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Karim HT, Lee S, Gerlach A, Stinley M, Berta R, Mahbubani R, Tudorascu DL, Butters MA, Gross JJ, Andreescu C. Hippocampal subfield volume in older adults with and without mild cognitive impairment: Effects of worry and cognitive reappraisal. Neurobiol Aging 2024; 141:55-65. [PMID: 38823204 PMCID: PMC11246796 DOI: 10.1016/j.neurobiolaging.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 06/03/2024]
Abstract
Studies have confirmed that anxiety, especially worry and rumination, are associated with increased risk for cognitive decline, including Alzheimer's disease and related dementias (ADRD). Hippocampal atrophy is a hallmark of ADRD. We investigated the association between hippocampus and its subfield volumes and late-life global anxiety, worry, and rumination, and emotion regulation strategies. We recruited 110 participants with varying worry severity who underwent magnetic resonance imaging and clinical interviews. We conducted cross-sectional regression analysis between each subfield and anxiety, worry, rumination, reappraisal, and suppression while adjusting for age, sex, race, education, cumulative illness burden, stress, neuroticism, and intracranial volume. We imputed missing data and corrected for multiple comparisons across regions. Greater worry was associated with smaller subiculum volume, whereas greater use of reappraisal was associated with larger subiculum and CA1 volume. Greater worry may be detrimental to the hippocampus and to subfields involved in early ADRD pathology. Use of reappraisal appears protective of hippocampal structure. Worry and reappraisal may be modifiable targets for ADRD prevention.
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Affiliation(s)
- Helmet T Karim
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Soyoung Lee
- Department of Psychiatry, University of Maryland, Baltimore, MD, United States
| | - Andrew Gerlach
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mark Stinley
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Rachel Berta
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Rebecca Mahbubani
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Dana L Tudorascu
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States; Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Meryl A Butters
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - James J Gross
- Department of Psychology, Stanford University, Stanford, CA, United States
| | - Carmen Andreescu
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States.
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Gao N, Ye C, Chen H, Hao X, Ma T. MRI-based axis-referenced morphometric model corresponding to lamellar organization for assessing hippocampal atrophy in dementia. Hum Brain Mapp 2024; 45:e26715. [PMID: 38994693 PMCID: PMC11240145 DOI: 10.1002/hbm.26715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/21/2024] [Accepted: 05/04/2024] [Indexed: 07/13/2024] Open
Abstract
Research on the local hippocampal atrophy for early detection of dementia has gained considerable attention. However, accurately quantifying subtle atrophy remains challenging in existing morphological methods due to the lack of consistent biological correspondence with the complex curving regions like the hippocampal head. Thereby, this article presents an innovative axis-referenced morphometric model (ARMM) that follows the anatomical lamellar organization of the hippocampus, which capture its precise and consistent longitudinal curving trajectory. Specifically, we establish an "axis-referenced coordinate system" based on a 7 T ex vivo hippocampal atlas following its entire curving longitudinal axis and orthogonal distributed lamellae. We then align individual hippocampi by deforming this template coordinate system to target spaces using boundary-guided diffeomorphic transformation, while ensuring that the lamellar vectors adhere to the constraint of medial-axis geometry. Finally, we measure local thickness and curvatures based on the coordinate system and boundary surface reconstructed from vector tips. The morphometric accuracy is evaluated by comparing reconstructed surfaces with those directly extracted from 7 T and 3 T MRI hippocampi. The results demonstrate that ARMM achieves the best performance, particularly in the curving head, surpassing the state-of-the-art morphological models. Additionally, morphological measurements from ARMM exhibit higher discriminatory power in distinguishing early Alzheimer's disease from mild cognitive impairment compared to volume-based measurements. Overall, the ARMM offers a precise morphometric assessment of hippocampal morphology on MR images, and sheds light on discovering potential image markers for neurodegeneration associated with hippocampal impairment.
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Affiliation(s)
- Na Gao
- Electronic & Information Engineering SchoolHarbin Institute of Technology (Shenzhen)ShenzhenChina
| | - Chenfei Ye
- International Research Institute for Artificial Intelligence, Harbin Institute of Technology at ShenzhenShenzhenChina
| | - Hantao Chen
- Electronic & Information Engineering SchoolHarbin Institute of Technology (Shenzhen)ShenzhenChina
| | - Xingyu Hao
- Electronic & Information Engineering SchoolHarbin Institute of Technology (Shenzhen)ShenzhenChina
| | - Ting Ma
- Electronic & Information Engineering SchoolHarbin Institute of Technology (Shenzhen)ShenzhenChina
- International Research Institute for Artificial Intelligence, Harbin Institute of Technology at ShenzhenShenzhenChina
- Peng Cheng LaboratoryShenzhenChina
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Gao N, Chen H, Guo X, Hao X, Ma T. Geodesic shape regression based deep learning segmentation for assessing longitudinal hippocampal atrophy in dementia progression. Neuroimage Clin 2024; 43:103623. [PMID: 38821013 PMCID: PMC11179422 DOI: 10.1016/j.nicl.2024.103623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 04/12/2024] [Accepted: 05/25/2024] [Indexed: 06/02/2024]
Abstract
Longitudinal hippocampal atrophy is commonly used as progressive marker assisting clinical diagnose of dementia. However, precise quantification of the atrophy is limited by longitudinal segmentation errors resulting from MRI artifacts across multiple independent scans. To accurately segment the hippocampal morphology from longitudinal 3T T1-weighted MR images, we propose a diffeomorphic geodesic guided deep learning method called the GeoLongSeg to mitigate the longitudinal variabilities that unrelated to diseases by enhancing intra-individual morphological consistency. Specifically, we integrate geodesic shape regression, an evolutional model that estimates smooth deformation process of anatomical shapes, into a two-stage segmentation network. We adopt a 3D U-Net in the first-stage network with an enhanced attention mechanism for independent segmentation. Then, a hippocampal shape evolutional trajectory is estimated by geodesic shape regression and fed into the second network to refine the independent segmentation. We verify that GeoLongSeg outperforms other four state-of-the-art segmentation pipelines in longitudinal morphological consistency evaluated by test-retest reliability, variance ratio and atrophy trajectories. When assessing hippocampal atrophy in longitudinal data from the Alzheimer's Disease Neuroimaging Initiative (ADNI), results based on GeoLongSeg exhibit spatial and temporal local atrophy in bilateral hippocampi of dementia patients. These features derived from GeoLongSeg segmentation exhibit the greatest discriminatory capability compared to the outcomes of other methods in distinguishing between patients and normal controls. Overall, GeoLongSeg provides an accurate and efficient segmentation network for extracting hippocampal morphology from longitudinal MR images, which assist precise atrophy measurement of the hippocampus in early stage of dementia.
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Affiliation(s)
- Na Gao
- School of Electronic & Information Engineering, Harbin Institute of Technology (Shenzhen), Shenzhen, China
| | - Hantao Chen
- School of Electronic & Information Engineering, Harbin Institute of Technology (Shenzhen), Shenzhen, China
| | - Xutao Guo
- School of Electronic & Information Engineering, Harbin Institute of Technology (Shenzhen), Shenzhen, China; Peng Cheng Laboratory, Shenzhen, China
| | - Xingyu Hao
- School of Electronic & Information Engineering, Harbin Institute of Technology (Shenzhen), Shenzhen, China
| | - Ting Ma
- School of Electronic & Information Engineering, Harbin Institute of Technology (Shenzhen), Shenzhen, China; Peng Cheng Laboratory, Shenzhen, China; Guangdong Provincial Key Laboratory of Aerospace Communication and Networking Technology, Harbin Institute of Technology (Shenzhen), Shenzhen, Guangdong, China.
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Robinson CG, Coleman T, Buciuc M, Singh NA, Pham NTT, Machulda MM, Graff-Radford J, Whitwell JL, Josephs KA. Behavioral and Neuropsychiatric Differences Across Two Atypical Alzheimer's Disease Variants: Logopenic Progressive Aphasia and Posterior Cortical Atrophy. J Alzheimers Dis 2024; 97:895-908. [PMID: 38143349 PMCID: PMC10842893 DOI: 10.3233/jad-230652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND Posterior cortical atrophy (PCA) and logopenic progressive aphasia (LPA) are two common atypical Alzheimer's disease (AD) variants. Little is known about behavioral and neuropsychiatric symptoms or activities of daily living (ADLs) in PCA and LPA, and whether they differ across syndromes. OBJECTIVE To characterize the behavioral and neuropsychiatric profiles and ADLs of PCA and LPA and compare presence/absence and severity of symptoms between syndromes. METHODS Seventy-eight atypical AD patients, 46 with PCA and 32 with LPA, completed the Neuropsychiatric Inventory Questionnaire (NPI-Q) and Cambridge Behavioral Inventory-Revised (CBI-R) at baseline and longitudinally over-time. Mann-Whitney U and Fisher's Exact Tests assessed for differences in symptoms between the two syndromes with significance set at p≤0.01. To eliminate demographic differences as confounders the groups were matched, and differences reanalyzed. RESULTS PCA were younger at onset (p = 0.006), at time of baseline assessment (p = 0.02) and had longer disease duration (p = 0.01). Neuropsychiatric symptoms were common in PCA and LPA, although more common and severe in PCA. At baseline, PCA had a higher NPI-Q total score (p = 0.01) and depression subscore (p = 0.01) than LPA. Baseline total CBI-R scores were also higher in PCA than LPA (p = 0.001) with PCA having worse scores in all 10 CBI-R categories. Longitudinally, there was no difference between groups on the NPI-Q. However, on the CBI-R, PCA had faster rates of worsening on self-grooming (p = 0.01) and self-dressing (p = 0.01) compared to LPA. CONCLUSIONS Behavioral and neuropsychiatric symptoms are common in PCA and LPA although these symptoms are more common and severe in PCA.
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Affiliation(s)
| | - Tia Coleman
- Department of Neurology, Mayo Clinic, Rochester, MN
| | - Marina Buciuc
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | | | | | - Mary M. Machulda
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
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Pluta R, Kocki J, Bogucki J, Bogucka-Kocka A, Czuczwar SJ. LRP1 and RAGE Genes Transporting Amyloid and Tau Protein in the Hippocampal CA3 Area in an Ischemic Model of Alzheimer's Disease with 2-Year Survival. Cells 2023; 12:2763. [PMID: 38067191 PMCID: PMC10706460 DOI: 10.3390/cells12232763] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 11/21/2023] [Accepted: 12/02/2023] [Indexed: 12/18/2023] Open
Abstract
Explaining changes at the gene level that occur during neurodegeneration in the CA3 area is crucial from the point of view of memory impairment and the development of post-ischemic dementia. An ischemic model of Alzheimer's disease was used to evaluate changes in the expression of genes related to amyloid transport in the CA3 region of the hippocampus after 10 min of brain ischemia with survival of 2, 7 and 30 days and 12, 18 and 24 months. The quantitative reverse transcriptase PCR assay revealed that the expression of the LRP1 and RAGE genes involved in amyloid transport was dysregulated from 2 days to 24 months post-ischemia in the CA3 area of the hippocampus. LRP1 gene expression 2 and 7 days after ischemia was below control values. However, its expression from day 30 to 24 months, survival after an ischemic episode was above control values. RAGE gene expression 2 days after ischemia was below control values, reaching a maximum increase 7 and 30 days post-ischemia. Then, after 12, 18 and 24 months, it was again below the control values. The data indicate that in the CA3 area of the hippocampus, an episode of brain ischemia causes the increased expression of the RAGE gene for 7-30 days during the acute phase and that of LRP1 from 1 to 24 months after ischemia during the chronic stage. In other words, in the early post-ischemic stage, the expression of the gene that transport amyloid to the brain increases (7-30 days). Conversely, in the late post-ischemic stage, amyloid scavenging/cleaning gene activity increases, reducing and/or preventing further neuronal damage or facilitating the healing of damaged sites. This is how the new phenomenon of pyramidal neuronal damage in the CA3 area after ischemia is defined. In summary, post-ischemic modification of the LRP1 and RAGE genes is useful in the study of the ischemic pathways and molecular factors involved in the development of Alzheimer's disease.
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Affiliation(s)
- Ryszard Pluta
- Department of Pathophysiology, Medical University of Lublin, 20-090 Lublin, Poland;
| | - Janusz Kocki
- Department of Clinical Genetics, Medical University of Lublin, 20-080 Lublin, Poland;
| | - Jacek Bogucki
- Department of Organic Chemistry, Faculty of Pharmacy, Medical University of Lublin, 20-093 Lublin, Poland;
| | - Anna Bogucka-Kocka
- Department of Biology and Genetics, Medical University of Lublin, 20-093 Lublin, Poland;
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Gao N, Liu Z, Deng Y, Chen H, Ye C, Yang Q, Ma T. MR-based spatiotemporal anisotropic atrophy evaluation of hippocampus in Alzheimer's disease progression by multiscale skeletal representation. Hum Brain Mapp 2023; 44:5180-5197. [PMID: 37608620 PMCID: PMC10502645 DOI: 10.1002/hbm.26460] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/14/2023] [Accepted: 08/02/2023] [Indexed: 08/24/2023] Open
Abstract
Increasing evidence has shown a higher sensitivity of Alzheimer's disease (AD) progression by local hippocampal atrophy rather than the whole volume. However, existing morphological methods based on subfield-volume or surface in imaging studies are not capable to describe the comprehensive process of hippocampal atrophy as sensitive as histological findings. To map histological distinctive measurements onto medical magnetic resonance (MR) images, we propose a multiscale skeletal representation (m-s-rep) to quantify focal hippocampal atrophy during AD progression in longitudinal cohorts from the Alzheimer's Disease Neuroimaging Initiative (ADNI). The m-s-rep captures large-to-small-scale hippocampal morphology by spoke interpolation over label projection on skeletal models. To enhance morphological correspondence within subjects, we align the longitudinal m-s-reps by surface-based transformations from baseline to subsequent timepoints. Cross-sectional and longitudinal measurements derived from m-s-rep are statistically analyzed to comprehensively evaluate the bilateral hippocampal atrophy. Our findings reveal that during the early AD progression, atrophy primarily affects the lateral-medial extent of the hippocampus, with a difference of 1.8 mm in lateral-medial width in 2 years preceding conversion (p < .001), and the medial head exhibits a maximum difference of 3.05%/year in local atrophy rate (p = .011) compared to controls. Moreover, progressive mild cognitive impairment (pMCI) exhibits more severe and widespread atrophy in the head and body compared to stable mild cognitive impairment (sMCI), with a maximum difference of 1.21 mm in thickness in the medial head 1 year preceding conversion (p = .012). In summary, our proposed method can quantitatively measure the hippocampal morphological changes on 3T MR images, potentially assisting the pre-diagnosis and prognosis of AD.
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Affiliation(s)
- Na Gao
- Department of Electronic & Information EngineeringHarbin Institute of Technology (Shenzhen)ShenzhenChina
| | - Zhiyuan Liu
- Department of Computer ScienceUniversity of North Carolina atChapel HillNorth CarolinaUSA
| | - Yuesheng Deng
- Department of Electronic & Information EngineeringHarbin Institute of Technology (Shenzhen)ShenzhenChina
| | - Hantao Chen
- Department of Electronic & Information EngineeringHarbin Institute of Technology (Shenzhen)ShenzhenChina
| | - Chenfei Ye
- International Research Institute for Artificial IntelligenceHarbin Institute of Technology at ShenzhenShenzhenChina
- Peng Cheng LaboratoryShenzhenChina
| | - Qi Yang
- Department of Radiology, Beijing Chaoyang HospitalCapital Medical UniversityBeijingChina
- Key Lab of Medical Engineering for Cardiovascular DiseaseMinistry of EducationBeijingChina
- Beijing Advanced Innovation Center for Big Data‐Based Precision MedicineBeijingChina
| | - Ting Ma
- Department of Electronic & Information EngineeringHarbin Institute of Technology (Shenzhen)ShenzhenChina
- International Research Institute for Artificial IntelligenceHarbin Institute of Technology at ShenzhenShenzhenChina
- Peng Cheng LaboratoryShenzhenChina
- Guangdong Provincial Key Laboratory of Aerospace Communication and Networking TechnologyHarbin Institute of Technology (Shenzhen)ShenzhenChina
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Qu H, Ge H, Wang L, Wang W, Hu C. Volume changes of hippocampal and amygdala subfields in patients with mild cognitive impairment and Alzheimer's disease. Acta Neurol Belg 2023:10.1007/s13760-023-02235-9. [PMID: 37043115 DOI: 10.1007/s13760-023-02235-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 03/06/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Automated segmentation of hippocampal and amygdala subfields could improve classification accuracy of Mild Cognitive Impairments (MCI) and Alzheimer's Disease (AD) individuals. METHODS We applied T1-weighted magnetic resonance imaging (MRI) for 21 AD, 39 MCI and 32 normal control (NC) participants at 3-Tesla MRI. Twelve hippocampal subfields and 9 amygdala subfields in each hemisphere were analyzed using FreeSurfer 6.0. RESULTS Smaller volumes were observed in right/left whole hippocampus, right/left hippocampal tail, right/left subiculum, right Cornu ammonis 1(CA1), right/left molecular layer, right granule cell-molecular layer-dentate gyrus (GC-ML-DG), right CA4, right fimbria, right whole amygdala, right/left accessory basal, right anterior amygdala area, left central, left medial and right/left cortical nucleus of AD group compared to both MCI and NC groups (p < 0.001). The volumes of right presubiculum, right CA3, right hippocampus-amygdala-transition-area (HATA), right lateral, right basal, right central, right medial, right cortico-amygdaloid transition (CAT) and right paralaminar nucleus were significantly larger in NC than AD group (p ≤ 0.001), while the volumes of right subiculum, right CA1, right molecular layer, right whole hippocampus, right whole amygdala, right basal and right accessory basal were significantly larger in NC than MCI group (p ≤ 0.002). Trend analysis showed that most hippocampus and amygdala subfields have a trend of atrophy with the decline of cognitive function. Six core components were identified by the hierarchical clustering. The combined Receiver operating characteristic (ROC) analysis achieved the diagnostic performances (AUC: 0.81) in differentiating AD from MCI; (AUC: 0.79) in differentiating MCI from NC and (AUC: 0.97) in differentiating AD from NC. CONCLUSIONS Volumetric differences of hippocampus and amygdala were at a finer subfields scale, and the volumes of right basal nucleus, left parasubiculum, left medial nucleus, left GC-ML-DG, left hippocampal fissure, and right fimbria can be employed as neuroimaging biomarkers to assist the clinical diagnosis of MCI and AD.
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Affiliation(s)
- Hang Qu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou Jiangsu, China
- Department of Radiology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Haitao Ge
- School of Medical Imaging, Xuzhou Medical University, Xuzhou, China
| | - Liping Wang
- Department of Biobank, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Wei Wang
- Department of Radiology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Chunhong Hu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou Jiangsu, China.
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Constantinides VC, Tentolouris-Piperas V, Paraskevas GP, Pyrgelis ES, Velonakis G, Karavasilis E, Toulas P, Boufidou F, Stefanis L, Kapaki E. Hippocampal subfield volumetry in corticobasal syndrome of diverse underlying pathologies. J Neurol 2023; 270:2059-2068. [PMID: 36565349 DOI: 10.1007/s00415-022-11538-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Multiple pathologies may underlie corticobasal syndrome (CBS), including Alzheimer's disease (AD). Typical amnestic AD is characterized by early selective hippocampal atrophy. The profile of hippocampal atrophy in AD patients presenting as CBS (CBS-AD), compared to CBS patients of non-AD pathologies (CBS-nAD) and amnestic AD patients, has not been studied. OBJECTIVES To compare hippocampal subfield atrophy patterns between CBS-AD, CBS-nAD, typical amnestic AD patients, and control subjects. METHODS Automated hippocampal subfield volumetry was performed via the hippocampal subfield segmentation pipeline of Freesurfer 6.0 on 3D T1-weighted images. CBS patients were classified as CBS-AD or CBS-nAD based on CSF AD biomarkers by applying the AT(N) classification system. Mean volumes of nine hippocampal subfields, head-body-tail segments, total hippocampus, and entorhinal and parahippocampal gyrus cortical thickness were measured. RESULTS Eighty-three subjects were included (CBS-AD: n = 14; CBS-nAD: n = 17; amnestic AD: n = 29; controls: n = 23). CBS-AD patients had greater whole hippocampal and hippocampal subfield atrophy compared to CBS-nAD. CBS-AD and amnestic AD patients did not differ in subfield volumes. CBS-nAD did not exhibit hippocampal atrophy compared to controls, with the exception of fimbria. (Cohen's d = 1.27; p = 0.038). Presubiculum (Cohen's d = 1.00; p = 0.002) and hippocampal body (Cohen's d = 0.95; p = 0.001) volumes exhibited the greatest differences between CBS-AD and CBS-nAD. Hippocampal subfield volume provided combined sensitivity and specificity < 80% for the discrimination of CBS-AD from CBS-nAD. CONCLUSION CBS-AD and amnestic AD patients exhibit comparable, and significantly greater hippocampal atrophy compared to CBS-nAD patients. Hippocampal subfield volumetry in CBS is indicative of an AD underlying pathology.
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Affiliation(s)
- Vasilios C Constantinides
- First Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Eginition Hospital, 72-74 Vas. Sophias Ave., 11528, Athens, Greece.
| | - Vasileios Tentolouris-Piperas
- First Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Eginition Hospital, 72-74 Vas. Sophias Ave., 11528, Athens, Greece
| | - George P Paraskevas
- First Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Eginition Hospital, 72-74 Vas. Sophias Ave., 11528, Athens, Greece
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Attikon Hospital, Athens, Greece
| | - Efstratios-Stylianos Pyrgelis
- First Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Eginition Hospital, 72-74 Vas. Sophias Ave., 11528, Athens, Greece
| | - Georgios Velonakis
- Second Department of Radiology, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Efstratios Karavasilis
- Second Department of Radiology, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panagiotis Toulas
- Second Department of Radiology, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Fotini Boufidou
- First Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Eginition Hospital, 72-74 Vas. Sophias Ave., 11528, Athens, Greece
| | - Leonidas Stefanis
- First Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Eginition Hospital, 72-74 Vas. Sophias Ave., 11528, Athens, Greece
| | - Elisabeth Kapaki
- First Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Eginition Hospital, 72-74 Vas. Sophias Ave., 11528, Athens, Greece
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Isella V, Licciardo D, Nastasi G, Impagnatiello V, Ferri F, Mapelli C, Crivellaro C, Musarra M, Morzenti S, Appollonio I, Ferrarese C. Clinical and metabolic imaging features of late-onset and early-onset posterior cortical atrophy. Eur J Neurol 2022; 29:3147-3157. [PMID: 35950612 PMCID: PMC9804481 DOI: 10.1111/ene.15520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/12/2022] [Accepted: 08/04/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE Late-onset (LO) and early-onset (EO) dementia show neurobiological and clinical differences. Clinical and 18 fluoro-deoxy-glucose positron emission tomography (FDG-PET) features of LO and EO posterior cortical atrophy (LO_PCA, EO_PCA), the visual variant of Alzheimer's disease (AD), were compared. LO_PCA patients were also compared with a group of patients with LO typical AD (tAD). METHODS Thirty-seven LO_PCA patients (onset age ≥ 65 years), 29 EO_PCA patients and 40 tAD patients who all underwent a standard neuropsychological battery were recruited; PCA patients were also assessed for the presence of posterior signs and symptoms. Brain FDG-PET was available in 32 LO_PCA cases, 23 EO_PCA cases and all tAD cases, and their scans were compared with scans from 30 healthy elderly controls. Within the entire PCA sample FDG uptake was also correlated with age at onset as a continuous variable. RESULTS The main difference between the two PCA groups was a higher prevalence of Bálint-Holmes symptoms in EO cases, which was associated with the presence of severe bilateral occipito-temporo-parietal hypometabolism, whilst LO_PCA patients showed reduction of FDG uptake mainly in the right posterior regions. The latter group also showed mesial temporal hypometabolism, similarly to the tAD group, although with a right rather than left lateralization. Correlation analysis confirmed the association between older age and decreased limbic metabolism and between younger age and decreased left parietal metabolism. CONCLUSIONS The major involvement of the temporal cortex in LO cases and of the parietal cortex in EO cases reported previously within the AD spectrum holds true also for the visual variant of AD.
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Affiliation(s)
- Valeria Isella
- Neurology, School of MedicineUniversity of Milano—BicoccaMonzaItaly,Milan Center for NeurosciencesNeuroMIMilanItaly
| | - Daniele Licciardo
- Milan Center for NeurosciencesNeuroMIMilanItaly,Neurology DepartmentSan Gerardo HospitalMonzaLombardiaItaly
| | - Giulia Nastasi
- Neurology DepartmentASST of VimercateVimercateLombardiaItaly
| | - Valentina Impagnatiello
- Milan Center for NeurosciencesNeuroMIMilanItaly,Neurology DepartmentSan Gerardo HospitalMonzaLombardiaItaly
| | - Francesca Ferri
- Milan Center for NeurosciencesNeuroMIMilanItaly,Neurology DepartmentSan Gerardo HospitalMonzaLombardiaItaly
| | | | | | - Monica Musarra
- Nuclear Medicine UnitSan Gerardo HospitalMonzaLombardiaItaly
| | | | - Ildebrando Appollonio
- Neurology, School of MedicineUniversity of Milano—BicoccaMonzaItaly,Milan Center for NeurosciencesNeuroMIMilanItaly,Neurology DepartmentSan Gerardo HospitalMonzaLombardiaItaly
| | - Carlo Ferrarese
- Neurology, School of MedicineUniversity of Milano—BicoccaMonzaItaly,Milan Center for NeurosciencesNeuroMIMilanItaly,Neurology DepartmentSan Gerardo HospitalMonzaLombardiaItaly
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Butts AM, Machulda MM, Martin P, Przybelski SA, Duffy JR, Graff-Radford J, Knopman DS, Petersen RC, Jack CR, Lowe VJ, Josephs KA, Whitwell JL. Temporal Cortical Thickness and Cognitive Associations among Typical and Atypical Phenotypes of Alzheimer's Disease. J Alzheimers Dis Rep 2022; 6:479-491. [PMID: 36186727 PMCID: PMC9484150 DOI: 10.3233/adr-220010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/29/2022] [Indexed: 11/15/2022] Open
Abstract
Background The hippocampus and temporal lobe are atrophic in typical amnestic Alzheimer's disease (tAD) and are used as imaging biomarkers in treatment trials. However, a better understanding of how temporal structures differ across atypical AD phenotypes and relate to cognition is needed. Objective Our goal was to compare temporal lobe regions between tAD and two atypical AD phenotypes (logopenic progressive aphasia (LPA) and posterior cortical atrophy (PCA)), and assess cognitive associations. Methods We age and gender-matched 77 tAD participants to 50 LPA and 27 PCA participants, all of which were amyloid-positive. We used linear mixed-effects models to compare FreeSurfer-derived hippocampal volumes and cortical thickness of entorhinal, inferior and middle temporal, and fusiform gyri, and to assess relationships between imaging and memory, naming, and visuospatial function across and within AD phenotype. Results Hippocampal volume and entorhinal thickness were smaller bilaterally in tAD than LPA and PCA. PCA showed greater right inferior temporal and bilateral fusiform thinning and LPA showed greater left middle and inferior temporal and left fusiform thinning. Atypical AD phenotypes differed with greater right hemisphere thinning in PCA and greater left hemisphere thinning in LPA. Verbal and visual memory related most strongly to hippocampal volume; naming related to left temporal thickness; and visuospatial related to bilateral fusiform thickness. Fewer associations remained when examined within AD group. Conclusion Atypical AD phenotypes are associated with greater thinning of lateral temporal structures, with relative sparing of medial temporal lobe, compared to tAD. These findings may have implications for future clinical trials in AD.
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Affiliation(s)
- Alissa M. Butts
- Department of Neurology, Division of Neuropsychology, Medical College of Wisconsin, Milwaukee, WI, USA,External Research Collaborator, Mayo Clinic, Rochester, MN, USA
| | - Mary M. Machulda
- Department of Psychiatry and Psychology, Division of Neuropsychology, Mayo Clinic, Rochester, MN, USA
| | - Peter Martin
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | | | | | - Val J. Lowe
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Jennifer L. Whitwell
- Department of Radiology, Mayo Clinic, Rochester, MN, USA,Correspondence to: Jennifer L. Whitwell, PhD, Professor of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA. E-mail:
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Singh NA, Tosakulwong N, Graff-Radford J, Machulda MM, Pham NTT, Sintini I, Weigand SD, Schwarz CG, Senjem ML, Carrasquillo MM, Ertekin-Taner N, Jack CR, Lowe VJ, Josephs KA, Whitwell JL. APOE ε4 influences medial temporal atrophy and tau deposition in atypical Alzheimer's disease. Alzheimers Dement 2022; 19:10.1002/alz.12711. [PMID: 35691047 PMCID: PMC9742387 DOI: 10.1002/alz.12711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Apolipoprotein E (APOE) ε4 is an important genetic risk factor for typical Alzheimer's disease (AD), influencing brain volume and tau burden. Little is known about its influence in atypical presentations of AD. METHODS An atypical AD cohort of 140 patients diagnosed with either posterior cortical atrophy or logopenic progressive aphasia underwent magnetic resonance imaging and positron emission tomography. Linear mixed effects models were fit to assess the influence of APOE ε4 on cross-sectional and longitudinal regional metrics. RESULTS At baseline, APOE ε4 carriers had smaller hippocampal and amygdala volumes and greater tau standardized uptake volume ratio in the hippocampus and entorhinal cortex compared to non-carriers while longitudinally, APOE ε4 non-carriers showed faster rates of atrophy and tau accumulation in the entorhinal cortex, with faster tau accumulation in the hippocampus. DISCUSSION APOE ε4 influences patterns of neurodegeneration and tau deposition and was associated with more medial temporal involvement, although there is evidence that non-carriers may be catching up over time.
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Affiliation(s)
| | | | | | - Mary M. Machulda
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | | | - Irene Sintini
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Stephen D. Weigand
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | | | - Val J. Lowe
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Josephs KA, Pham NTT, Graff-Radford J, Machulda MM, Lowe VJ, Whitwell JL. Medial Temporal Atrophy in Posterior Cortical Atrophy and Its Relationship to the Cingulate Island Sign. J Alzheimers Dis 2022; 86:491-498. [DOI: 10.3233/jad-215263] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background: It has been hypothesized that medial temporal sparing may be related to preserved posterior cingulate metabolism and the cingulate island sign (CIS) on [18F]fluorodeoxyglucose (FDG) PET in posterior cortical atrophy (PCA). Objective: To assess the severity of medial temporal atrophy in PCA and determine whether the presence of a CIS is related to medial temporal sparing. Methods: Fifty-five PCA patients underwent MRI and FDG-PET. The degree and symmetry of medial temporal atrophy on MRI was visually assessed using a five-point scale for both hemispheres. Visual assessments of FDG-PET coded the presence/absence of a CIS and whether the CIS was symmetric or asymmetric. Hippocampal volumes and a quantitative CIS were also measured. Results: Medial temporal atrophy was most commonly mild or moderate, was symmetric in 55% of patients, and when asymmetric was most commonly worse on the right (76%). Older age and worse memory performance were associated with greater medial temporal atrophy. The CIS was observed in 44% of the PCA patients and was asymmetric in 50% of these. The patients with a CIS showed greater medial temporal asymmetry, but did not show lower medial temporal atrophy scores, compared to those without a CIS. Hippocampal volumes were not associated with quantitative CIS. Conclusion: Mild medial temporal atrophy is a common finding in PCA and is associated with memory impairment. However, medial temporal sparing was not related to the presence of a CIS in PCA.
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Affiliation(s)
| | | | | | - Mary M. Machulda
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Val J. Lowe
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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13
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Chaudhary S, Zhornitsky S, Chao HH, van Dyck CH, Li CSR. Emotion Processing Dysfunction in Alzheimer's Disease: An Overview of Behavioral Findings, Systems Neural Correlates, and Underlying Neural Biology. Am J Alzheimers Dis Other Demen 2022; 37:15333175221082834. [PMID: 35357236 PMCID: PMC9212074 DOI: 10.1177/15333175221082834] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
We described behavioral studies to highlight emotional processing deficits in Alzheimer's disease (AD). The findings suggest prominent deficit in recognizing negative emotions, pronounced effect of positive emotion on enhancing memory, and a critical role of cognitive deficits in manifesting emotional processing dysfunction in AD. We reviewed imaging studies to highlight morphometric and functional markers of hippocampal circuit dysfunction in emotional processing deficits. Despite amygdala reactivity to emotional stimuli, hippocampal dysfunction conduces to deficits in emotional memory. Finally, the reviewed studies implicating major neurotransmitter systems in anxiety and depression in AD supported altered cholinergic and noradrenergic signaling in AD emotional disorders. Overall, the studies showed altered emotions early in the course of illness and suggest the need of multimodal imaging for further investigations. Particularly, longitudinal studies with multiple behavioral paradigms translatable between preclinical and clinical models would provide data to elucidate the time course and underlying neurobiology of emotion processing dysfunction in AD.
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Affiliation(s)
- Shefali Chaudhary
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Simon Zhornitsky
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Herta H. Chao
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA,VA Connecticut Healthcare System, West Haven, CT, USA
| | - Christopher H. van Dyck
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA,Department of Neuroscience, Yale University School of Medicine, New Haven, CT, USA,Interdepartmental Neuroscience Program, Yale University School of Medicine, New Haven, CT, USA
| | - Chiang-Shan R. Li
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA,Department of Neuroscience, Yale University School of Medicine, New Haven, CT, USA,Interdepartmental Neuroscience Program, Yale University School of Medicine, New Haven, CT, USA,Wu Tsai Institute, Yale University, New Haven, CT, USA
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14
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Buciuc M, Duffy JR, Machulda MM, Graff-Radford J, Pham NTT, Martin PR, Senjem ML, Jack CR, Ertekin-Taner N, Dickson DW, Lowe VJ, Whitwell JL, Josephs KA. Clinical, Imaging, and Pathologic Characteristics of Patients With Right vs Left Hemisphere-Predominant Logopenic Progressive Aphasia. Neurology 2021; 97:e523-e534. [PMID: 34088877 DOI: 10.1212/wnl.0000000000012322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/27/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess and compare demographic, clinical, neuroimaging, and pathologic characteristics of a cohort of patients with right hemisphere-predominant vs left hemisphere-predominant logopenic progressive aphasia (LPA). METHODS This is a case-control study of patients with LPA who were prospectively followed at Mayo Clinic and underwent [18F]-fluorodeoxyglucose (FDG) PET scan. Patients were classified as rLPA if right temporal lobe metabolism was ≥1 SD lower than left temporal lobe metabolism. Patients with rLPA were frequency-matched 3:1 to typical left-predominant LPA based on degree of asymmetry and severity of temporal lobe metabolism. Patients were compared on clinical, imaging (MRI, FDG-PET, β-amyloid, and tau-PET), and pathologic characteristics. RESULTS Of 103 prospectively recruited patients with LPA, 8 (4 female) were classified as rLPA (7.8%); all patients with rLPA were right-handed. Patients with rLPA had milder aphasia based on the Western Aphasia Battery-Aphasia Quotient (p = 0.04) and less frequent phonologic errors (p = 0.015). Patients with rLPA had shorter survival compared to typical LPA: hazard ratio 4.0 (1.2-12.9), p = 0.02. There were no other differences in demographics, handedness, genetics, or neurologic or neuropsychological tests. Compared to the 24 frequency-matched patients with typical LPA, patients with rLPA showed greater frontotemporal hypometabolism of the nondominant hemisphere on FDG-PET and less atrophy in amygdala and hippocampus of the dominant hemisphere. Autopsy evaluation revealed a similar distribution of pathologic findings in both groups, with Alzheimer disease pathologic changes being the most frequent pathology. CONCLUSIONS rLPA is associated with less severe aphasia but has shorter survival from reported symptom onset than typical LPA, possibly related to greater involvement of the nondominant hemisphere.
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Affiliation(s)
- Marina Buciuc
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL
| | - Joseph R Duffy
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL
| | - Mary M Machulda
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL
| | - Jonathan Graff-Radford
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL
| | - Nha Trang Thu Pham
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL
| | - Peter R Martin
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL
| | - Matthew L Senjem
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL
| | - Clifford R Jack
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL
| | - Nilüfer Ertekin-Taner
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL
| | - Dennis W Dickson
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL
| | - Val J Lowe
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL
| | - Jennifer L Whitwell
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL
| | - Keith Anthony Josephs
- From the Departments of Neurology (M.B., J.R.D., J.G.-R., K.A.J.), Psychiatry and Psychology (M.M.M.), Radiology (N.T.T.P., M.L.S., C.R.J., V.J.L., J.L.W.), Health Science Research (P.R.M.), and Information Technology (M.L.S.), Mayo Clinic, Rochester, MN; and Departments of Neurology (N.E.-T.) and Neuroscience (N.E.-T., D.W.D.), Mayo Clinic, Jacksonville, FL.
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