutemetamol PET study. ¹⁸F-FDG PET images were first obtained using wbPET, followed by dhPET. ¹⁸F-flutemetamol PET images were first obtained using wbPET, followed by dhPET. Images acquired using dhPET and wbPET were compared by visual inspection, voxelwise analysis, and SUV ratio (SUVR). Results: All ¹⁸F-FDG and ¹⁸F-flutemetamol images acquired using dhPET were judged as visually better than those acquired using wbPET. The voxelwise analysis demonstrated that accumulations in the cerebellum, in the lateral occipital cortices, and around the central sulcus area in dhPET ¹⁸F-FDG images were lower than those in wbPET ¹⁸F-FDG images, whereas accumulations around the ventricle systems were higher in dhPET ¹⁸F-FDG images than those in wbPET ¹⁸F-FDG images. Accumulations in the cerebellar dentate nucleus, in the midbrain, in the lateral occipital cortices, and around the central sulcus area in dhPET images were lower than those in wbPET images, whereas accumulations around the ventricle systems were higher in dhPET ¹⁸F-flutemetamol images than those in wbPET ¹⁸F-flutemetamol images. The mean cortical SUVRs of ¹⁸F-FDG and ¹⁸F-flutemetamol dhPET images were significantly higher than those of ¹⁸F-FDG and ¹⁸F-flutemetamol wbPET images, respectively. Conclusion: The dhPET images had better image quality by visual inspection and higher SUVRs than wbPET images. Although there were several regional accumulation differences between dhPET and wbPET images, understanding this phenomenon will enable full use of the features of this dhPET system in clinical practice.

Pathophysiological Underpinnings of Extra-Motor Neurodegeneration in Amyotrophic Lateral Sclerosis: New Insights From Biomarker Studies

Amyotrophic lateral sclerosis (ALS) and frontotemporal lobar degeneration (FTLD) lie at opposing ends of a clinical, genetic, and neuropathological continuum. In the last decade, it has become clear that cognitive and behavioral changes in patients with ALS are more frequent than previously recognized. Significantly, these non-motor features can impact the diagnosis, prognosis, and management of ALS. Partially overlapping neuropathological staging systems have been proposed to describe the distribution of TAR DNA-binding protein 43 (TDP-43) aggregates outside the corticospinal tract. However, the relationship between TDP-43 inclusions and neurodegeneration is not absolute and other pathophysiological processes, such as neuroinflammation (with a prominent role of microglia), cortical hyperexcitability, and synaptic dysfunction also play a central role in ALS pathophysiology. In the last decade, imaging and biofluid biomarker studies have revealed important insights into the pathophysiological underpinnings of extra-motor neurodegeneration in the ALS-FTLD continuum. In this review, we first summarize the clinical and pathophysiological correlates of extra-motor neurodegeneration in ALS. Next, we discuss the diagnostic and prognostic value of biomarkers in ALS and their potential to characterize extra-motor neurodegeneration. Finally, we debate about how biomarkers could improve the diagnosis and classification of ALS. Emerging imaging biomarkers of extra-motor neurodegeneration that enable the monitoring of disease progression are particularly promising. In addition, a growing arsenal of biofluid biomarkers linked to neurodegeneration and neuroinflammation are improving the diagnostic accuracy and identification of patients with a faster progression rate. The development and validation of biomarkers that detect the pathological aggregates of TDP-43 in vivo are notably expected to further elucidate the pathophysiological underpinnings of extra-motor neurodegeneration in ALS. Novel biomarkers tracking the different aspects of ALS pathophysiology are paving the way to precision medicine approaches in the ALS-FTLD continuum. These are essential steps to improve the diagnosis and staging of ALS and the design of clinical trials testing novel disease-modifying treatments.

Dementia and Major Neurocognitive Disorders: Some Lessons Learned One Century after the first Alois Alzheimer's Clinical Notes

Over 100 years ago, Alois Alzheimer presented the clinical signs and symptoms of what has been later called "Alzheimer Dementia" in a young woman whose name was Augustine Deter [...].