La lunga attesa: towards a molecular approach to neuroimaging and therapeutics in Alzheimer's disease

Potential of fluorescent nanoprobe in diagnosis and treatment of Alzheimer's disease

Alzheimer's disease (AD) is well known for its insidious nature, slow progression and high incidence as a neurodegenerative disease. In the past, diagnosis of AD mainly depended on analysis of a patient's cognitive ability and behavior. Without a unified standard for analysis methods, this is prone to produce incorrect diagnoses. Currently, definitive diagnosis mainly relies on histopathological examination. Because of the advantages of precision, noninvasiveness, low toxicity and high spatiotemporal resolution, fluorescent nanoprobes are suitable for the early diagnosis of AD. This review summarizes the research progress of different kinds of fluorescent nanoprobes for AD diagnosis and therapy in recent years and provides an outlook on the development prospects of fluorescent nanoprobes.

Amyloid PET in neurodegenerative diseases with dementia

Alzheimer's disease (AD) is a neurodegenerative condition characterized by progressive cognitive decline and memory loss, and is the most common form of dementia. Amyloid plaques with neurofibrillary tangles are a neuropathological hallmark of AD that produces synaptic dysfunction and culminates later in neuronal loss. Amyloid PET is a useful, available and non-invasive technique that provides in vivo information about the cortical amyloid burden. In the latest revised criteria for the diagnosis of AD biomarkers were defined and integrated: pathological and diagnostic biomarkers (increased retention on fibrillar amyloid PET or decreased Aβ_1-42 and increased T-Tau or P-Tau in CSF) and neurodegeneration or topographical biomarkers (temporoparietal hypometabolism on ¹⁸F-FDG PET and temporal atrophy on MRI). Recently specific recommendations have been created as a consensus statement on the appropriate use of the imaging biomarkers, including amyloid PET: early-onset cognitive impairment/dementia, atypical forms of AD, mild cognitive impairment with early age of onset, and to differentiate between AD and other neurodegenerative diseases that occur with dementia. Amyloid PET is also contributing to the development of new therapies for AD, as well as in research studies for the study of other neurodegenerative diseases that occur with dementia where the deposition of Aβ amyloid is involved in its pathogenesis. In this paper, we review some general concepts and study the use of amyloid PET in depth and its relationship with neurodegenerative diseases and other diagnostic techniques.

Quantitative approaches to amyloid imaging

Alzheimer's disease (AD), an irreversible, progressive neurodegenerative disorder clinically characterized by memory loss and cognitive decline, is the leading cause of dementia in the elderly, leading invariably to death within 7-10 years after diagnosis. In vivo amyloid imaging with positron emission tomography (PET) is allowing new insights into β-amyloid (Aβ) deposition in the brain, facilitating research into the causes, diagnosis, and future treatment of dementias, where Aβ may play a role. Non-invasive quantification of Aβ burden in the brain with PET has proven useful in the early and differential diagnosis of dementias, showing significantly higher retention in grey matter of AD patients when compared with healthy controls (HC) or patients with frontotemporal lobe degeneration (FTLD). With the advent of new therapeutic strategies aimed at reducing Aβ burden in the brain to potentially prevent or delay functional and irreversible cognitive loss, there is increased interest in developing agents that allow assessment of Aβ burden in vivo. A key aspect for Aβ burden quantification is the application of compartmental or graphical analyses to the kinetic data in order to obtain quantitative and reproducible statements that allow comparison with other nosological groups, correlation with cognitive or biological parameters, and selection, monitoring, and follow-up of individuals in disease modifying therapeutic trials. It is also a necessary step in the validation of simplified approaches that could be applied in routine clinical settings. With the availability of novel amyloid imaging agents radiolabeled with either (11)C (half-life 20 min) or (18)F (half-life 110 min), a description of different image acquisition approaches is provided.

Amyloid PET Ligands for Dementia

The progressive nature of neurodegeneration suggests an age-dependent process that ultimately leads to synaptic failure and neuronal damage in cortical areas of the brain critical for memory and higher mental functions. The increasing age of the population in developed countries suggests that, if unchecked, these disorders will become increasingly prevalent. In the absence of specific biologic markers, direct pathologic examination of brain tissue still is the only definitive method for establishing a diagnosis of Alzheimer disease (AD) and other types of dementia. Pathologic hallmarks of AD are intracellular neurofibrillary tangles (NFT) and extracellular amyloid plaques. NFT are intraneuronal bundles of paired helical filaments mainly composed of the aggregates of an abnormally phosphorylated form of tau protein; neuritic plaques consist of dense extracellular aggregates of β-amyloid (Aβ), surrounded by reactive gliosis and dystrophic neurites. To date, all available evidence strongly supports the notion that an imbalance between the production and removal of Aβ leading to its progressive accumulation is central to the pathogenesis of AD. A growing understanding of the molecular mechanisms of Aβ formation, degradation, and neurotoxicity is being translated into new therapeutic approaches. Whereas AD is the most common cause of dementia in the elderly, postmortem studies have found dementia with Lewy Bodies and frontotemporal lobe degeneration each to account for about 20% of cases. Molecular neuroimaging techniques such as PET have been used for the in vivo assessment of molecular processes at their sites of action, permitting detection of subtle pathophysiological changes in the brain at asymptomatic stages The development of molecular imaging methods for noninvasively assessing disease-specific traits such as Aβ burden in AD is allowing early diagnosis at presymptomatic stages, more accurate differential diagnosis and, when available, the evaluation and monitoring of disease-modifying therapy.

Amyloid imaging in Alzheimer's disease and other dementias

With the advent of new therapeutic strategies aimed at reducing β-amyloid (Aβ) burden in the brain to potentially prevent or delay functional and irreversible cognitive loss, there is increased interest in developing agents that allow assessment of Aβ burden in vivo. Molecular neuroimaging techniques such as positron emission tomography (PET), in conjunction with related biomarkers in plasma and cerebrospinal fluid, are proving valuable in the early and differential diagnosis of Alzheimer's disease (AD). (11)C-PiB PET has proven useful in the discrimination of dementias, showing significantly higher PiB retention in grey matter of AD patients when compared with healthy controls or patients with frontotemporal dementia. (11)C-PiB PET also appears to be more accurate than FDG for the diagnosis of AD. Despite apparently underestimating the Aβ burden in the brain, (11)C-PiB PET is an optimal method to differentiate healthy controls from AD, matching histopathological reports in aging and dementia and reflecting the true regional density of Aβ plaques in cortical areas. High striatal Aβ deposition seems to be typical for carriers of familial forms of AD, whilst ApoE ε4 carriers, independent of diagnosis or disease severity, present with higher Aβ burden than non- ε4 carriers. Characterization of the binding properties of PiB has shown that despite binding to other misfolded proteins in vitro, PiB is extremely selective for Aβ at the concentrations achieved during a PET scan. Aβ burden as assessed by PET does not correlate with measures of cognition or cognitive decline in AD. Approximately 30% of apparently healthy older people, and 50-60% of people with mild cognitive impairment, present with cortical (11)C-PiB retention. In these groups, Aβ burden does correlate with episodic memory and rate of memory decline. These observations suggest that Aβ deposition is not part of normal ageing, supporting the hypothesis that Αβ deposition occurs well before the onset of symptoms and is likely to represent preclinical AD. Further longitudinal observations, coupled with different disease-specific tracers and biomarkers are required not only to confirm this hypothesis, but also to better elucidate the role of Αβ deposition in the course of Alzheimer's disease.

The ART of loss: Abeta imaging in the evaluation of Alzheimer's disease and other dementias

Molecular neuroimaging based on annihilation radiation tomographic (ART) techniques such as positron emission tomography (PET), in conjunction with related biomarkers in plasma and cerebrospinal fluid (CSF), are proving valuable in the early and differential diagnosis of Alzheimer's disease (AD). With the advent of new therapeutic strategies aimed at reducing beta-amyloid (Abeta) burden in the brain to potentially prevent or delay functional and irreversible cognitive loss, there is increased interest in developing agents that allow assessment of Abeta burden in vivo. Abeta burden as assessed by molecular imaging matches histopathological reports of Abeta plaque distribution in aging and dementia and appears more accurate than FDG for the diagnosis of AD. Abeta imaging is also a very powerful tool in the differential diagnosis of AD from fronto-temporal dementia (FTD). Although Abeta burden as assessed by PET does not correlate with measures of cognitive decline in AD, it does correlate with memory impairment and rate of memory decline in mild cognitive impairment (MCI) and healthy older subjects. Approximately 30% of asymptomatic controls present cortical (11)C-PiB retention. These observations suggest that Abeta deposition is not part of normal ageing, supporting the hypothesis that Abeta deposition occurs well before the onset of symptoms and is likely to represent preclinical AD. Further longitudinal observations are required to confirm this hypothesis and to better elucidate the role of Abeta deposition in the course of Alzheimer's disease.