PET imaging of β-amyloid
Amyloid β (Aβ) is a peptide fragment (usually 39-42 amino acids) of the amyloid precursor protein (APP), which is a type-1 transmembrane protein. Aβ is cleaved from APP by β and γ-secretases, first at the NH2 terminus of Aβ by β-secretase, and then at the carboxylic acid terminus by γ-secretase, releasing Aβ from the rest of the APP into the extracellular space. Amyloid β is soluble and does not seem to possess a unique tertiary fold, but when abundant, can aggregate into fibrillar β-pleated sheet structure. Aβ42 is especially prone to self-aggregation. Amyloidosis is characterized by extracellular deposits of insoluble amyloid fibrils, leading to progressive dysfunction of the affected organ(s).
The extracellular Aβ aggregates are the main component of senile plaques in the brains of Alzheimer's disease (AD) patients. Amyloid plaques are also found in other neurological disorders, including Parkinson's disease, dementia with Lewy bodies, cerebral amyloid angiopathy (CAA), idiopathic normal pressure hydrocephalus (iNPH), and traumatic brain injury (TBI). The other characteristic protein depots in AD, intracellular neurofibrillary tangles, are composed of filaments of hyperphosphorylated tau protein.
APP and its two homologs amyloid-like proteins 1 and 2 (APLP1 and APLP2) have important functions in growth of neuron dendrites and axons, and synaptogenesis. They are also present in platelets, vascular endothelial cells, and in circulation. The CSF concentrations of Aβ42 and intermediate APP proteolysis products α-APP and β-APP are reduced in RR and PR forms of multiple sclerosis. Proteolytic processing of APP is upregulated in damaged axons, leading to accumulation of β-APP. Aβ can trigger microglial activation, and its levels are higher than normal in MS lesions. A component of myelin, MBP, inhibits Aβ fibril assembly.
Cardiac amyloidosis is caused by deposition of "amyloid" proteins (not Aβ) in the heart, leading to hypertrophy, diastolic dysfunction, and heart failure. Despite the different origins and contents of the protein deposits, cardiac amyloidosis is also being investigated as a potential target for β-amyloid PET (Antoni et al., 2013; Kero et al., 2016).
Higher concentrations of circulating APP and Aβ are associated with higher cardiovascular risk. Amyloid β is present in atherosclerotic plaques, possibly specifically in vulnerable plaques, providing a target for Aβ-PET (Hellberg et al., 2019).
Several PET radioligands have been developed for imaging amyloid-β plaques, including [11C]PIB, [18F]flutemetamol, [18F]florbetapir ([18F]AV-45, Amyvid), [18F]florbetaben ([18F]BAY94-9172), [18F]NAV4694 (AZD4694), and [18F]FACT. [18F]FDDNP is a radioligand that mainly binds Aβ but also to the neurofibrillary tangles.
Thioflavin T derivatives, such as [11C]PIB, [18F]florbetaben, [18F]florbetabir, and [18F]NAV4694, are not specific to fibrillar amyloid-β but have affinity to all molecular structures containing β-pleated sheets, including myelin. [11C]PIB binding is reduced in areas of white matter hyper-intensities (WMH) (Goodheart et al., 2015; Glodzik et al., 2015). The uptake of amyloid-β PET radioligands represents binding to both fibrillar and non-fibrillar Aβ (Biechele et al., 2022).
Flores et al (2023) reported that high level of skull uptake was seen in ∼16% of [18F]florbetabir PET scans; this was not caused only by defluorination of the radioligand, because increased [11C]PIB uptake in skull was seen in these cases, too. Skull uptake was more common on women, and lower skull density was related to higher [18F]florbetabir uptake. Skull uptake impacted quantitative estimates in temporal regions, and the resulting sex and age difference should be addressed in relevant PET studies (Flores et al., 2023).
Clinical brain studies with different Aβ radioligands can be converted to the same quantitative scale using centiloid scale method (Klunk et al., 2015; Rowe et al., 2016): The same young healthy subjects and typical AD subjects must be scanned twice with the two radioligands, usually [11C]PIB as the standard. PET images are transformed into reference brain atlas space based on anatomical MR or CT scans. From each a subject a ratio between cerebral neocortex and whole cerebellum is calculated. A linear transformation is then used to scale the mean of the young healthy subjects to a centiloid value of 0, and the mean of AD subjects to centiloid value of 100.
Global Aβ burden in human brain can be quantified from static PET scan as a single parameter AβL, which can be calculated using automated algorithm AmyloidIQ. AβL is calculated by modelling an SUVR image as a linear combination of two canonic images: K and NS. AβL is the scaling factor of the carrying capacity canonic image K (Whittington et al., 2018 and 2019). The method has also been applied to calculation of tau protein load (Whittington et al., 2021).
- Analysis of [11C]PIB PET
- Analysis of [18F]flutemetanol
- tau protein
- Cholinergic system
- Alzheimer's disease
Catafau AM, Bullich S. Amyloid PET imaging: applications beyond Alzheimer's disease. Clin Transl Imaging 2015; 3: 39-55. doi: 10.1007/s40336-014-0098-3.
Chapleau M, Iaccarino L, Soleimani-Meigooni D, Rabinovici GD. The role of amyloid PET in imaging neurodegenerative disorders: a review. J Nucl Med. 2022; 63(suppl 1): 13S-19S. doi: 10.2967/jnumed.121.263195.
Eckroat TJ, Mayhoub AS, Garneau-Tsodikova S. Amyloid-β probes: review of structure-activity and brain-kinetics relationships. Beilstein J Org Chem. 2013; 9: 1012-1044. doi: 10.3762/bjoc.9.116.
Eisenmenger LB, Huo EJ, Hoffman JM, Minoshima S, Matesan MC, Lewis DH, Lopresti BJ, Mathis CA, Okonkwo DO, Mountz JM. Advances in PET imaging of degenerative, cerebrovascular, and traumatic causes of dementia. Semin Nucl Med. 2016; 46(1): 57-87. doi: 10.1053/j.semnuclmed.2015.09.003.
Elbert DL, Patterson BW, Bateman RJ. Analysis of compartmental model of amyloid beta production, irreversible loss and exchange in humans. Math Biosci. 2015; 261: 48-61. doi: 10.1016/j.mbs.2014.11.004.
Klunk WE, Koeppe RA, Price JC, Benzinger TL, Devous MD Sr, Jagust WJ, Johnson KA, Mathis CA, Minhas D, Pontecorvo MJ, Rowe CC, Skovronsky DM, Mintun MA. The Centiloid Project: standardizing quantitative amyloid plaque estimation by PET. Alzheimers Dement. 2015; 11(1): 1-15. doi: 10.1016/j.jalz.2014.07.003.
Matias-Guiu JA, Oreja-Guevara C, Cabrera-Martin MN, Moreno-Ramos T, Carreras JL, Matias-Guiu J. Amyloid proteins and their role in multiple sclerosis. Considerations in the use of amyloid-PET imaging. Front Neurol. 2016; 7:53. doi: 10.3389/fneur.2016.00053.
Mathis CA, Wang Y, Klunk WE. Imaging β-amyloid plaques and neurofibrillary tangles in the aging human brain. Curr Pharm Design 2004; 10: 1469-1492. doi: 10.2174/1381612043384772.
Nordberg A. PET imaging of amyloid in Alzheimer's disease. Lancet Neurol. 2004; 3: 519-527. doi: 10.1016/S1474-4422(04)00853-1.
Prvulovic D, Hampel H. Amyloid β (Aβ) and phospho-tau (p-tau) as diagnostic biomarkers in Alzheimer's disease. Clin Chem Lab Med. 2011; 49(3): 367-374. doi: 10.1515/CCLM.2011.087.
Rowe CC, Villemagne VL. Amyloid imaging with PET in early Alzheimer disease diagnosis. Med Clin N Am.2013; 97: 377-398. doi: 10.1016/j.mcna.2012.12.017
Rowe CC, Jones G, Doré V, Pejoska S, Margison L, Mulligan RS, Chan JG, Young K, Villemagne VL. Standardized expression of 18F-NAV4694 and 11C-PiB β-amyloid PET results with the centiloid scale. J Nucl Med. 2016; 57(8): 1233-1237. doi: 10.2967/jnumed.115.171595.
Shokouhi S, Claassen D, Riddle WR. Imaging brain metabolism and pathology in Alzheimer's disease with positron emission tomography. J Alzheimers Dis Parkinsonism 2014; 4:2. doi: 10.4172/2161-0460.1000143.
Thal DR, Attems J, Ewers M. Spreading of amyloid, tau, and microvascular pathology in Alzheimer's disease: findings from neuropathological and neuroimaging studies. J Alzheimers Dis. 2014; 42(Suppl 4):S421-S429. doi: 10.3233/JAD-141461.
Updated at: 2023-02-02
Created at: 2015-08-17
Written by: Vesa Oikonen