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1.  Feasibility of Discriminating Uric-Acid from Non-Uric-Acid Renal Stones Using Serially Acquired Low- and High-energy CT Scans on a Single-Source CT Scanner 
To demonstrate the feasibility of differentiating uric acid (UA) and non-uric-acid (NUA) renal stones using two consecutive, spatially-registered low- and high-energy scans acquired on a conventional CT system.
Materials and Methods
A total of 34 patients undergoing clinically indicated dual-source, dual-energy CT exams to differentiate UA and NUA kidney stones were enrolled in this IRB-approved study. Immediately after clinically-indicated dual-source, dual-energy CT and written informed consent, two consecutive scans (one at 80 kV and one at 140 kV) were performed on a conventional CT scanner over the region limited to stones identified on the dual-source scan. After 3D deformable registration of the 80 and 140 kV images, UA and non-UA stones were identified using commercial software. Sensitivity, specificity, and accuracy of stone classification were calculated using the dual-source results as the reference standard.
A total of 469 stones were identified in dual-source exams (26 UA and 443 NUA). Average in-plane stone diameter was 4.4 ± 2.5 mm (range 2.0 to 18.9 mm). Overall sensitivity, specificity, and accuracy for identifying UA stones were 73%, 90%, and 89%, respectively. The sensitivity, specificity, and accuracy were 95%, 97%, and 97% for stones ≥3 mm (n = 341, 19 UA and 322 NUA).
Accurate differentiation of UA and NUA renal stones is feasible using two consecutively-acquired and spatially-registered conventional CT scans.
PMCID: PMC4280671  PMID: 25539242
2.  Prominent Phenotypic Variability Associated with Mutations in Progranulin 
Neurobiology of aging  2007;30(5):739-751.
Mutations in progranulin (PGRN) are associated with frontotemporal dementia with or without parkinsonism. We describe the prominent phenotypic variability within and among eight kindreds evaluated at Mayo Clinic Rochester and/or Mayo Clinic Jacksonville in whom mutations in PGRN were found. All available clinical, genetic, neuroimaging and neuropathologic data was reviewed. Age of onset ranged from 49 to 88 years and disease duration ranged from 1 to 14 years. Clinical diagnoses included frontotemporal dementia (FTD), primary progressive aphasia, FTD with parkinsonism, parkinsonism, corticobasal syndrome, Alzheimer’s disease, amnestic mild cognitive impairment, and others. One kindred exhibited maximal right cerebral hemispheric atrophy in all four affected individuals, while another had maximal left hemisphere involvement in all three of the affected. Neuropathologic examination of 13 subjects revealed frontotemporal lobar degeneration with ubiquitin-positive inclusions plus neuronal intranuclear inclusions in all cases. Age of onset, clinical phenotypes and MRI findings associated with most PGRN mutations varied significantly both within and among kindreds. Some kindreds with PGRN mutations exhibited lateralized topography of degeneration across all affected individuals.
PMCID: PMC3164546  PMID: 17949857
Frontotemporal dementia; FTDP-17; Progranulin; PGRN; MRI
3.  Antemortem MRI based Structural Abnormality Index (STAND)-Scores Correlate with Postmortem Braak Neurofibrillary Tangle Stage 
NeuroImage  2008;42(2):559-567.
The clinical diagnosis of Alzheimer Disease (AD) does not exactly match the pathological findings at autopsy in every subject. Therefore, in-vivo imaging measures, such as Magnetic Resonance Imaging (MRI) that measure anatomical variations in each brain due to atrophy, would be clinically useful independent supplementary measures of pathology. We have developed an algorithm that extracts atrophy information from individual patient’s 3D MRI scans and assigns a STructural Abnormality iNDex (STAND)-score to the scan based on the degree of atrophy in comparison to patterns extracted from a large library of clinically well characterized AD and CN (cognitively normal) subject’s MRI scans. STAND-scores can be adjusted for demographics to give adjusted-STAND (aSTAND)-scores which are typically > 0 for subjects with abnormal brains. Since histopathological findings are considered to represent the “ground truth”, our objective was to assess the sensitivity of aSTAND-scores to pathological AD staging. This was done by comparing antemortem MRI based aSTAND-scores with post mortem grading of disease severity in 101 subjects who had both antemortem MRI and postmortem Braak neurofibrillary tangle (NFT) staging. We found a rank correlation of 0.62 (p<0.0001) between Braak NFT stage and aSTAND-scores. The results show that optimally extracted information from MRI scans such as STAND-scores accurately capture disease severity and can be used as an independent approximate surrogate marker for in-vivo pathological staging as well as for early identification of AD in individual subjects.
PMCID: PMC3097053  PMID: 18572417
Alzheimer Disease; neurofibrillary tangles; amnestic mild cognitive impairment; Braak NFT stage; magnetic resonance imaging
4.  Mild cognitive impairment associated with limbic and neocortical lewy body disease: a clinicopathological study 
Brain  2009;133(2):540-556.
There are little data on the relationship between Lewy body disease and mild cognitive impairment syndromes. The Mayo Clinic aging and dementia databases in Rochester, Minnesota, and Jacksonville, Florida were queried for cases who were diagnosed with mild cognitive impairment between 1 January 1996 and 30 April 2008, were prospectively followed and were subsequently found to have autopsy-proven Lewy body disease. The presence of rapid eye movement sleep behaviour disorder was specifically assessed. Mild cognitive impairment subtypes were determined by clinical impression and neuropsychological profiles, based on prospective operational criteria. The diagnosis of clinically probable dementia with Lewy bodies was based on the 2005 McKeith criteria. Hippocampal volumes, rate of hippocampal atrophy, and proton magnetic resonance spectroscopy were assessed on available magnetic resonance imaging and spectroscopy scans. Eight subjects were identified; six were male. Seven developed dementia with Lewy bodies prior to death; one died characterized as mild cognitive impairment. The number of cases and median age of onset (range) for specific features were: seven with rapid eye movement sleep behaviour disorder—60 years (27–91 years), eight with cognitive symptoms—69 years (62–89 years), eight with mild cognitive impairment—70.5 years (66–91 years), eight with parkinsonism symptoms—71 years (66–92 years), six with visual hallucinations—72 years (64–90 years), seven with dementia—75 years (67–92 years), six with fluctuations in cognition and/or arousal—76 years (68–92 years) and eight dead—76 years (71–94 years). Rapid eye movement sleep behaviour disorder preceded cognitive symptom onset in six cases by a median of 10 years (2–47 years) and mild cognitive impairment diagnosis by a median of 12 years (3–48 years). The mild cognitive impairment subtypes represented include: two with single domain non-amnestic mild cognitive impairment, three with multi-domain non-amnestic mild cognitive impairment, and three with multi-domain amnestic mild cognitive impairment. The cognitive domains most frequently affected were attention and executive functioning, and visuospatial functioning. Hippocampal volumes and the rate of hippocampal atrophy were, on average, within the normal range in the three cases who underwent magnetic resonance imaging, and the choline/creatine ratio was elevated in the two cases who underwent proton magnetic resonance spectroscopy when they were diagnosed as mild cognitive impairment. On autopsy, six had neocortical-predominant Lewy body disease and two had limbic-predominant Lewy body disease; only one had coexisting high-likelihood Alzheimer's disease. These findings indicate that among Lewy body disease cases that pass through a mild cognitive impairment stage, any cognitive pattern or mild cognitive subtype is possible, with the attention/executive and visuospatial domains most frequently impaired. Hippocampal volume and proton magnetic resonance spectroscopy data were consistent with recent data in dementia with Lewy bodies. All cases with rapid eye movement sleep behaviour disorder and mild cognitive impairment were eventually shown to have autopsy-proven Lewy body disease, indicating that rapid eye movement sleep behaviour disorder plus mild cognitive impairment probably reflects brainstem and cerebral Lewy body disease.
PMCID: PMC2822633  PMID: 19889717
mild cognitive impairment; dementia; dementia with Lewy bodies; Lewy body disease; neuropathology
5.  Alzheimer's Disease-Like Phenotype Associated With the c.154delA Mutation in Progranulin 
Archives of neurology  2010;67(2):171-177.
To characterize a kindred with a familial neurodegenerative disorder associated with a mutation in progranulin (PGRN), emphasizing the unique clinical features in this kindred.
Clinical, radiologic, pathologic, and genetic characterization of a kindred with a familial neurodegenerative disorder.
Multispecialty group academic medical center.
Affected members of a kindred with dementia +/- parkinsonism associated with a unique mutation in PGRN.
Main Outcome Measure
Genotype-phenotype correlation.
Ten affected individuals were identified, among whom six presented with initial amnestic complaints resulting in initial diagnoses of AD or amnestic mild cognitive impairment (MCI). A minority of individuals presented with features characteristic of FTD. The ages of onset of generation II (mean 75.8 years, range 69-80 years) were far greater than those of generation III (mean 60.7 years, range 55-66 years). The pattern of cerebral atrophy varied widely among affected individuals. Neuropathology in six individuals showed frontotemporal lobar degeneration with ubiquitin positive neuronal cytoplasmic and intranuclear inclusions (FTLD-U + NII). PGRN analysis revealed a single base pair deletion in exon 2 (c.154delA), causing a frameshift (p.Thr52Hisfs×2) and therefore creation of a premature termination codon and likely null allele.
We describe a large kindred in which the majority of affected individuals had clinical presentations resembling AD or amnestic MCI in association with a mutation in PGRN and underlying FTLD-U + NII neuropathology. This is in distinct contrast to previously reported kindreds, where clinical presentations have typically been within the spectrum of FTLD. The basis for the large difference in age of onset between generations will require further study.
PMCID: PMC2902004  PMID: 20142525
MRI; progranulin; frontotemporal dementia; PGRN
6.  Distinct anatomical subtypes of the behavioural variant of frontotemporal dementia: a cluster analysis study 
Brain  2009;132(11):2932-2946.
The behavioural variant of frontotemporal dementia is a progressive neurodegenerative syndrome characterized by changes in personality and behaviour. It is typically associated with frontal lobe atrophy, although patterns of atrophy are heterogeneous. The objective of this study was to examine case-by-case variability in patterns of grey matter atrophy in subjects with the behavioural variant of frontotemporal dementia and to investigate whether behavioural variant of frontotemporal dementia can be divided into distinct anatomical subtypes. Sixty-six subjects that fulfilled clinical criteria for a diagnosis of the behavioural variant of frontotemporal dementia with a volumetric magnetic resonance imaging scan were identified. Grey matter volumes were obtained for 26 regions of interest, covering frontal, temporal and parietal lobes, striatum, insula and supplemental motor area, using the automated anatomical labelling atlas. Regional volumes were divided by total grey matter volume. A hierarchical agglomerative cluster analysis using Ward's clustering linkage method was performed to cluster the behavioural variant of frontotemporal dementia subjects into different anatomical clusters. Voxel-based morphometry was used to assess patterns of grey matter loss in each identified cluster of subjects compared to an age and gender-matched control group at P < 0.05 (family-wise error corrected). We identified four potentially useful clusters with distinct patterns of grey matter loss, which we posit represent anatomical subtypes of the behavioural variant of frontotemporal dementia. Two of these subtypes were associated with temporal lobe volume loss, with one subtype showing loss restricted to temporal lobe regions (temporal-dominant subtype) and the other showing grey matter loss in the temporal lobes as well as frontal and parietal lobes (temporofrontoparietal subtype). Another two subtypes were characterized by a large amount of frontal lobe volume loss, with one subtype showing grey matter loss in the frontal lobes as well as loss of the temporal lobes (frontotemporal subtype) and the other subtype showing loss relatively restricted to the frontal lobes (frontal-dominant subtype). These four subtypes differed on clinical measures of executive function, episodic memory and confrontation naming. There were also associations between the four subtypes and genetic or pathological diagnoses which were obtained in 48% of the cohort. The clusters did not differ in behavioural severity as measured by the Neuropsychiatric Inventory; supporting the original classification of the behavioural variant of frontotemporal dementia in these subjects. Our findings suggest behavioural variant of frontotemporal dementia can therefore be subdivided into four different anatomical subtypes.
PMCID: PMC2768663  PMID: 19762452
behavioural variant frontotemporal dementia; atrophy; cluster analysis; voxel-based morphometry
7.  Effects of age on the glucose metabolic changes in mild cognitive impairment 
Background and Purpose
Decreased glucose metabolism in the temporal and parietal lobes on [18F]fluorodeoxyglucose (FDG) PET is recognized as an early imaging marker for the Alzheimer’s disease (AD) pathology. Our objective was to investigate the effects of age on FDG PET findings in aMCI.
25 patients with aMCI at 55–86 years of age (median = 73), and 25 age and gender matched cognitively normal (CN) subjects underwent FDG PET. SPM5 was used to compare the FDG uptake in aMCI-old (>73 years) and aMCI-young (>73 years) patients to CN subjects. The findings in the aMCI-old patients were independently validated in a separate cohort of 10 aMCI and 13 CN subjects older than 73 years of age.
The pattern of decreased glucose metabolism and gray matter atrophy in the medial temporal, posterior cingulate, precuneus, lateral parietal and temporal lobes in aMCI-young subjects was consistent with the typical pattern observed in AD. The pattern of glucose metabolic changes in aMCI-old subjects was different, predominantly involving the frontal lobes and the left parietal lobe. Gray matter atrophy in aMCI-old subjects was less pronounced than the aMCI-young subjects involving the hippocampus and the basal forebrain in both hemispheres
Pathological heterogeneity may be underlying the absence of AD-like glucose metabolic changes in older compared to younger aMCI patients. This may be an important consideration for the clinical use of temporoparietal hypometabolism on FDG PET as a marker for early diagnosis of AD in aMCI.
PMCID: PMC2890033  PMID: 20299441
8.  Very Early Semantic Dementia With Progressive Left≫Right Temporal Lobe Atrophy: An Eight-Year Longitudinal Study 
Archives of neurology  2008;65(12):1659-1663.
Semantic dementia (SD) is a syndrome within the spectrum of frontotemporal lobar degenerations (FTLD) characterized by fluent progressive aphasia (particularly anomia) and loss of word meaning.
To report a unique case of very early semantic dementia with slowly progressive course allowing insights into the early natural history of this disorder.
Case report.
Tertiary care university hospital and academic center.
A 62-year-old female retired teacher presenting with “memory” complaints.
Main Outcome Measures
Clinical course, neuropsychological data, MRI.
The patient was first evaluated when standard neuropsychological measures were normal, but subtle left anterior temporal lobe atrophy was present. Over the follow-up period of eight years, she developed profound anomia and loss of word meaning associated with progressive left anterior temporal lobe atrophy consistent with semantic dementia. In more recent years, anterograde memory impairment as well as mild prosopagnosia have evolved in association with left hippocampal atrophy and subtle atrophy in the homologous gyri of the right anterior temporal lobe. She remains functionally independent despite her current deficits.
Early identification of patients who will develop semantic dementia is difficult and might be missed with standard clinical, neuropsychological, and structural neuroimaging evaluations. Recognition of this relatively rare syndrome is important for early diagnosis and prognostication, and particularly for therapeutic interventions in the future.
PMCID: PMC2902001  PMID: 19064755
frontotemporal lobar degeneration; semantic dementia; MRI; neuropsychology
9.  Comparison of 18F-FDG and PiB PET in Cognitive Impairment 
The purpose of this study was to compare the diagnostic accuracy of glucose metabolism and amyloid deposition as demonstrated by 18F-FDG and Pittsburg Compound B (PiB) PET to evaluate subjects with cognitive impairment.
Subjects were selected from existing participants in the Mayo Alzheimer’s Disease Research Center or Alzheimer’s Disease Patient Registry programs. A total of 20 healthy controls and 17 amnestic mild cognitive impairment (aMCI), 6 nonamnestic mild cognitive impairment (naMCI), and 13 Alzheimer disease (AD) subjects were imaged with both PiB and 18F-FDG PET between March 2006 and August 2007. Global measures for PiB and 18F-FDG PET uptake, normalized to cerebellum for PiB and pons for 18F-FDG, were compared. Partial-volume correction, standardized uptake value (SUV), and cortical ratio methods of image analysis were also evaluated in an attempt to optimize the analysis for each test.
Significant discrimination (P < 0.05) between controls and AD, naMCI and aMCI, naMCI and AD, and aMCI and AD by PiB PET measurements was observed. The paired groupwise comparisons of the global measures demonstrated that PiB PET versus 18F-FDG PET showed similar significant group separation, with only PiB showing significant separation of naMCI and aMCI subjects.
PiB PET and 18F-FDG PET have similar diagnostic accuracy in early cognitive impairment. However, significantly better group discrimination in naMCI and aMCI subjects by PiB, compared with 18F-FDG, was seen and may suggest early amyloid deposition before cerebral metabolic disruption in this group.
PMCID: PMC2886669  PMID: 19443597
PET; dementia; 18F-FDG; PiB
This study compares diagnostic accuracy of magnetic resonance (MR)-based hippocampal volumetry, single voxel (SV) 1H MR Spectroscopy (MRS) and MR diffusion weighted imaging (DWI) measurements in discriminating patients with amnestic mild cognitive impairment (MCI), Alzheimer’s disease (AD) and normally aging elderly. Sixty-one normally aging elderly, 24 MCI, and 22 AD patients underwent MR-based hippocampal volumetry, 1H MRS, and DWI. 1H MRS voxels were placed over both of the posterior cingulate gyri and N-acetyl aspartate (NAA) / creatine (Cr), myoinositol (MI) /Cr and NAA /MI ratios were obtained. Apparent diffusion coefficient (ADC) maps were derived from DWI and hippocampal borders were traced to measure hippocampal ADC. At 80% specificity, the most sensitive single measurement to discriminate MCI (79 %) and AD (86 %) from controls was hippocampal volumes. The most sensitive single measurement to discriminate AD from MCI was posterior cingulate gyrus NAA /Cr (67 %). At high specificity (>85 –90%) combinations of MR measures had superior diagnostic sensitivity compared to any single MR measurement for the AD vs. control and control vs. MCI comparisons. The MR measures that best discriminate more from less affected individuals along the cognitive continuum from normal to AD vary with disease severity. Selection of imaging measures used for clinical assessment or monitoring efficiency of therapeutic intervention should be tailored to the clinical stage of the disease.
PMCID: PMC2796574  PMID: 12411762
Alzheimer’s disease; mild cognitive impairment; 1H MRS; diffusion weighted imaging; hippocampal volumetry; MRI
Neurology  2005;64(5):902-904.
This study tests if measures of hippocampal water diffusivity at baseline can predict future progression to Alzheimer’s Disease (AD) in amnestic mild cognitive impairment (aMCI). Higher baseline hippocampal diffusivity was associated with a greater hazard of progression to AD in aMCI (p=0.002). MR diffusion weighted imaging (DWI) may help identify patients with aMCI who will progress to AD as well or better than structural MRI measures of hippocampal atrophy.
PMCID: PMC2771335  PMID: 15753434
12.  Longitudinal 1H MRS changes in mild cognitive impairment and Alzheimer’s disease 
Neurobiology of aging  2006;28(9):1330-1339.
Magnetic Resonance (MR)- based volume measurements of atrophy are potential markers of disease progression in patients with amnestic mild cognitive impairment (aMCI) and Alzheimer’s disease (AD). Longitudinal changes in 1H MR spectroscopy (1H MRS) metabolite markers have not been characterized in aMCI subjects. Our objective was to determine the longitudinal 1H MRS metabolite changes in patients with aMCI, and AD, and to compare 1H MRS metabolite ratios and ventricular volumes in tracking clinical disease progression in AD. The neuronal integrity marker N-acetylaspartate/Creatine ratio declined in aMCI and AD patients compared to cognitively normal elderly. The changein 1H MRS metabolite ratios correlated with clinical progression about as strongly as the rate of ventricular expansion, suggesting that 1H MRS metabolite ratios may be useful markers for the progression of AD. Choline/Creatine ratio declined in stable aMCI, compared to converter aMCI patients and cognitively normal elderly, which may be related to a compensatory mechanism in aMCI patients who did not to progress to AD.
PMCID: PMC2766807  PMID: 16860440
1H MR spectroscopy; 1H MRS; imaging; Alzheimer’s disease; mild cognitive impairment; serial; longitudinal; N-acetylaspartate; choline
13.  FLAIR Histogram Segmentation for Measurement of Leukoaraiosis Volume 
The purpose of this study was to develop a method to measure brain and white matter hyperintensity (leukoaraiosis) volume that is based on the segmentation of the intensity histogram of fluid attenuated inversion recovery (FLAIR) images, and to assess the accuracy and reproducibility of the method. Whole head synthetic image phantoms with manually introduced leukoaraiosis lesions of varying severity were constructed. These synthetic image phantom sets incorporated image contrast and anatomic features which mimicked leukoaraiosis found in real life. One set of synthetic image phantoms was used to develop the segmentation algorithm (FLAIR-histoseg). A second set was used to measure its accuracy. Test re-test reproducibility was assessed in 10 elderly volunteers who were imaged twice. The mean absolute error of the FLAIR-histoseg method for measurement of leukoaraiosis volume was 6.6% and for brain volume 1.4%. The mean test re-test coefficient of variation for leukoaraiosis volume was 1.4% and for brain volume was 0.3%. We conclude that the FLAIR-histoseg method is an accurate and reproducible method for measuring leukoaraiosis and whole brain volume in elderly subjects.
PMCID: PMC2755497  PMID: 11747022
quantitative MRI; pulse sequences; segmentation; white matter disease; dementia
14.  Hippocampal Volumes, Proton Magnetic Resonance Spectroscopy Metabolites, and Cerebrovascular Disease in Mild Cognitive Impairment Subtypes 
Archives of neurology  2008;65(12):1621-1628.
Although a majority of patients with amnestic mild cognitive impairment (aMCI) progress to Alzheimer disease, the natural history of nonamnestic MCI (naMCI) is less clear. Noninvasive imaging surrogates for underlying pathological findings in MCI would be clinically useful for identifying patients who may benefit from disease-specific treatments at the prodromal stage of dementia.
To determine the characteristic magnetic resonance imaging (MRI) and proton MR spectroscopy (1H MRS) profiles of MCI subtypes.
Case-control study.
Community-based sample at a tertiary referral center.
Ninety-one patients with single-domain aMCI, 32 patients with multiple-domain aMCI, 20 patients with single- or multiple-domain naMCI, and 100 cognitively normal elderly subjects frequency-matched by age and sex.
Main Outcome Measures
Posterior cingulate gyrus 1H MRS metabolite ratios, hippocampal volumes, and cerebrovascular disease on MRI.
Patients with single-domain aMCI were characterized by small hippocampal volumes and elevated ratios of myo-inositol to creatine levels. Patients with naMCI on average had normal hippocampal volumes and 1H MRS metabolite ratios, but a greater proportion (3 of 20 patients [15%]) had cortical infarctions compared with patients with single-domain aMCI (6 of 91 [7%]). For characterization of MCI subtypes, 1H MRS and structural MRI findings were complementary.
The MRI and 1H MRS findings in singledomain aMCI are consistent with a pattern similar to that of Alzheimer disease. Absence of this pattern on average in patients with naMCI suggests that cerebrovascular disease and other neurodegenerative diseases may be contributing to the cognitive impairment in many individuals with naMCI.
PMCID: PMC2743393  PMID: 19064749
15.  Methodological Considerations for Measuring Rates of Brain Atrophy 
To systematically compare two techniques for measuring brain atrophy rates from serial magnetic resonance imaging (MRI) studies.
Materials and Methods
Using the separation in atrophy rate between cohorts of cognitively normal elderly subjects and patients with Alzheimer's disease (AD) as the gold standard, we evaluated 1) different methods of computing volume change; 2) different methods for steps in image preprocessing - intensity normalization, alignment mask used, and bias field correction; 3) the effect of MRI acquisition hardware changes; and 4) the sensitivity of the method to variations in initial manual volume editing. For each of the preceding evaluations, measurements of whole-brain and ventricular atrophy rates were calculated.
In general, greater separation between the clinical groups was seen with ventricular rather than whole-brain measures. Surprisingly, neither the use of bias field correction nor a major hardware change between the scan pairs affected group separation.
Atrophy rate measurements from serial MRI are candidates for use as surrogate markers of disease progression in AD and other dementing neurodegenerative disorders. The final method has excellent precision and accurately captures the expected biology of AD - arguably the two most important features if this technique is to be used as a biomarker of disease progression.
PMCID: PMC2740859  PMID: 12815635
serial MRI; Alzheimer's Disease; Brain Atrophy
16.  Comparison of Different Methodological Implementations of Voxel-Based Morphometry in Neurodegenerative Disease 
NeuroImage  2005;26(2):600-608.
Voxel-based morphometry (VBM) is a popular method for probing inter-group differences in brain morphology. Variation in the detailed implementation of the algorithm, however, will affect the apparent results of VBM analyses and in turn the inferences drawn about the anatomic expression of specific disease states. We qualitatively assessed group comparisons of 43 normal elderly control subjects and 51 patients with probable Alzheimer's disease, using five different VBM variations. Based on the known pathologic expression of the disease, we evaluated the biological plausibility of each. The use of a custom template and custom tissue class prior probability images (priors) produced inter-group comparison maps with greater biological plausibility than the use of the Montreal Neurological Institute (MNI) template and priors. We present a method for initializing the normalization to a custom template, and conclude that, when incorporated into the VBM processing chain, it yields the most biologically plausible inter-group differences of the five methods presented.
PMCID: PMC2739382  PMID: 15907317
17.  Beta-amyloid burden is not associated with rates of brain atrophy 
Annals of neurology  2008;63(2):204-212.
To test the hypothesis that beta-amyloid (Aβ) burden is associated with rates of brain atrophy.
Forty-five subjects who had been prospectively studied, died, and had an autopsy diagnosis of low, intermediate, or high probability of Alzheimer's disease that had two volumetric head MRI scans were identified. Compact, as well as total (compact + diffuse) Aβ burden was measured using a computerized image analyzer with software program to detect the proportion of grey matter occupied by Aβ. Visual ratings of Aβ burden were also performed. The boundary-shift integral (BSI) was used to calculate change over time in whole brain and ventricular volume. All BSI results were annualized by adjusting for scan interval. Demographics, cognitive measures, clinical diagnoses, apolipoprotein E genotype, neurofibrillary tangle pathology, and vascular lesion burden were determined.
There was no correlation between compact or total Aβ burden, or visual Aβ 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 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 to non-demented subjects.
These findings suggest that rate of brain volume loss is not determined by the amount of insoluble Aβ in the grey matter.
PMCID: PMC2735194  PMID: 17894374
18.  Atrophy Rates Accelerate in Amnestic Mild Cognitive Impairment 
Neurology  2007;70(19 Pt 2):1740-1752.
We tested if rates of brain atrophy accelerate in individuals with amnestic mild cognitive impairment (aMCI) as they progress to typical late onset Alzheimer's Disease (AD). We included comparisons to aMCI subjects who did not progress (labeled aMCI-S) and also to cognitively normal elderly subjects (CN).
We studied 46 aMCI subjects who progressed to AD (labeled aMCI-P), 46 CN, and 23 aMCI-S. All subjects must have had three or more serial MRI scans. Rates of brain shrinkage and ventricular expansion were measured across all available serial MRI scans in each subject. Change in volumes relative to the point at which subjects progressed to a clinical diagnosis of AD (the index date) was modeled in aMCI-P. Change in volumes relative to age was modeled in all three clinical groups.
In aMCI-P the change in pre to post index rate (i.e. acceleration) of ventricular expansion was 1.7 cm3/yr, and acceleration in brain shrinkage was 5.3 cm3/yr. Brain volume declined and ventricular volume increased in all three groups with age. Volume changes decelerated with increasing age in aMCI-P, and to a lesser extent aMCI-S, but were linear in the matched CN. Among all aMCI subjects, rates of atrophy were greater in apolipoprotein E ε4 carriers than non-carriers.
Rates of atrophy accelerate as individuals progress from aMCI to typical late onset AD. Rates of atrophy are greater in younger than older aMCI-P and aMCI-S subjects. We did not find that atrophy rates varied with age in 70 – 90 year old CN subjects.
PMCID: PMC2734477  PMID: 18032747
19.  MRI patterns of atrophy associated with progression to AD in amnestic Mild Cognitive Impairment 
Neurology  2007;70(7):512-520.
To compare the patterns of grey matter loss in subjects with amnestic Mild Cognitive Impairment (aMCI) who progress to Alzheimer's disease within a fixed clinical follow-up time versus those who remain stable.
Twenty-one aMCI subjects were identified from the Mayo Clinic Alzheimer's research program that remained clinically stable for their entire observed clinical course (aMCI-S), where the minimum required follow-up time from MRI to last follow-up assessment was three years. These subjects were age and gender-matched to 42 aMCI subjects who progressed to AD within 18 months of the MRI (aMCI-P). Each subject was then age and gender-matched to a control subject. Voxel-based morphometry (VBM) was used to assess patterns of grey matter atrophy in the aMCI-P and aMCI-S groups compared to the control group, and compared to each other.
The aMCI-P group showed bilateral loss affecting the medial and inferior temporal lobe, temporoparietal association neocortex and frontal lobes, compared to controls. The aMCI-S group showed no regions of grey matter loss when compared to controls. When the aMCI-P and aMCI-S groups were compared directly, the aMCI-P group showed greater loss in the medial and inferior temporal lobes, the temporoparietal neocortex, posterior cingulate, precuneus, anterior cingulate, and frontal lobes than the aMCI-S group.
The regions of loss observed in aMCI-P are typical of subjects with AD. The lack of grey matter loss in the aMCI-S subjects is consistent with the notion that patterns of atrophy on MRI at baseline map well onto the subsequent clinical course.
PMCID: PMC2734138  PMID: 17898323
20.  Focal atrophy in Dementia with Lewy Bodies on MRI: a distinct pattern from Alzheimer's disease 
Brain : a journal of neurology  2007;130(Pt 3):708-719.
Dementia with Lewy Bodies (DLB) is the second most common cause of degenerative dementia after Alzheimer's disease (AD). However, unlike in AD the patterns of cerebral atrophy associated with DLB have not been well established. The aim of this study was to identify a signature pattern of cerebral atrophy in DLB and to compare it to the pattern found in AD. Seventy-two patients that fulfilled clinical criteria for probable DLB were age and gender-matched to 72 patients with probable AD and 72 controls. Voxel-based morphometry (VBM) was used to assess patterns of grey matter atrophy in the DLB and AD groups, relative to controls, after correction for multiple comparisons (p<0.05). Study specific templates and prior probability maps were used to avoid normalization and segmentation bias. Region-of-interest (ROI) analyses were also performed comparing loss of the midbrain, substantia innominata (SI), temporoparietal cortex and hippocampus between the groups. The DLB group showed very little cortical involvement on VBM with regional grey matter loss observed primarily in the dorsal midbrain, SI and hypothalamus. In comparison, the AD group showed a widespread pattern of grey matter loss involving the temporoparietal association cortices and the medial temporal lobes. The SI and dorsal midbrain were involved in AD however they were not identified as a cluster of loss discrete from uninvolved surrounding areas, as observed in the DLB group. On direct comparison between the two groups, the AD group showed greater loss in the medial temporal lobe and inferior temporal regions than the DLB group. The ROI analysis showed reduced SI and midbrain grey matter in both the AD and DLB groups. The SI grey matter was reduced more in AD than DLB, yet the midbrain was reduced more in DLB than AD. The hippocampus and temporoparietal cortex showed significantly greater loss in the AD group compared to the DLB group. A pattern of relatively focused atrophy of the midbrain, hypothalamus and SI, with a relative sparing of the hippocampus and temporoparietal cortex, is therefore suggestive of DLB and may aid in the differentiation of DLB from AD. These findings support recent pathological studies showing an ascending pattern of Lewy Body progression from brainstem to basal areas of the brain. Damage to this network of structures in DLB may affect a number of different neurotransmitter systems which in turn may contribute to a number of the core clinical features of DLB.
PMCID: PMC2730778  PMID: 17267521
Dementia with Lewy Bodies; Alzheimer's disease; voxel-based morphometry; magnetic resonance imaging; neurotransmitter systems
21.  11C PiB and Structural MRI Provide Complementary Information in Imaging of AD and Amnestic MCI 
Brain : a journal of neurology  2008;131(Pt 3):665-680.
Twenty cognitively normal (CN), 17 amnestic mild cognitive impairment (aMCI), and 8 subjects with probable Alzheimer's disease (AD) were imaged with both magnetic resonance imaging (MRI) and the amyloid labeling ligand 11C Pittsburgh Compound B (PiB). PiB retention was quantified as the ratio of uptake in cortical regions of interest (ROIs) to the uptake in the cerebellar ROI in images acquired 40-60 minute 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.
AD subjects had high global cortical PiB retention and low hippocampal volume; most CN subjects had low PiB retention and high hippocampal volume; and on average aMCI subjects were intermediate on both PiB and hippocampal volume. A target-to-cerebellar ratio of 1.5 was used to designate subjects as high vs. low PiB cortical retention. All AD subjects fell above this ratio as did 6/20 CN subjects and 9/17 MCI subjects, indicating bi-modal PiB retention in CN and aMCI. Interestingly, we found no consistent differences in learning and memory performance between high vs. low PiB CN subjects or high vs. low aMCI subjects.
The SPM/VBM voxel-wise comparisons of AD vs. CN subjects provided complementary information in that clear and meaningful similarities and differences in topographic 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. Lateral temporoparietal association cortex displayed both significant PiB retention and grey matter loss.
A voxel-wise SPM conjunction analysis of PiB uptake revealed that subjects with high PiB retention (high CN, high aMCI, and AD) shared a common PiB retention topographic pattern regardless of clinical category, and this PiB topographic pattern matched that of amyloid plaque distribution that has been established in autopsy studies of AD.
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 CN vs. aMCI which was not significant for PiB. PiB and MRI provided complementary information such that clinical diagnostic classification with both, in combination, was superior to either alone.
PMCID: PMC2730157  PMID: 18263627
Alzheimer's disease; Mild Cognitive Impairment; Pittsburgh Compound B; amyloid imaging; Magnetic Resonance Imaging; hippocampus
22.  Serial PIB and MRI in normal, mild cognitive impairment and Alzheimer's disease: implications for sequence of pathological events in Alzheimer's disease 
Brain  2009;132(5):1355-1365.
The purpose of this study was to use serial imaging to gain insight into the sequence of pathologic events in Alzheimer's disease, and the clinical features associated with this sequence. We measured change in amyloid deposition over time using serial 11C Pittsburgh compound B (PIB) positron emission tomography and progression of neurodegeneration using serial structural magnetic resonance imaging. We studied 21 healthy cognitively normal subjects, 32 with amnestic mild cognitive impairment and 8 with Alzheimer's disease. Subjects were drawn from two sources—ongoing longitudinal registries at Mayo Clinic, and the Alzheimer's disease Neuroimaging Initiative (ADNI). All subjects underwent clinical assessments, MRI and PIB studies at two time points, approximately one year apart. PIB retention was quantified in global cortical to cerebellar ratio units and brain atrophy in units of cm3 by measuring ventricular expansion. The annual change in global PIB retention did not differ by clinical group (P = 0.90), and although small (median 0.042 ratio units/year overall) was greater than zero among all subjects (P < 0.001). Ventricular expansion rates differed by clinical group (P < 0.001) and increased in the following order: cognitively normal (1.3 cm3/year) <  amnestic mild cognitive impairment (2.5 cm3/year) <  Alzheimer's disease (7.7 cm3/year). Among all subjects there was no correlation between PIB change and concurrent change on CDR-SB (r = −0.01, P = 0.97) but some evidence of a weak correlation with MMSE (r =−0.22, P = 0.09). In contrast, greater rates of ventricular expansion were clearly correlated with worsening concurrent change on CDR-SB (r = 0.42, P < 0.01) and MMSE (r =−0.52, P < 0.01). Our data are consistent with a model of typical late onset Alzheimer's disease that has two main features: (i) dissociation between the rate of amyloid deposition and the rate of neurodegeneration late in life, with amyloid deposition proceeding at a constant slow rate while neurodegeneration accelerates and (ii) clinical symptoms are coupled to neurodegeneration not amyloid deposition. Significant plaque deposition occurs prior to clinical decline. The presence of brain amyloidosis alone is not sufficient to produce cognitive decline, rather, the neurodegenerative component of Alzheimer's disease pathology is the direct substrate of cognitive impairment and the rate of cognitive decline is driven by the rate of neurodegeneration. Neurodegeneration (atrophy on MRI) both precedes and parallels cognitive decline. This model implies a complimentary role for MRI and PIB imaging in Alzheimer's disease, with each reflecting one of the major pathologies, amyloid dysmetabolism and neurodegeneration.
PMCID: PMC2677798  PMID: 19339253
Alzheimer's disease; amyloid imaging; magnetic resonance imaging, longitudinal imaging; mild cognitive impairment; Pittsburgh compound B

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