Diagnosis and management of dementia with Lewy bodies: Fourth consensus report of the DLB Consortium

Clinical characteristics of pathological confirmed DLB without parkinsonism

INTRODUCTION

The misdiagnosis rate of Dementia with Lewy Bodies (DLB) remains high. Accurate diagnosis is paramount in the era of anti-amyloid therapy. The main objective of the current study is to elucidate early clinical features of pathologically confirmed DLB without parkinsonism (DLB-nP) that potentially resemble Alzheimer's disease (AD).

METHODS

We accessed the National Alzheimer's Coordinating Center database from 2005 to December 2022 data freeze and included 3159 Alzheimer's disease, 91 DLB-nP, and 307 DLB with parkinsonism (DLBP) cases. Diagnosis of AD and DLB were based on existing pathological criteria. First visit data was analyzed.

RESULTS

Clinician-determined memory impairment is common in DLB-nP (87.9 % vs. AD 97.4 %) but is associated with a higher risk of AD diagnosis. Misdiagnosis as AD in DLB-nP stands at 75.8 %. Visual hallucinations (VH) or hallucinations are the only variables favoring DLB-nP diagnosis, but they only account for 22 % and 14 % of the cohort, respectively. After patients with VH were removed from the model, the misdiagnosis rate as AD increased to 85.2 %, and nighttime behavior was the only variable found to favor DLB-nP diagnosis. Visuospatial dysfunction is more common in DLB-P than DLB-nP but does not distinguish DLB-nP from AD.

CONCLUSION

Amnestic presentation, while favoring AD diagnosis, is common in DLB without parkinsonism, and misdiagnosis is common. While VH remains the most prominent clinical feature for prompting DLB diagnosis, misdiagnosis becomes more profound in its absence during the early phase. In this study, exercising great caution during clinical assessment appears to be the fundamental way to minimize misdiagnosis for patients with amnestic presentation yet without parkinsonism and VH.

Stability and Accuracy of a Diagnosis of Parkinson Disease Over 10 Years

BACKGROUND AND OBJECTIVES

Accurate diagnosis of Parkinson disease (PD) remains challenging, with variability and clinical uncertainty, especially in nonspecialized settings. Despite advancements in diagnostic criteria and biological markers, misdiagnosis continues to affect patient care and research. This study aimed to assess the long-term diagnostic stability of PD and evaluate the accuracy of initial diagnoses over time in a large, consecutive cohort diagnosed by neurologists, with or without movement disorder specialization.

METHODS

We conducted a retrospective longitudinal analysis of patients diagnosed with PD between 2006 and 2020. Patient records were reviewed over a median follow-up period of 10 years, with more than half of the cohort tracked from motor symptom onset to death. Diagnostic evaluations included dopamine transporter (DAT) imaging and neuropathologic examinations for a subset of patients, based on clinical indications. Two movement disorder specialists cross-validated diagnoses through retrospective chart reviews.

RESULTS

The cohort included 1,626 patients (mean age 69.0 years, 44.1% female). Of these, 10.6% (n = 172) had their diagnoses revised by treating neurologists, and 2.7% (n = 44) were revised based on chart reviews or neuropathologic findings. The median time to diagnosis revision was 22 months (interquartile range = 43). The most common revised diagnoses were vascular parkinsonism, progressive supranuclear palsy, and multiple system atrophy, with 4.7% (n = 77) classified as clinically undetermined parkinsonism. In a secondary analysis separating PD and dementia with Lewy bodies (DLB), the revision rate increased to 17.7%. DAT imaging had been performed on 588 patients and was more frequently used in revised cases. Postmortem neuropathologic examinations had been conducted in only 3% of deceased patients, with 64% confirming the initial PD diagnosis.

DISCUSSION

This study demonstrates significant diagnostic instability in PD, with 13.3% of diagnoses revised, primarily within 2 years. When DLB is considered separately, the revision rate increases to 17.7%. Despite frequent DAT imaging and limited postmortem examinations, clinical uncertainty persists among practicing neurologists, contrasting with lower misdiagnosis rates in specialized centers. These findings highlight the need for systematic application of diagnostic criteria, regular reevaluation of diagnoses, more frequent autopsies, and the development of accessible diagnostic biomarkers.

Longitudinal Evolution of Posterior Cortical Atrophy: Diagnostic Delays, Overlapping Phenotypes, and Clinical Outcomes

BACKGROUND AND OBJECTIVES

Although several large studies have evaluated individuals with posterior cortical atrophy (PCA) cross-sectionally, its longitudinal progression remains poorly characterized. The objectives of this study were to determine the longitudinal trajectory of PCA, encompassing the temporal aspects of diagnosis, the spectrum of clinical manifestations, and patient outcomes.

METHODS

This retrospective study included participants evaluated and diagnosed with PCA at the Mayo Clinic, between 1995 and 2023. Clinical data (demographics, neurologic evaluations, and cognitive tests at initial presentation and late stage) were extracted from medical records. Initial clinical diagnoses during previous medical evaluations, including ophthalmologic assessments after onset of neurologic symptoms, were documented. Participants were retrospectively classified as PCA-pure if they solely met PCA criteria or as PCA-plus if they exhibited complex phenotypes also meeting criteria for other neurodegenerative syndromes. CSF analyses and neuropathology findings were documented.

RESULTS

The cohort of 558 participants (65% female) had a mean age at symptom onset of 61 ± 8 years, with 68% meeting early-onset criteria (younger than 65 years). The mean duration from symptom onset to diagnosis was 3.6 ± 2.5 years. Ophthalmologic/optometric evaluations (49%) and completion of ophthalmologic procedures (16%) were common before PCA diagnosis. Psychiatric diagnoses were made in 23% of participants before PCA diagnosis, particularly among younger women. Common initial symptoms included misplacement of items, difficulties with reading and driving, and concerns pertaining to basic visual processing. Notable signs were constructional apraxia, dyscalculia, simultanagnosia, and space perception deficits. CSF biomarkers were consistent with Alzheimer disease in 139 of 158 individuals (88%). Superimposed features of non-PCA clinical syndromes were observed in a quarter of the participants at presentation, with frequency of PCA-plus cases increasing longitudinally. Longitudinal analysis of Short Test of Mental Status scores predicted an initial rapid decline in cognitive function, with the rate of decline gradually slowing over 0-10 years (time coefficient [SE] = -4.20 [0.29], p < 0.001).

DISCUSSION

This study highlights the protracted time from symptom onset and frequent misdiagnoses/misattribution of symptoms in PCA. Ophthalmologic evaluations often preceded neurologic assessments. Psychiatric diagnoses were more frequent among younger women. These observations highlight the need to improve diagnostic processes and earlier recognition of PCA, which may enhance the effectiveness of emerging disease-modifying therapies.

Adult Neurogenesis in the Subventricular Zone of Patients with Huntington's and Parkinson's Diseases and following Long-Term Treatment with Deep Brain Stimulation

OBJECTIVE

Parkinson's and Huntington's diseases are characterized by progressive neuronal loss. Previous studies using human postmortem tissues have shown the impact of neurodegenerative disorders on adult neurogenesis. The extent to which adult neural stem cells are activated in the subventricular zone and whether therapeutic treatments such as deep brain stimulation promote adult neurogenesis remains unclear. The goal of the present study is to assess adult neural stem cells activation and neurogenesis in the subventricular zone of patients with Huntington's and Parkinson's diseases who were treated or not by deep brain stimulation.

METHODS

Postmortem brain samples from Huntington's and Parkinson's disease patients who had received or not long-term deep brain stimulation of the subthalamic nucleus were used.

RESULTS

Our results indicate a significant increase in the thickness of the subventricular zone and in the density of proliferating cells and activated stem cells in the brain of Huntington's disease subjects and Parkinson's disease patients treated with deep brain stimulation. We also observed an increase in the density of immature neurons in the brain of these patients.

INTERPRETATION

Overall, our data indicate that long-term deep brain stimulation of the subthalamic nucleus promotes cell proliferation and neurogenesis in the subventricular zone that are reduced in Parkinson's disease. Taken together, our results also provide a detailed characterization of the cellular composition of the adult human subventricular zone and caudate nucleus in normal condition and in Parkinson's and Huntington's diseases and demonstrate the plasticity of these regions in response to neurodegeneration. ANN NEUROL 2025;97:894-906.

Correlating hippocampal and amygdala volumes with neuropathological burden in Down syndrome and Alzheimer's disease and related neurodegenerative pathologies using 7T postmortem MRI

Limbic-predominant age-related TDP-43 encephalopathy neuropathologic change (LATE-NC), is common in elderly brains and often seen in conjunction with Alzheimer's disease neuropathologic change (ADNC). LATE-NC typically begins in the amygdala and spreads to the hippocampus and neocortex. Whether it contributes to hippocampal and amygdala atrophy in Down syndrome (DS) remains unexplored. We analyzed amygdala and hippocampal volumes and neuropathological burden in 12 DS cases and 54 non-DS cases with AD and related neurodegenerative pathologies (ADRNP) using 7 Tesla (7T) postmortem ex vivo MRI. Postmortem and antemortem hippocampal volumes were significantly correlated in a subset of 17 cases with available antemortem MRI scans. DS cases had smaller hippocampal and amygdala volumes than ADRNP cases; these correlated with more severe Braak stage but not with Thal phase. LATE-NC and hippocampal sclerosis (HS) were uncommon in DS cases. In ADRNP cases, lower hippocampal volumes associated with dementia duration, advanced Thal phase, Braak NFT stage, C score, LATE-NC stage, HS and arteriolosclerosis severity; reduced amygdala volumes correlated with severe LATE-NC stage, HS, and arteriolosclerosis severity, but not with Thal phase or Braak NFT stage. Lewy body pathology did not affect hippocampal or amygdala volume in either cohort. Thus, hippocampal volumes in ADRNP were influenced by both ADNC and LATE-NC, and amygdala volumes were primarily influenced by LATE-NC. In DS, hippocampal and amygdala volumes were primarily influenced by tau pathology.

Peripheral innate immunophenotype in neurodegenerative disease: blood-based profiles and links to survival

The innate immune system plays an integral role in the progression of many neurodegenerative diseases. In addition to central innate immune cells (e.g., microglia), peripheral innate immune cells (e.g., blood monocytes, natural killer cells, and dendritic cells) may also differ in these conditions. However, the characterization of peripheral innate immune cell types across different neurodegenerative diseases remains incomplete. This study aimed to characterize peripheral innate immune profiles using flow cytometry for immunophenotyping of peripheral blood mononuclear cells in n = 148 people with Alzheimer's disease (AD), frontotemporal dementia (FTD), corticobasal syndrome (CBS), progressive supranuclear palsy (PSP), Lewy body dementia (LBD) as compared to n = 37 healthy controls. To compare groups, we used multivariate dissimilarity analysis and principal component analysis across 19 innate immune cell types. We identified pro-inflammatory profiles that significantly differ between patients with all-cause dementia and healthy controls, with some significant differences between patient groups. Regression analysis confirmed that time to death following the blood test correlated with the individuals' immune profile weighting, positively to TREM2+ and non-classical monocytes and negatively to classical monocytes. Taken together, these results describe transdiagnostic peripheral immune profiles and highlight the link between prognosis and the monocyte cellular subdivision and function (as measured by surface protein expression). The results suggest that blood-derived innate immune profiles can inform sub-populations of cells relevant for specific neurodegenerative diseases that are significantly linked to accelerated disease progression and worse survival outcomes across diagnoses. Blood-based innate immune profiles may contribute to enhanced precision medicine approaches in dementia, helping to identify and monitor therapeutic targets and stratify patients for candidate immunotherapies.

Clinical Evolution of Neuropsychiatric Symptoms in Alzheimer's Disease and Dementia With Lewy Bodies in a Post-Mortem Cohort

BACKGROUND

Almost all patients with neurodegenerative dementias experience neuropsychiatric symptoms (NPS) but the timing and clinical course is highly variable.

METHODS

In a prospective cohort study in Western Norway, patients with a new diagnosis of mild dementia were assessed annually in the Neuropsychiatric Inventory (NPI) for up to 9 years until death. Patients with post-mortem neuropathological diagnoses of Alzheimer's disease (pAD) (n = 37), Lewy body disease (pLBD) (n = 14) or meeting criteria for both AD and LBD (mixed AD+LBD) (n = 11) were included in this study. Neuropathological assessment was performed according to standardised protocols and blind to clinical information. In mixed effects logistic regression, longitudinal change in NPS was explored across neuropathological diagnoses and substrates. Additionally, the odds of NPS early and late in disease was evaluated in logistic regression.

RESULTS

Early onset hallucinations were significantly more common in pLBD than pAD (OR 0.069 [95% CI 0.012-0.397], p = 0.003) or mixed AD+LBD (OR 0.09 [95% CI 0.010-0.771], p = 0.028) and there was a greater increase in the odds of hallucinations over time in pAD and AD+LBD than pLBD such that there was was no difference in the prevalence of late-onset hallucinations between pLBD, pAD or AD+LBD. Hallucinations early in disease were associated with higher LBD α-synuclein stages and neocortical LBD, in addition and sparser amyloid distribution. Higher density of amyloid plaques, tau tangles, cerebrovascular disease and increasing additional co-pathologies were associated with increasing odds of hallucinations over time.

CONCLUSIONS

LBD, without significant comorbid AD pathology, is associated with hallucinations early in the course of disease while multiple other pathologies may be implicated in aetiology of late-onset hallucinations. Hallucinations increase in AD+LBD as disease progresses, a trajectory more closely aligned with AD than LBD.

Non-motor Symptoms and Treatments in Parkinson's Disease

SYNOPSIS

Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor and non-motor symptoms. The non-motor features may precede the onset of motor symptoms and occur throughout all stages of PD. The non-motor symptoms reflect multisystem involvement of the central and peripheral nervous systems, multiple neurotransmitters, and multiple pathologies. PD management necessitates a comprehensive approach to address non-motor symptoms, including pharmacologic and non-pharmacological interventions and often multiple different disciplines or specialists in the PD care team. This review article discusses symptoms and treatments for the non-motor symptoms of PD including those affecting mood, cognition, behavior, sleep, autonomic function, and sensory systems.

Validation of the Turkish version of the Lewy body composite risk score

The Lewy Body Composite Risk Score (LBCRS) has been developed to increase the sensitivity and specificity of the diagnosis attributable to Lewy body pathology outside of specialty centers. We aimed to assess the validity and reliability of the Turkish version of the LBCRS in patients with dementia with Lewy Bodies (DLB) and investigate the discriminative power of the test in Turkish patients with Alzheimer's disease (AD) and DLB, and control group. The sample population (n = 512) comprised DLB (n = 113), DLB-Mild Cognitive Impairment (MCI)(n = 12), AD (n = 42), AD-MCI (n = 21), and control group (n = 324). A significant group difference was observed in the Turkish version of the LBCRS scores of the five groups (p < .001). The Cronbach's α value was 0.82 (95% CI: 0.799-0.868). The test-retest reliability score of the scale was r = 0.94 and p < .001. The subscales of the LBCRS (motor and nonmotor subdomains of the disease) were determined to explain 65.961% of the total variance with an eigenvalue >1. In patients with DLB, the cutoff score of ≥3 showed sensitivity (92%) and specificity (81%) (area under the curve [AUC] = 0.883, 95% CI: 0.815-0.951), p < .001) compared with the AD. Compared to the control group, the cutoff score of ≥3 showed a sensitivity of 98% and specificity of 97% (AUC = 0.994, 95% CI: 0.989-0.999, p < .001). The Turkish version of LBCRS permits accurate diagnosis of DLB with high sensitivity and specificity. Also, it can be useful to inform the caregivers regarding the course of the disease during the follow-up.

Practical Assessment of Neuropsychiatric Symptoms: Updated Reliability, Validity, and Cutoffs for the Neuropsychiatric Inventory Questionnaire

OBJECTIVES

To improve assessment of neuropsychiatric symptoms (NPS) by expanding the measurement properties of the Neuropsychiatric Inventory Questionnaire (NPI-Q).

DESIGN

Multicenter, longitudinal observational study.

SETTING

Several Alzheimer's Disease Research Centers (ADRCs).

PARTICIPANTS

Individuals (n = 45,274) who presented to an ADRC with a collateral and completed the NPI-Q.

MEASUREMENTS

The NPI-Q total severity score, four NPI-Q subscales, dementia stage, expert NPS rating, consensus rating of dementia syndrome, global cognitive screening, collateral rating of daily functioning, and self-rating of depression.

RESULTS

There was strong evidence of criterion validity with both dementia stage and expert NPS rating for the NPI-Q total severity index, which informed cutoffs and interpretive ranges. Furthermore, subscales had adequate classification of dementia syndromes and appropriate convergent relationships with cognition, daily functioning, and mood. There was good-to-excellent evidence of reliability for the NPI-Q total severity index over several years, and subscales had adequate-to-good reliability.

CONCLUSIONS

This is the first study to provide empirically established cutoffs, interpretive ranges, and evidence of reliability over a period longer than a month on the NPI-Q and its subscales. This will improve assessment of NPS in clinical and research contexts.

ARTICLE SUMMARY

Neuropsychiatric symptoms of neurodegeneration are increasingly understood as early disease markers with tremendous functional impact later in disease, but are often missed or misdiagnosed. The most common measure of these symptoms, the Neuropsychiatric Inventory Questionnaire (NPI-Q), does not have clinically actionable guidance, which this article provided. We established cutscores for several conditions and test-retest reliability over longer periods for the total score and subscales using a multicenter database.

A simple method to evaluate the pentagon copy test of the Mini-Mental State Examination for the differentiation of dementia with Lewy bodies

There are many commonalities between the clinical symptoms of dementia with Lewy bodies (DLB) and those of Alzheimer's disease (AD). The accurate differentiation of these two diseases is an important neuropsychological issue. The Mini-Mental State Examination (MMSE) is often used as a screening test for dementing disorders. We created evaluation items for the pentagon copy test of MMSE and developed a simple, highly accurate evaluation method for differentiating DLB in combination with conventional evaluation items such as the Qualitative Scoring MMSE Pentagon Test (QSPT). Subjects were divided into three groups: DLB (n = 119), AD (n = 50), and Normal (n = 26). The severities of DLB and AD ranged from mild cognitive impairment (MCI) to mild dementia. We compared the results of the pentagon copy test. We found that the rates of patients with abnormalities in "motor incoordination" and "gestalt destruction" were higher in the DLB group than the AD group. Furthermore, receiver operating characteristic curve analysis suggested the differentiation of DLB with high accuracy (sensitivity: 0.70, specificity: 0.78) using the criterion of patients meeting one of the following three characteristics: "the number of angles on QSPT: scores other than 4," "major tremor (Parkinsonism-related tremor) is present," and "gestalt destruction (distortion in overall coherence) is present." This evaluation method may be clinically useful for evaluating MCI to mild DLB patients because the burden on patients is low.

Clinicopathological Correlations of Neurodegenerative Diseases in the National Brain Biobank of Korea

BACKGROUND AND PURPOSE

The National Brain Biobank of Korea (NBBK) is a brain bank consortium supported by the Korea Disease Control and Prevention Agency and the Korea National Institute of Health, and was launched in 2015 to support research into neurodegenerative disease dementia (NDD). This study aimed to introduce the NBBK and describes clinicopathological correlations based on analyses of data collected from the NBBK.

METHODS

Four hospital-based brain banks have been established in South Korea: Samsung Medical Center Brain Bank (SMCBB), Seoul National University Hospital Brain Bank (SNUHBB), Pusan National University Hospital Brain Bank (PNUHBB), and Myongji Hospital Brain Bank (MJHBB). Clinical and pathological data were collected from these brain banks using standardized protocols. The prevalence rates of clinical and pathological diagnoses were analyzed in order to characterize the clinicopathological correlations.

RESULTS

Between August 2016 and December 2023, 185 brain specimens were collected and pathologically evaluated (SNUHBB: 117; PNUHBB: 27; SMCBB: 34; MJHBB: 7). The age at consent was 70.8±12.6 years, and the age at autopsy was 71.7±12.4 years. The four-most-common clinical diagnoses were Alzheimer's disease (AD) dementia (20.0%), idiopathic Parkinson's disease (15.1%), unspecified dementia (11.9%), and cognitively unimpaired (CU) (11.4%). Most cases of unspecified dementia had a pathological diagnosis of central nervous system (CNS) vasculopathy (31.8%) or AD (31.8%). Remarkably, only 14.2% of CU cases had normal pathological findings. The three-most-common pathological diagnoses were AD (26.5%), CNS vasculopathy (14.1%), and Lewy body disease (13.5%).

CONCLUSIONS

These clinical and neuropathological findings provide a deeper understanding of the mechanisms underlying NDD in South Korea.

Validation of an algorithm for detecting turning in people with cognitive impairment, considering dementia disease subtype

BACKGROUND

Turning manoeuvres are an essential component of mobility and are vital for effective real-world navigation. Turning is more challenging than straight-line walking, involving complex cognitive functions to execute multi-segment co-ordination. Therefore, people with cognitive impairment (PwCI) may be more susceptible to impaired turning performance. Inertial measurement units (IMUs) can be used to quantify turning performance; however, IMU-based algorithms have not yet been validated for PwCI, or across dementia disease subtypes.

RESEARCH QUESTION

Is a custom-built algorithm for accurately detecting turn start and end valid for use in PwCI and in different dementia disease subtypes?

METHODS

Sixty-six PwCI due to Alzheimer's disease, Lewy body disease and vascular dementia, along with 23 cognitively healthy older adults (controls) were included. Participants wore an IMU on their lower back while completing six 10-m intermittent walks, segmented by 180° turns. A 2D colour video camera was used as the reference system. Videos were reviewed by two independent blinded raters annotating turn start and end. Agreement (intra-class correlation (ICC (2,1)), Spearman's rho and Limits of agreement) and error (Root mean square error; RMSE and bias) between the raters (rater 1 vs. 2) and the algorithm (rater vs. algorithm) were evaluated.

RESULTS

There was excellent agreement (rater-rater and rater-algorithm) for detecting turn start and end for PwCI and across dementia disease subtypes (rho = 1.00, ICC = 1.00). The error between raters was lower (RMSE < 0.72 s, bias < 0.41 s) than the error between raters and algorithm (RMSE < 1.29 s, bias < 1.4 s). Error was lowest for controls (RMSE < 0.94 s), followed by AD (RMSE < 1.21 s) and LBD (RMSE < 1.29 s).

SIGNIFICANCE

Key findings suggest that this algorithm can detect turn start and end using an IMU in PwCI in agreement with a reference system (video ratings). Future research should consider the clinical application of turning assessment in PwCI, such as its ability to differentiate dementia disease subtypes to support accurate diagnosis.

Distinct trajectories of subjective cognitive decline before diagnosis of neurocognitive disorders: Longitudinal modelling over 18 years

BACKGROUND

Subjective cognitive decline (SCD) is an established predictor of neurocognitive disorders (NCD) (i.e. mild cognitive impairment and dementia). Yet, its construct remains contentious. Many individuals with SCD do not progress to NCD, leading to an alternative term in the literature - 'functional cognitive disorders' - to describe the SCD experience in these individuals.

OBJECTIVES

To examine the distinct differences in trajectories of SCD between those who did and did not eventually develop NCD.

DESIGN

Case-control study.

SETTING

Alzheimer's Disease Centers across USA.

PARTICIPANTS

A total of 5,167 participants aged ≥50 years were followed up near-annually to evaluate for SCD and NCD (median follow-up=8.1 years; range=1.0-18.0). Cases were defined as those who developed incident NCD during follow-up; controls completed ≥10 years of follow-up and had normal cognition throughout follow-up period.

MEASUREMENTS

SCD was evaluated with a yes/no question based on "perceived decline in memory relative to previously attained abilities". The trajectories of SCD were modelled with mixed-effect logistic regression, using a backward timescale.

RESULTS

Those who developed NCD (cases) had new onset of SCD within past 20 years, which became particularly noticeable 13-14 years before diagnosis, and became even more evident in the last 4 years. Those who did not develop NCD (controls) reported SCD since younger age, with the probability of SCD remaining constant over time. The distinctive trajectories were consistent across Alzheimer's and non-Alzheimer's disease, and among those with higher baseline rates of SCD due to psychiatric conditions.

CONCLUSIONS

SCD exhibits distinctive trajectories among those who do and do not progress to NCD. These distinctive trajectories can inform NCD risk for early interventions, and guide public health messaging to distinguish high-risk SCD from normal ageing. Future SCD scales may possibly need to evaluate symptom changes over a longer, 20-year horizon to better capture the new onset of SCD within this longer timeframe.

Mild behavioral impairment in idiopathic REM sleep behavior disorder and Lewy body disease continuum

To investigate the clinical impact of mild behavioral impairment (MBI) in a predefined cohort with Lewy body disease (LBD) continuum. Eighty-four patients in the LBD continuum participated in this study, including 35 patients with video-polysomnography-confirmed idiopathic REM sleep behavior disorder (iRBD) and 49 clinically established LBD. Evaluations included the Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS), neuropsychological tests, and MBI Checklist (MBI-C). We examined the clinical associates of MBI-C and its diagnostic values in predicting disease severity and cognitive impairment across the LBD continuum. Participants were classified into 19 cognitively normal (CN), 45 mild cognitive impairment (MCI), and 20 dementia groups. Median MBI-C total scores were 1.0, 8.0, and 18.5 for CN, MCI, and dementia groups, respectively, with a significant increasing trend (p < 0.001). The MBI-C total score demonstrated significant correlations with the MDS-UPDRS part 1 (r = 0.504, p < 0.001) and total scores (r = 0.508, p < 0.001). Furthermore, significant correlations were observed between MBI-C and cognitive performances in frontal/executive (DSC: r = -0.314, p = 0.006; TMT-B: r = -0.338, p = 0.003) and attentional (TMT-A: r = -0.343, p = 0.002) domains. A cutoff 5.0 effectively differentiated the MCI from CN groups (area under the curve (AUC = 0.74). Furthermore, the MBI-C effectively discriminated the iRBD patients with high phenoconversion risk against those with low-risk (cut-off 4.0, AUC = 0.72). The MBI-C may be a useful screening questionnaire reflecting clinical severity across the LBD continuum. Longitudinal studies are needed to determine its value in monitoring disease progression in prodromal LBD.

Screening properties of the updated normative framework for the Italian MMSE in MCI and dementia

BACKGROUND

This study aimed to assess the screening properties of Foderaro et al.s' updated normative framework for the Italian MMSE in detecting mild cognitive impairment (MCI) and dementia due to neurodegenerative, chronic cerebrovascular, and mixed etiologies, as well as in differentiating between these two syndromes.

METHODS

Data on 234 patients with either MCI (N = 83) or dementia (N = 151) due to Alzheimer's disease (N = 112), Lewy body disease (N = 11), frontotemporal lobar degeneration (N = 20), chronic cerebrovascular disease (N = 39), or mixed (N = 47) etiologies having been administered Foderaro et al.'s version of the MMSE were retrospectively recruited. Moreover, N = 247 healthy controls (HCs) with a normal Montreal Cognitive Assessment performance were prospectively recruited. Receiver-operating characteristics analyses were run to test the capability of both raw and demographically adjusted MMSE scores to discriminate both HCs from MCI/dementia and MCI from dementia. For these comparisons, screening metrics were also computed at Foderaro et al.'s cut-off (<26.02).

RESULTS

The capability of demographically adjusted MMSE scores to discriminate both HCs from dementia and MCI from dementia was excellent (AUC = 0.91 and 0.93, respectively), whilst good for MCI case-finding (AUC = 0.85). Consistently, the screening metrics associated with the cut-off at hand were optimal-to-excellent for dementia case-finding (sensitivity = 0.95; specificity = 0.99) and for the differentiation between MCI and dementia (sensitivity = 0.95; specificity = 0.64), whilst imbalanced for detecting MCI (sensitivity = 0.35; specificity = 0.99).

DISCUSSION

Foderaro et al.'s updated normative framework for the Italian MMSE has optimal screening properties for both dementia case-finding and the discrimination between MCI and dementia, being at variance unbalanced towards specificity when it comes to detecting MCI.

A Real-world Pharmacovigilance Study Of FDA Adverse Event Reporting System (FAERS) Events For Gender Of Voriconazole Drugs

To detect the gender variations in adverse events (AEs) of voriconazole, promote personalised medicine.A normalized dataset from Q1 2004 to Q4 2022 from the US Food and Drug Administration's Adverse Event Reporting System (FAERS) was analyses. The reporting odds ratio (ROR), proportional reporting ratio (PRR), and P value were used to examine data from the FAERS database to detect risk signals and quantify the presence and extent of gender variations in voriconazole adverse events.A total of 7670 cases (female/male (2785/4885)) of adverse reactions to voriconazole were analysed, and drug interaction (ROR 1.30 (1.10,1.54)), death and sudden death (ROR 1.31 (1.06,1.61)), actinic keratosis (ROR 1.98 (1.10,3.57)) were found to be significantly more frequent in male patients than in female patients.We found that gender was a determinant in voriconazole-related AEs using FAERS. Our results require future validation due to the inherent limits of this open data source, but they also identify potential contributing elements for a customised side effect profiling.

The potential of brain organoids in addressing the heterogeneity of synucleinopathies

Synucleinopathies are a group of diseases characterized by neuronal and glial accumulation of α-synuclein (aSyn) linked with different clinical presentations, including Parkinson's disease (PD), Parkinson's disease with dementia (PDD), Dementia with Lewy Bodies (DLB) and Multiple system atrophy (MSA). Interestingly, the structure of the aSyn aggregates can vary across different synucleinopathies. Currently, it is unclear how the aSyn protein can aggregate into diverse structures and affect distinct cell types and various brain regions, leading to different clinical symptoms. Recent advances in induced pluripotent stem cells (iPSCs)-based brain organoids (BOs) technology provide an unprecedented opportunity to define the etiology of synucleinopathies in human brain cells within their three-dimensional (3D) context. In this review, we will summarize current advances in investigating the mechanisms of synucleinopathies using BOs and discuss the scope of this platform to define mechanisms underlining the selective vulnerability of cell types and brain regions in synucleinopathies.

Multicenter Validation of the English Version of the Dépistage Cognitif de Québec: a Cognitive Screening Tool for Atypical Dementias

BACKGROUND

Early detection of atypical dementia remains difficult partly because of the absence of specific cognitive screening tools. This creates undue delays in diagnosis and management. The Dépistage Cognitif de Québec (DCQ; dcqtest.org) was developed in French and later validated in participants with atypical syndromes. We report the validation of the English version.

METHODS

This multicentre prospective validation study was conducted in 10 centers across Canada and the United States on 260 English-speaking participants aged over 50. We translated and modified the original French DCQ to add targeted stimuli to the Visusopatial Index and social cognition vignettes to the Behavioral Index. A backward translation was performed and equivalence between languages was assessed by administering both tests to 30 bilingual participants.

RESULTS

Mean DCQ total score (out of 100) was 95.0 (SD = 3.6). Spearman's correlation coefficient showed a strong and significant correlation (r = 0.49, p < .001) with the Montreal Cognitive Assessment. Test-retest reliability was good (Spearman's coefficient = 0.72, p < .001) and interrater reliability, excellent (intraclass correlation = 0.97, p < .001). Normative data shown in percentiles were stratified by age and education for a population-based sample of 260 English-speaking controls aged between 50 and 87 years old.

CONCLUSIONS

Similar to the French version, the English DCQ proved to be a valid cognitive screening test. The original version was very sensitive to detect atypical dementias such as primary progressive aphasias, Alzheimer's disease' variants and syndromes along the frontotemporolobar degeneration spectrum. This 20-min test can be administered à la carte and offers an alternative to detailed comprehensive neuropsychological evaluations.

Caregiving Activities and Outcomes Among Family Caregivers of Individuals With and Without Parkinson's Disease and Lewy Body Dementia in California Caregiver Resource Centers

PURPOSE

To describe characteristics and outcomes of family caregivers for persons with Parkinson's disease and Lewy body dementia (PD/LBD) and compare them to those of other family caregivers.

METHOD

Using a California statewide database, we examined caregiver characteristics and outcomes (strain, loneliness, worse health, and depressive symptoms) and compared them by care recipient diagnosis (PD/LBD, Alzheimer's disease and related dementias, or other chronic conditions) using descriptive statistics and multivariable logistic regression.

RESULTS

PD/LBD caregivers were more likely to identify as female, married, and college-educated; engage in high-intensity caregiving; and report their care recipient wakes them or others up at night. In multivariable models, PD/LBD caregiving was associated with worse health. Among PD/LBD caregivers, performing medical/nursing tasks was associated with higher odds of strain, loneliness, worse health, and depressive symptoms.

CONCLUSION

PD/LBD caregivers are a distinct group who often experience high-demand caregiving. Tailored support can help address the unique needs of this population. [Research in Gerontological Nursing, xx(x), xx-xx.].

Clinical and brain volumetric correlates of decreased DTI-ALPS, suggestive of local glymphatic dysfunction, in iRBD

Glymphatic alterations may underlie neurodegeneration in alpha-synucleinopathies. Reduced Diffusion-Tensor Imaging ALong the Perivascular Space (DTI-ALPS), a proxy of perivascular glymphatic activity, has been scarcely studied in isolated REM sleep behaviour disorder (iRBD), a prodromal synucleinopathy stage. Furthermore, its associations with clinical symptoms and brain structural abnormalities remain unexplored. We assessed the DTI-ALPS in sixty-two patients with iRBD and twenty-three healthy controls (HC), exploring its associations with clinical symptoms, cortical thickness and brain volumetric data. iRBD patients exhibited a lower DTI-ALPS and poorer odor identification, semantic fluency and processing speed relative to HC. The DTI-ALPS positively correlated with cognitive performance, olfactory function and amygdalar, hippocampal, brainstem and diencephalic volumes, and negatively with age in iRBD. Perivascular glymphatic activity is compromised in iRBD and is associated with brain atrophy and clinical risk factors of progression to alpha-synucleinopathies, supporting the potential of the DTI-ALPS index as an early imaging neurodegeneration marker.

Harmonizing Aβ deposition threshold for 18F-florbetaben PET imaging: Addressing discrepancies and calibration between PET/CT and PET/MRI

PURPOSE

Discrepancies between PET/CT and PET/MRI scanners can affect the determination of amyloid beta (Aβ) deposition thresholds in patients with cognitive impairment. This study aimed to identify these differences and propose a calibration method to standardize Aβ quantification across imaging modalities.

METHODS

A total of 133 patients with cognitive impairment underwent Aβ PET imaging and were divided into four groups: a head-to-head PET/CT and PET/MRI cohort (group A, n = 6), an independent PET/CT cohort (group B, n = 48), an independent PET/MRI cohort (group C, n = 79), and another independent PET/MRI cohort (group D, n = 10). Standardized uptake value ratios (SUVR) of global cortical target (CTXsuvr) and centiloid (CL) values were compared within group A and between groups B and C. A whole cerebellum (WC)-referenced SUVR method was used to calibrate CL values in group C, with verification in group D.

RESULTS

CTXsuvr values were significantly higher in PET/MRI than in PET/CT in both group A (P < 0.05) and group C versus group B (P < 0.001). Aβ-negative/positive cases showed mean ± variance of CTXsuvr as 1.023 ± 0.104/1.479 ± 0.203 in group B and 1.146 ± 0.100/1.743 ± 0.254 in group C, with cutoffs of 1.140 (CL = 20) and 1.401 (CL = 60), respectively. WC-referenced calibration adjusted PET/MRI cutoff to 1.132 (CL = 19) in group C, aligning it with PET/CT thresholds and validated in group D.

CONCLUSION

WC-referenced SUVR calibration effectively mitigates differences in Aβ thresholds between PET/CT and PET/MRI, enhancing Aβ quantification standardization in multi-modal imaging.

Practical brain MRI guidelines for anti-Aβ antibody treatment in early symptomatic Alzheimer's disease

PURPOSE

These guidelines aim to support magnetic resonance imaging (MRI) diagnosis in patients receiving anti-amyloid β (Aβ) antibody treatment without restricting treatment eligibility.

MATERIALS AND METHODS

These guidelines were collaboratively established by Japan Radiological Society, The Japanese Society of Neuroradiology, and Japanese Society for Magnetic Resonance in Medicine by reviewing existing literature and the results of clinical trials.

RESULTS

Facility standards should comply with the "Optimal Use Promotion Guidelines" of Japan, and physicians should possess comprehensive knowledge of amyloid-related imaging abnormalities (ARIA) and expertise in brain MRI interpretation. The acquisition of knowledge regarding amyloid-related imaging abnormalities, brain MRI, anti-Aβ antibody introduction, and post-treatment diagnosis are also recommended.

CONCLUSION

These guidelines facilitate the accurate diagnosis and effective management of ARIA; ensure the safe administration of anti-Aβ drugs; and provide a framework for MRI facilities, includes staffing requirements and the use of MRI management systems.

Cerebral microbleeds: prevalence and relationship to clinical features in cognitive impairment with lewy body disease

BACKGROUND

The burden of cerebral microbleeds (CMBs) is greater in patients with dementia with Lewy bodies (DLB) than in those with Parkinson disease dementia (PDD), while few studies have been carried out in a large sample size, or focused on the prodromal stage. Thus, we investigated the clinical prevalence of CMBs and its relationship to clinical features in patients with DLB, PDD, mild cognitive impairment with Lewy bodies (MCI-LB) and Parkinson's disease with MCI (PD-MCI) in this study.

METHODS

In this retrospective multicenter cohort study, the study population consisted of 486 patients with DLB, 262 cases with PDD, 74 cases with MCI-LB and 107 cases with PD-MCI from 22 memory clinics between January 2018 and June 2022 in China. Demographic and clinical information were collected by reviewing medical records. CMBs were classified as "present" or "absent" in the Gradient Recalled-Echo or Susceptibility Weighted Imaging.

RESULTS

The prevalence of CMBs was significantly greater in patients with DLB with 24.69% (95% CI [20.92%, 28.78%]) than patients with PDD with 20.23% (95% CI [5.54%, 25.61%]), patients with MCI-LB with 16.22% (95% CI [8.67%, 26.61%]), and patients with PD-MCI with 12.15% (95% CI [6.63%, 19.88%]). There were sex and age differences in this prevalence. In all patients, the presence of CMBs was significantly and independently associated with the presence of visual hallucination (OR = 1.597, 95% CI [1.014, 2.517], p = 0.044) and fluctuating cognition (OR = 1.707, 95% CI [1.140, 2.556], p = 0.009); and it was associated with the severity of hallucination (B = 0.775, SE = 0.368, p = 0.036) and disinhibition (B = 0.363, SE = 0.148, p = 0.014) reflected by NPI. Moreover, CMBs in DLB were associated with the presence of parkinsonism symptoms (OR = 1.821, 95% CI [1.001, 3.314], p = 0.05), and the scores of UPDRS-III (B = 4.711, SE = 1.939, p = 0.016) and Hoehn-Yahn stage (B = 0.452, SE = 0.165, p = 0.007).

CONCLUSION

Patients with DLB had a higher proportion of CMBs than PDD, MCI-LB and PD-MCI. CMBs in all DLB, PDD, MCI-LB and PD-MCI cases were associated with the presence of visual hallucination and fluctuating cognition; in DLB were associated with motor function.

Urolithin improves α-synuclein aggregation and DNMT1 expression in rotenone model of Parkinson's disease

α-synuclein aggregation is a key hallmark of Parkinson's disease (PD), dementia with Lewy bodies (DLB), and multiple system atrophy (MSA). We examined the multi-targeting effects of urolithin (UA, UB, UC, UD, UE, UM5, and UM6) against α-synuclein aggregation using an in-silico and in-vitro approach. For in-silico analysis, several potential targets were selected like 1XQ8 (α-synuclein monomer), 1H1D (catechol-o-methyltransferase), 2BK3 (monoamine oxidase-B), 3IAM (NADH dehydrogenase), 4I5I (Sirtuin-1), and 5WVO [DNA methyltransferase-1], which play key role in α-synuclein aggregation, levodopa degradation, and mitochondrial dysfunction. In protein-protein docking analysis, 5HF9 (acetylcholinesterase, AChE) was found to interact with 1XQ8 dimer, forming a more stable complex with two additional H-bonds and one salt bridge, which indicates AChE's role as a nucleator in α-synuclein aggregation. In ligand docking and molecular dynamic studies, urolithin-A (UA) formed a more stable complex with 1XQ8, 4I5I, and 5WVO compared to specific inhibitor 1XQ8-ZPD2 and specific activator 4I5I-resveratrol. While other urolithins (UE, UM5, UC, and UD) displayed a more stable complex with 5HF9, 2BK3, 1H1D, and 3IAM compared to specific inhibitor 5HF9-physostigmine, 2BK3-selegiline, 1H1D-BIA, and specific activator 3IAM-resveratrol complexes, respectively. The blood-brain barrier permeability of UA (QPlogBB: -0.97) was predicted to be more than levodopa (QPlogBB: -1.44) and less than rotenone (QPlogBB: 0.08). DNMT1 inhibitor (5-Aza-dC) and rotenone robustly decreased the DNMT1 and α-synuclein expression in Neuro 2 A cells which was significantly reversed by UA treatment at 31.25 µM concentration. These findings indicate the potential of urolithins, specifically UA, UC, UD, UE, and UM5 against α-synuclein aggregation.

Liganded magnetic nanoparticles for magnetic resonance imaging of α-synuclein

Aggregation of the protein α-synuclein (α-syn) is the histopathological hallmark of neurodegenerative diseases such as Parkinson's disease (PD), dementia with Lewy bodies (DLB), and multiple system atrophy (MSA), which are collectively known as synucleinopathies. Currently, patients with synucleinopathies are diagnosed by physical examination and medical history, often at advanced stages of disease. Because synucleinopathies are associated with α-syn aggregates, and α-syn aggregation often precedes onset of symptoms, detecting α-syn aggregates would be a valuable early diagnostic for patients with synucleinopathies. Here, we design a liganded magnetic nanoparticle (LMNP) functionalized with an α-syn-targeting peptide to be used as a magnetic resonance imaging (MRI)-based biomarker for α-syn. Our LMNPs bind to aggregates of α-syn in vitro, cross the blood-brain barrier in mice with mannitol adjuvant, and can be used as an MRI contrast agent to distinguish mice with α-synucleinopathy from age-matched, wild-type control mice in vivo. These results provide evidence for the potential of magnetic nanoparticles that target α-syn for diagnosis of synucleinopathies.

Association of Cardiovascular Autonomic Failure With Progression and Phenoconversion in Isolated REM Sleep Behavior Disorder

BACKGROUND AND OBJECTIVES

Isolated REM sleep behavior disorder (iRBD) is a prodromal state of α-synucleinopathies, presenting years before overt neurodegenerative disorders. Autonomic nervous system (ANS) involvement, particularly cardiovascular autonomic failure, may indicate progression. However, its role as a (multidimensional) marker for disease progression and phenoconversion remains unclear. This study aimed to investigate whether cardiovascular autonomic failure and symptoms of autonomic dysfunction serve as multidimensional markers in patients with iRBD.

METHODS

We conducted a prospective cohort study of patients with iRBD (iRBDs) and controls. Participants underwent cardiovascular reflex tests (CRTs) with beat-to-beat monitoring of blood pressure (BP) and ANS symptom assessments at baseline and annually. Primary outcomes were prevalence and progression of cardiovascular autonomic failure and the risk factors of phenoconversion. Longitudinal changes were evaluated through mixed-effects regression, predictors associated with conversion with Cox regression analysis.

RESULTS

Sixty-four iRBDs (mean age 68.89 ± 6.75 years, 75% male) and 67 controls (66.57 ± 7.91 years, 68% male) were recruited. At baseline, iRBDs exhibited a prevalent sympathetic cardiovascular dysfunction, with more frequent neurogenic orthostatic hypotension (nOH in 9 iRBDs) and abnormal BP responses to CRTs (pathologic Valsalva maneuver [VM] overshoot in 27 iRBDs). Longitudinal data demonstrated progressive deterioration of sympathetic baroreflex function, with increased prevalence of nOH (7 iRBDs with incident nOH; yearly odds ratio [OR] = 2.44) and deterioration of parasympathetic cardiovagal function. Thirteen patients (20.3%) phenoconverted to α-synucleinopathies. Neurogenic OH (hazard ratio [HR] = 5.05), altered sympathetic baroreflex function (pathologic VM HR = 3.49), and blunted parasympathetic cardiovagal responses (pathologic deep breathing heart rate ratio HR = 3.27) were significant risk factors for phenoconversion; their early appearance 5 years from iRBD onset increased the conversion risk, up to 4-fold. Symptoms of autonomic failure were more prevalent in iRBD and deteriorated over time but failed to predict conversion.

DISCUSSION

Progressive deterioration of cardiovascular autonomic function is a feature of iRBDs and affects the risk of phenoconversion. Limitations include the relatively short follow-up period and small number of converters. This study highlights the importance of objective cardiovascular autonomic testing as a multidimensional marker for risk stratification in iRBD.

Autonomic Dysfunction in Patients With Dementia With Lewy Bodies and Its Relationship With Nigrostriatal Denervation

BACKGROUND AND OBJECTIVES

Diagnosing dementia with Lewy bodies (DLBs) is challenging because of symptom overlap with other neurodegenerative diseases. Although dysautonomia is a recognized supportive diagnostic criterion, its prevalence and extent remain underexplored. We aimed to evaluate autonomic dysfunction in patients with DLB using a comprehensive battery of autonomic function tests (AFTs) and to investigate whether this dysfunction differs between patients with and without nigrostriatal denervation.

METHODS

This prospective cohort study was performed at a Memory Clinic in Rome, Italy. Patients meeting diagnostic criteria for possible DLB were enrolled and underwent AFTs including head-up tilt test (HUTT), Valsalva maneuver, deep breathing, cold face, hand grip (HG), and electrochemical skin conductance. Dopamine transporter SPECT (DaT-SPECT) was performed to assess nigrostriatal transmission. We compared results from AFTs in (1) patients with DLB vs healthy controls (HCs) and (2) patients with DLB with pathologic vs normal DaT-SPECT.

RESULTS

Twenty-two patients with DLB (median age: 72.00 [10.00] years, %female: 21.75) and 20 HCs (median age: 69.00 [5.25] years, %female: 40) were enrolled. Only 1 patient (4.5%) showed neurogenic orthostatic hypotension (nOH) at HUTT. However, patients with DLB showed cardiovascular adrenergic dysfunction, represented by lower Valsalva overshoot (r = -0.553, 95% CI -0.773 to -0.214, p = 0.008) and HG Δdiastolic blood pressure (r = -0.703, 95% CI -0.844 to -0.470, p < 0.0001); parasympathetic cardiovagal dysfunction, reflected in the lower Valsalva ratio (r = -0.812, 95% CI -0.912 to -0.622, p < 0.0001) and sinus arrhythmia at deep breathing (r = -0.682, 95% CI -0.837 to -0.426, p < 0.001); and reduced sudomotor function in hands (r = -0.648, 95% CI -0.809 to -0.395, p < 0.001) and feet (r = -0.600, 95% CI -0.781 to -0.327, p < 0.001). Multivariable analyses found that age and sex were not associated with AFTs, but a higher Mini-Mental State Examination score was associated with better Valsalva ratio (B = 0.038, 95% CI 0.010-0.066, p = 0.010). Patients with normal DaT-SPECT had worse HG responses than those with pathologic DaT-SPECT (r = -0.686, 95% CI -0.895 to -0.231, p = 0.029).

DISCUSSION

Despite the absence of overt nOH, patients with DLB show covert dysautonomia encompassing adrenergic, parasympathetic, and sudomotor dysfunction, highlighting the importance of standardized autonomic evaluation. Patients with normal DaT-SPECT exhibited greater peripheral autonomic impairment, reflected by lower HG responses, suggesting diverse α-synuclein pathology trajectories within DLB. Further research is needed to explore autonomic nervous system dysfunctions across different DLB subtypes and stages.

Electroconvulsive therapy for dementia with Lewy bodies: A systematic review and Japanese multicenter survey

Management of psychiatric symptoms in dementia with Lewy bodies (DLB) is challenging due to hypersensitivity to psychotropic medications. Electroconvulsive therapy (ECT) is a potential therapeutic option for DLB, but its efficacy and safety remain uncertain. We systematically reviewed articles on ECT for DLB, including those published in Japanese-language journals, and surveyed institutions certified by the Japanese Psychogeriatric Society. Of 41 peer-reviewed articles, 32 were from Japan. The proportion of prodromal DLB cases was significantly higher in Japan (34.8 %) than in other countries (9.5 %) (p = 0.044). Cardiac [123I]-metaiodobenzylguanidine scintigraphy and/or striatal dopamine transporter imaging were significantly more frequently in Japan (71.8 %) than in other countries (5.5 %) (p < 0.001). ECT has shown effectiveness in treating depression, catatonia, agitation and psychosis. It was generally considered safe, with transient delirium being the most common side effect, occurring in 16.1 % of Japanese cases. However, current evidence is limited to case studies and lacks randomized controlled trials. The survey confirmed that ECT is widely performed for DLB in Japan, although the number of cases treated varied greatly across institutions. These findings underscore the need for standardized ECT guidelines for DLB. Multicenter studies with standardized assessments and longitudinal follow-up are essential to further research on ECT for DLB, including psychiatric-onset prodromal DLB.

Evaluation of 6 monoclonal antibodies against Ser129-phosphorylated α-synuclein: Critical role of proteinase K antigen retrieval and superior sensitivity of the D1R1R clone in human skin biopsies

α-Synuclein is an essential component of synucleinopathies including Parkinson disease, dementia with Lewy bodies, and multiple system atrophy (MSA). Misfolded-α-synuclein inclusions that contain high levels of Serine-129 phosphorylated (pS129-α-syn) are key diagnostic markers. Skin biopsies are a promising peripheral tissue for in vivo detection of aggregates using immunofluorescence staining. Several primary antibodies target pS129-α-syn but their diagnostic reliability remains uncertain. Common practice relies on clones EP1536Y and 81A without antigen retrieval; however, recent findings have underscored the need to validate additional methodologies and alternative clones. We compared the diagnostic accuracy of the standard protocol, alongside formic acid and proteinase K (PK) antigen retrieval to evaluate 4 additional monoclonal antibodies (J18, BBF19, pSyn#64, and D1R1R) in a cohort of 43 confirmed synucleinopathy patients (7 with MSA) and 33 healthy controls. The results showed that PK increased the detection rates for EP1536Y, 81A, and D1R1R, with D1R1R outperforming the others in sensitivity. J18, BBF19, and pSyn#64 exhibited insufficient specificity, limiting their clinical applicability. The improved accuracy with PK treatment and the promising performance of D1R1R mark critical advancements for reliable diagnosis, highlighting the importance of optimizing protocols and validating antibodies for dependable detection of pathological aggregates in skin biopsies.

A spit for a tip in dementia diagnosis: Evidence from saliva for dementia with Lewy bodies

Being the second most-frequent type of age-related neurodegenerative dementia, dementia with Lewy bodies (DLB) is currently exerting a huge burden on the healthcare system. Since DLB lacks a definitive biomarker profile, a diagnostic tool becomes indispensable for effectively distinguishing DLB from other neurodegenerative diseases with overlapping neuropathological and clinical features in their early stages. In this context, saliva could serve as a viable alternative to more invasive and costly methods, providing clear advantages in terms of safety and affordability. This is a commentary serving to contextualize the findings of D'Antonio et al., featured in the Journal of Alzheimer's Disease.

Efficacy of cholinesterase inhibitors treatment in dementia with Lewy bodies: A 3-year follow-up 'real world' study

BackgroundDementia with Lewy bodies (DLB) is the second most common dementia after Alzheimer's disease. Currently, no specific therapeutic agents are available for DLB. However, evidence of cholinergic deficits suggests that enhancing central cholinergic function may be a viable therapeutic approach.ObjectiveTo assess cognitive changes in DLB patients treated with cholinesterase inhibitors (ChEIs) in a real-world setting.MethodsThis retrospective study in a prospective database analyzed data from three dementia clinics between May 2012 and December 2022. Patients with DLB were divided into two groups: those treated with ChEIs and those untreated. Differences in changes in multiple cognitive-related scales between the two groups were analyzed.ResultsThe study included 204 DLB patients, with 133 (65.2%) in the ChEIs group and 71 (34.8%) in the non-ChEIs group. Initial demographic and clinical characteristics were similar between groups. Over time, patients in the ChEIs group showed significantly higher scores on the Mini-Mental State Examination and the Montreal Cognitive Assessment compared to the non-ChEIs group, indicating improved cognitive function. No significant differences were observed in activities of daily living scores.ConclusionsChEIs improved cognitive symptoms in DLB patients in the "real world" study. These findings are consistent with those from a previous small-sample randomized controlled trial. Longitudinal data indicate sustained benefits with continuous ChEIs use in three years. Overall, ChEIs show substantial potential for improving cognitive symptoms in DLB patients.

Visuospatial impairment in dementia: a new index to improve the clinical diagnosis of Alzheimer's disease

BACKGROUND

The differential diagnosis between Alzheimer's disease (AD) and other causes of dementia is essential but challenging. Therefore, there is an increasing need for early, reliable, and non-invasive tests to distinguish between different forms of dementia.

AIMS

To determine whether neuropsychological tests assessing visuospatial function can improve confidence in the clinical diagnosis of AD.

METHODS

Retrospective observational single-center cohort study involving all patients consecutively referred to our outpatient clinic for cognitive disorders who underwent neuropsychological assessment between 2013 and 2018. In addition to demographic and functional variables, each patient underwent neuropsychological tests to assess cognitive performance, memory, and executive, language, and visuospatial ability, according to clinical protocols. The clinical diagnosis of cognitive disorders, based on standard diagnostic criteria, served as the gold standard. Accuracy measures of visuospatial tests to diagnose AD were calculated. Additionally, a new index derived from the sum of four items (Rey-Osterrieth figure copying, Copy of Drawings, Clock Drawing Test, and years of schooling) was tested (ReDCOOL).

RESULTS

Of the 342 patients analyzed, 308 were diagnosed with dementia or mild cognitive impairment, including 60 with AD. AD patients exhibited the worst performance in visuospatial tests, and the utilization of the ReDCOOL index proved to be more dependable in identifying AD compared to other tests (AUROC 0.729, 95%CI 0.659-0.799; p < 0.001).

CONCLUSION

The ReDCOOL index appears to increase confidence in the clinical diagnosis of AD compared to each of the visuospatial tests considered. Furthermore, this index is easily calculated and does not prolong the time needed for clinical evaluation, as it does not require a customized patient assessment.

Brain network connectivity underlying neuropsychiatric symptoms in prodromal Lewy body dementia

Neuropsychiatric symptoms (NPS) are prevalent, emerge early, and are associated with poorer outcomes in Lewy body dementia (LBD). Research suggests NPS may reflect LBD-related dysfunction in distributed neuronal networks. This study investigated NPS neural correlates in prodromal LBD using resting-state functional MRI. Fifty-seven participants were included with mild cognitive impairment (MCI) with Lewy bodies (MCI-LB, n = 28) or Parkinson's disease (PD-MCI, n = 29). Functional MRI assessed connectivity within five resting-state networks: primary visual, dorsal attention, salience, limbic, and default mode networks. NPS were measured using the Neuropsychiatric Inventory. Principal component analyses identified three neuropsychiatric factors: affective disorder (apathy, depression), psychosis (delusions, hallucinations) and anxiety. Seed-to-voxel connectivity maps were analysed to determine associations between NPS and network connectivity. In PD-MCI, affective symptoms and anxiety were associated with greater connectivity between limbic orbitofrontal cortex and default mode areas, including medial prefrontal cortex, subgenual cingulate and precuneus, and weaker connectivity between limbic orbitofrontal cortex and the brainstem and between the salience network and medial prefrontal cortex (all pFWE<0.001). Psychosis severity in PD-MCI correlated with connectivity across multiple networks (all pFWE<0.001). In MCI-LB, no significant correlations were found between NPS severity and network connectivity. However, participants with anxiety demonstrated a trend towards greater connectivity within medial prefrontal areas than those without (pFWE=0.046). Altered connectivity within and between networks associated with mood disorders may explain affective and anxiety symptoms in PD-MCI. Neural correlates of NPS in MCI-LB, however, remain unclear, highlighting the need for research in larger, more diverse LBD populations to identify symptomatic treatment targets.

Sphingolipidoses: expanding the spectrum of α-synucleinopathies

Although α-synuclein pathology is typically associated with Lewy body diseases and multiple systems atrophy, increasing evidence indicates that it also occurs in a group of lysosomal storage disorders termed sphingolipidoses caused by the incomplete degradation, and subsequent accumulation, of a class of lipids termed sphingolipids. Notably, a number of genes that cause sphingolipidoses are also risk genes for Lewy body diseases, suggesting aetiological links between these distinct disorders. In the present review, we discuss the sphingolipidoses in which α-synuclein pathology has been reported: Gaucher disease, Krabbe disease, metachromatic leukodystrophy, Tay-Sachs disease and Anderson-Fabry disease, and describe the characteristic clinical and pathological features of these disorders, in addition to the evidence suggesting α-synuclein pathology occurs in these disorders. Finally, we evaluate the pathological mechanisms that underlie these rare disorders, with particular attention to how the enzymatic deficiency, substrate accumulation, or both, could contribute to the genesis of α-synuclein pathology and the implications of this for Lewy body diseases.

[18F]Florzolotau PET for the Differential Diagnosis of Parkinsonism in Patients with Suspected 4-Repeat Tauopathies

The second-generation tau radioligand [18F]florzolotau is a promising biomarker for 4-repeat (4R) tauopathies such as progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD), which are difficult to disentangle clinically. Prior studies evaluating the diagnostic accuracy of [18F]florzolotau PET focused on highly selected patient populations (e.g., PSP-Richardson syndrome or amyloid-β-negative corticobasal syndrome). The present study assesses the diagnostic performance of [18F]florzolotau PET in conjunction with visual reads in a real-world clinical cohort. Methods: Ninety-four consecutive patients with parkinsonism and possible 4R tauopathy undergoing [18F]florzolotau PET for differential diagnosis were enrolled and retrospectively analyzed. The interdisciplinary consensus diagnosis based on comprehensive clinical and imaging data (most notably, [18F]FDG PET) served as the reference standard. [18F]florzolotau PET was assessed visually using predefined 4R-like and Alzheimer disease (AD)-like binding patterns (on a 4-point scale). In addition, 4R-like cases were rated with respect to the cortical-subcortical gradient of 4R-like binding. The diagnostic performance was assessed by receiver operating characteristic (ROC) analyses. Results: The 4R-like pattern was more prevalent and more strongly expressed (84.3%, mean score, 2.0 ± 1.1) in patients with a consensus diagnosis of PSP/CBD (joint diagnostic group of clinically likely 4R tauopathies) than in all other groups (11.6%, 0.26 ± 0.75, P < 0.0001). An AD-like pattern was present in all patients with a consensus diagnosis of AD (100%, 2.5 ± 0.9) and at high frequency, albeit with lower magnitude, in all other patient groups (67.4%, 1.2 ± 1.1, P < 0.01). ROC analysis for the 4R-like pattern (PSP/CBD vs. all other patients) yielded an area under the ROC curve (AUC) of 0.87 (sensitivity, 84.3%; specificity, 88.4%). The diagnostic performance of [18F]florzolotau PET did not change when also considering the AD-like pattern (AUC, 0.88; logistic regression, factor AD-like pattern; P = 0.53) or excluding all cases with AD (AUC, 0.86). The presence of corticobasal syndrome in patients with 4R-like binding was strongly associated with preferentially cortical binding (AUC, 0.89). Conclusion: Based on a real-world population of patients with parkinsonism, we demonstrate that simple visual evaluation of [18F]florzolotau PET by an a priori-defined 4R-like binding pattern allows highly accurate identification of patients with a consensus diagnosis of PSP/CBD. Thus, [18F]florzolotau PET is a promising biomarker for differential diagnosis of neurodegenerative parkinsonian syndromes.

Divergent amygdala function in proposed brain-first and body-first Parkinson's disease: a resting-state functional magnetic resonance imaging study

BACKGROUND

The newly proposed α-Synuclein Origin and Connectome (SOC) Model classifies Parkinson's disease (PD) patients into brain-first and body-first subtypes. In brain-first patients, α-synuclein may originate in the amygdala of one cerebral hemisphere and disseminate ipsilaterally via the neural connectome. This study aimed to investigate the differences in clinical characteristics and amygdala function between these two subtypes and to evaluate whether amygdala function could serve as a marker for subtype distinctions.

METHODS

Resting-state functional MRI data of 66 early-stage PD patients and 17 healthy controls (HC) were retrieved from the Parkinson's Progression Markers Initiative database. PD patients with REM Sleep Behavior Disorder (RBD) were classified as the body-first subtype, while those without RBD were classified as the brain-first subtype.

RESULTS

We found that body-first patients had a longer disease duration and more severe autonomic dysfunction compared to brain-first patients. Amygdala-related FC in brain-first patients was similar to that in the HC group, with both groups showing stronger FC between the bilateral amygdala and the right postcentral gyrus than body-first patients. Importantly, the abnormal amygdala-related FC was negatively correlated with SCOPA-Aut scores (r = -0.361, P = 0.002) in PD patients. ROC analysis indicated that the area under the curve for the FC was 0.834.

CONCLUSION

Our findings suggest that the amygdala-related FC may serve as an effective indicator to differentiate brain-first and body-first subtypes. Moreover, functional abnormalities in the amygdala contribute to autonomic dysfunction, rather than depression or anxiety in early-stage PD patients. Further validation of these findings in trials with larger cohorts is needed.

A Novel CHMP2B Splicing Variant in Atypical Presentation of Familial Frontotemporal Lobar Degeneration

C-truncating variants in the charged multivesicular body protein 2B (CHMP2B) gene are a rare cause of frontotemporal lobar degeneration (FTLD), previously identified only in Denmark, Belgium, and China. We report a novel CHMP2B splice-site variant (c.35-1G>A) associated with familial FTLD in Spain. The cases were two monozygotic male twins who presented at ages 62 and 66 years with a slowly progressive behavioral variant of frontotemporal dementia and a syndrome mimicking dementia with Lewy bodies, respectively. Functional and in silico analyses supported the pathogenicity of this variant. Our findings contribute new insights into the genetic landscape and clinical heterogeneity of FTLD.

Dissection of blood-brain barrier dysfunction through CSF PDGFRβ and amyloid, tau, neuroinflammation, and synaptic CSF biomarkers in neurodegenerative disorders

BACKGROUND

Blood-brain barrier (BBB) dysfunction is an early event in neurodegenerative disorders. Pericytes are key cells for BBB maintenance. Upon pericyte injury, the platelet-derived growth factor receptor-β (PDGFRβ) is released in the cerebrospinal fluid (CSF). The relation of CSF PDGFRβ with markers of amyloid pathology, neuroinflammation, and axonal and synaptic damage across dementia remains unclear.

METHODS

Retrospectively, we quantified CSF PDGFRβ and CSF core Alzheimer's disease (AD), astrocytic (GFAP), microglial (sTREM 2, YKL-40), axonal (NfL), and synaptic (GAP-43, neurogranin) biomarkers in 210 patients from the Cognitive Neurology Centre, Paris, France, including n = 23 neurological controls (NC), n = 84 patients with mild cognitive impairment (MCI) [AD, n = 41; non-AD, n = 43], and n = 103 patients with dementia (AD, n = 73; non-AD, n = 30).

FINDINGS

Comparing clinical stages, CSF PDGFRβ levels were increased at the MCI stage (Cohen's d = 0.55 [CI95% 0.066, 1.0], P = 0.025) compared with NC. Non-AD MCI displayed higher levels than controls (Cohen's d = 0.74 [CI95% 0.22, 1.3], P = 0.042). No association was observed with CSF Aβ42/Aβ40 ratio but with p-tau 181 (β = 0.102 [CI95% 0.027, 0.176], P = 0.0080) and t-tau levels (β = 0.133 [0.054, 0.213], P = 0.0010). CSF PDGFRβ levels were positively associated with CSF neuroinflammation and synaptic markers levels. Higher CSF PDGFRβ levels were associated with lower MMSE scores at MCI (β = -1.23 [CI95% -2.33, -0.260], P = 0.015) and dementia stages (β = -2.24 [CI95% -3.62, -0.85], P = 0.0020). CSF neuroinflammation biomarkers mediated the association of CSF PDGFRβ with neurodegeneration and synaptic integrity markers.

INTERPRETATION

CSF PDGFRβ, a candidate biomarker of BBB dysfunction, is increased in the early stages of neurodegenerative disorders, in association with neuroinflammation and axonal and synaptic damage.

FUNDING

Association des Anciens Internes des Hôpitaux de Paris, Edmond de Rothschild Program, Fondation Vaincre Alzheimer, Demensförbundet, Gamla Tjänarinnor, Anna-Lisa och Bror Björnssons Stiftelse.

Hippocampal sclerosis in senile dementia of the neurofibrillary tangle type

INTRODUCTION

Senile dementia of the neurofibrillary tangle type (SD-NFT) is a subset of dementia in elderly individuals. Recent studies have reported a correlation between hippocampal sclerosis (HS) and aging. This study aimed to investigate the relationship between HS and SD-NFT.

METHODS

We conducted a clinical and neuropathological review of Japanese patients diagnosed with SD-NFT. Hematoxylin-eosin and Klüver-Barrera staining, Gallyas silver impregnation, and immunohistochemistry were employed. Pathological assessments focused on identifying HS, neuritic plaques, and phosphorylated transactive response DNA-binding protein 43 (p-TDP-43)-positive inclusions. Additionally, we quantified the densities of neurofibrillary tangles (NFTs) and ghost tangles (GTs) within the hippocampal CA1 region.

RESULTS

Nine patients met the criteria for SD-NFT from the patients who underwent consecutive autopsies from 1994 to 2022 at our institute. The mean ages at onset and death were 84.0 ± 6.8 years (range, 76-94 years) and 91.0 ± 7.0 years (range, 79-101 years), respectively. The mean dementia duration was 7.0 ± 4.0 years (range, 1-13 years). All patients exhibited memory loss although none were diagnosed with SD-NFT during their lifetime. The mean brain weight was 1124.2 ± 132.1 g (range, 980-1390 g). Three patients displayed HS. NFT and GT densities were significantly higher in patients with HS than in those without HS. No significant correlation was found between HS and p-TDP-43 inclusions in the medial temporal lobe.

CONCLUSION

In SD-NFT, NFTs are more strongly associated with HS. This finding enhances our understanding of the pathological underpinnings of HS in SD-NFT.

Electroconvulsive therapy ameliorates treatment-resistant depression in patient with Lewy body dementia

Lewy body dementia (LBD), the second most common degenerative dementia after Alzheimer's disease, is frequently associated with neuropsychiatric symptoms such as depression, anxiety, and apathy. These symptoms may precede cognitive decline, often resulting in misdiagnosis and inappropriate treatment. Electroconvulsive therapy (ECT) has emerged as a promising option for treatment-resistant depression in LBD. This report describes a 68-year-old female patient with LBD who received multiple ECT sessions for persistent severe depression and suicidal ideation. ECT led to marked symptom improvement across several hospitalizations. This case underscores the diagnostic and therapeutic challenges of neuropsychiatric symptoms in LBD and highlights ECT as a potential alternative when pharmacotherapy is inadequate. Early identification of LBD in patients with late-onset depression is essential to guide individualized treatment strategies.

Differentiating Progressive Supranuclear Palsy and Corticobasal Syndrome: Insights from Cerebrospinal Fluid Biomarkers-A Narrative Review

Background and Objectives: Despite ongoing research and evolving diagnostic criteria, progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS) remain notoriously difficult to differentiate, largely due to their overlapping clinical presentations and the absence of definitive biomarkers. Materials and Methods: We provide a comprehensive review of cerebrospinal fluid (CSF) biomarkers, which have proven valuable in the diagnosis of other neurodegenerative conditions, and their application to PSP and CBS. Results: The most promising results derive from a combination of biomarkers associated with Parkinson's disease, Alzheimer's disease, and neurofilament light chain. Furthermore, CSF proteomics analysis offers valuable insights into the pathogenesis of PSP and CBS and could also contribute to accurate diagnosis. Conclusions: CSF biomarkers hold significant potential for improving the differential diagnosis of PSP and CBS. A stepwise combination approach-starting with CSF α-synuclein and neurofilament light chain, followed by amyloid-β42 and total and phosphorylated tau-may provide clinicians with a practical framework for distinguishing PSP and CBS from other neurodegenerative disorders. To advance this field, future efforts should prioritize large-scale, multicenter studies employing standardized methodologies to enhance the validity and reproducibility of biomarker-based diagnostics. Importantly, considering the frequent pathological overlap between PSP and CBS, future studies would greatly benefit from pathology-confirmed cohorts to ensure diagnostic accuracy and to better delineate biomarker profiles across these challenging conditions.

MRI for diagnosing dementia - update 2025

Magnetic resonance imaging (MRI) plays a crucial role alongside clinical and neuropsychological assessments in diagnosing dementia. The recent and ongoing advancements in MRI technology have significantly enhanced the detection and characterization of the specific neurostructural changes seen in various neurodegenerative diseases, thereby significantly increasing the precision of diagnosis. Within this context of perpetual evolution, this review article explores the recent advances in MRI with regard to diagnosing dementia.A retrospective literature review was conducted by searching the PubMed and ScienceDirect databases for the keywords "dementia", "imaging", and "MRI". The inclusion criteria were scientific papers in English that revolved around the role of MRI as a diagnostic tool in the field of dementia. A specific time frame was not determined but the focus was on current articles, with an overall of 20 articles dating from the last 6 years (after 2018), corresponding to 55% of the total number of articles.This review provides a comprehensive overview of the latest advances in the radiologic diagnosis of dementia using MRI, with a particular focus on the last 6 years. Technical aspects of image acquisition for clinical and research purposes are discussed. MRI findings typical of dementia are described. The findings are divided into non-specific findings of dementia and characteristic findings for certain dementia subtypes. This provides information about possible causes of dementia. In addition, developed scoring systems that support MRI findings are presented, including the MTA score for Alzheimer's disease with corresponding illustrative figures.The symbiosis of clinical evaluation with high-field MRI methodologies enhances dementia diagnosis and offers a holistic and nuanced understanding of structural brain changes associated with dementia and its various subtypes. The latest advances, mainly involving the emergence of ultra-high-field (7T) MRI, despite having limited use in clinical practice, mark a pragmatic shift in the field of research. · High-field MRI (3T) and specialized sequences allow for the detection of early structural changes indicative of dementia.. · Characteristic neuroanatomical MRI patterns enable the differentiation between various subtypes of dementia.. · Established scales provide added value to the quantification and categorization of MRI findings in dementia.. · Akl E, Dyrba M, Görß D et al. MRI for diagnosing dementia - update 2024. Rofo 2025; DOI 10.1055/a-2563-0725.

Anosmia and Upper Limb Rigidity-A Potential Phenotype of Idiopathic Normal Pressure Hydrocephalus with Cerebrospinal Fluid α-Synuclein Seeds

BACKGROUND

The pathophysiology of idiopathic normal pressure hydrocephalus (iNPH) and its association with neurodegenerative disorders is poorly understood.

OBJECTIVES

The aim was to determine the prevalence of α-synuclein pathology in iNPH and its associations with clinical characteristics.

METHODS

We used α-synuclein seed amplification assay (synSAA) to retrospectively analyze cerebrospinal fluid (CSF) from a large single-center iNPH cohort (n = 144). Clinical assessments comprised Unified Parkinson's Disease Rating Scale part III, Mini-Mental State Examination, levodopa-challenge test, and olfactory identification test. Degenerative biomarkers (total-tau, phospho-tau, β-amyloid 1-42, and β-amyloid 1-40) were measured in CSF.

RESULTS

A total of 30.1% of iNPH patients were synSAA+, and presented significantly more upper limb (UL) rigidity, hallucinations, and worse olfactory performance than synSAA- cases. Anosmia was higher in synSAA+ patients (64.0%) than synSAA- patients (15.3%). Clinical assessments and other biomarkers did not significantly vary with synSAA status.

CONCLUSIONS

Underlying α-synuclein pathology is common in iNPH and presents with UL rigidity and olfactory dysfunction, suggesting a distinct synSAA+ phenotype in iNPH. © 2025 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Case Report: Lewy body dementia with unusual psychotic symptoms, atypically late parkinsonism, and patient sensitivity to first generation antipsychotics

Lewy body dementia is associated with abnormal eosinophilic A-synuclein neural inclusions (Lewy bodies) in the brain. It is a neurodegenerative illness-and the second most common type of dementia after Alzheimer's disease-that causes memory loss and severe problems in carrying out daily activities. In this report, we describe a case of Lewy body dementia that began with early psychotic symptoms with atypical features (transition from hallucinosis (hallucinatory insight) to true visual hallucinations) -without Parkinsonism. The patient exhibited sensitivity to first generation antipsychotic medication, which led to a worsening of her symptoms. Physicians should consider all possible diagnoses when confronted with atypical, early symptoms of visual hallucinosis or true hallucinations and dementia without Parkinsonism. Choosing antipsychotic medicines should be made with care given these patients' possible sensitivity to antipsychotics. The selection of antipsychotics should be consider among first, second and third generation options.

Case report: post COVID-19 encephalopathy and oral cenesthopathy

Post-COVID-19 encephalopathy is a neurological complication characterized by cognitive impairment, memory loss, and other neuropsychiatric symptoms in COVID-19 survivors. Oral cenesthopathy, a rare somatic delusion characterized by unusual oral sensations without physical findings, is typically associated with affective disorders and schizophrenia. This case report describes a 73-year-old female who developed post-COVID-19 encephalopathy, presenting initially with cognitive decline, followed by major depression and oral cenesthopathy 16 months after the infection. Comprehensive investigations excluded autoimmune encephalitis, Creutzfeldt-Jakob disease, and other structural or vascular abnormalities. Treatment with Aripiprazole and Carbamazepine resulted in partial improvement, though symptom control was limited by medication side effects. This case represents a rare presentation of long COVID syndrome, highlighting the complex neuropsychiatric sequelae of COVID-19. Further research is needed to explore the pathophysiology, treatment strategies, and long-term impacts of such manifestations.

Clinical utility of cerebrospinal fluid Alzheimer's disease biomarkers in the diagnostic workup of complex patients with cognitive impairment

Cerebrospinal fluid (CSF) biomarkers have been widely adopted in Alzheimer's disease (AD) diagnosis. However, no studies focused on the application of CSF biomarkers in the clinical practice of complex and atypical patients with cognitive impairment in China. This study aimed to evaluate the added value of CSF AD biomarkers in cognitively impaired patients with complex conditions in a memory clinical setting. A total of 633 participants were included from the National Center for Neurological Disorders in Shanghai, China. The CSF AD biomarkers were measured with ELISA. Cutoff values were firstly identified using Youden's index. The neurologists proposed etiology diagnosis with a percentage estimate of their confidence and prescribed medication before and after CSF disclosure. Changes in etiological diagnosis, diagnostic confidence, and management plan were compared across the groups. Of the 633 patients (mean [SD] age, 61.1 [11.3] years; 295 males [46.6%]), 372 (58.8%) were diagnosed with dementia, 103 (16.3%) with mild cognitive impairment, and 158 (24.9%) with subjective cognitive decline. Using those pre-defined cutoffs, we categorized patients into 3 groups: Alzheimer's continuum (68.1%), non-AD pathologic change (11.1%), and normal AD biomarkers (20.8%). After CSF disclosure, the proposed etiology changed in 158 (25.0%) participants and the prescribed medication changed in 200 (31.6%) patients. Mean diagnostic confidence increased from 69.5-83.0% (+13.5%; P < 0.001). In conclusion, CSF AD biomarkers significantly impacted the diagnosis, diagnostic confidence, and treatment plans for Chinese patients with complex cognitive impairment. CSF AD biomarkers are a useful tool for clinicians beyond routine clinical assessment.

Cerebrospinal fluid and blood neurofilament light chain in Parkinson's disease and atypical parkinsonian syndromes: a systematic review and Bayesian network meta-analysis

BACKGROUND AND OBJECTIVE

The value of neurofilament light chain (NfL) levels as a biomarker for the diagnosis and differential diagnosis in patients with Parkinson's disease (PD) and atypical parkinsonian syndromes (APS) remains controversial. Furthermore, few studies have directly compared NfL levels among specific APS categories. This study aimed to compare cerebrospinal fluid (CSF) and blood NfL levels among PD, APS, other PD-related disorders, and controls, as well as rank NfL levels across these groups.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched from the inception up to November 1st, 2024, to identify eligible studies reporting CSF or blood NfL concentrations in PD, PD dementia (PDD), multiple system atrophy (MSA), progressive supranuclear palsy (PSP), dementia with Lewy bodies (DLB), corticobasal syndrome (CBS), vascular parkinsonism (VP), essential tremor (ET), idiopathic rapid eye movement sleep behavior disorder (iRBD), and controls. The Bayesian approach was utilized to estimate the standardized mean difference (SMD) and the associated 95% credible intervals (CrIs) of NfL levels. The surface under the cumulative ranking curve (SUCRA) was employed to evaluate the ranking probabilities of NfL levels. Subgroup analysis and meta-regression were conducted to explore the sources of heterogeneity.

RESULTS

The present network meta-analysis (NMA) included 78 studies with 13,120 participants (4050 controls, 5021 PD, 191 PDD, 1173 MSA, 887 PSP, 1254 DLB, 319 CBS, 160 ET, 65 iRBD, and 0 VP). Of these, the NMA of CSF NfL included 34 studies with 6,013 participants, while the NMA of blood NfL included 49 studies with 7,787 participants. Both CSF and blood NfL levels were significantly elevated in patients with PD and APS compared to controls. Compared to PD patients, CSF NfL levels were significantly elevated in MSA (SMD 1.85; 95% CrI 1.55-2.15), CBS (1.42; 1.08-1.75), PSP (1.35; 1.06-1.64), and DLB 0.52; 0.20-0.85) patients. Similarly, blood NfL levels were significantly higher in patients with MSA (1.36; 1.02-1.71), PDD (1.19; 0.65-1.72), PSP (1.15; 0.77-1.54), CBS (0.92; 0.11-1.72), and DLB (0.63; 0.14-1.12) compared to PD. Among APS, CSF NfL levels in MSA patients were significantly higher than those in PSP, DLB, and CBS patients, while blood NfL levels in MSA patients were significantly higher only compared to DLB. In both CSF and blood NfL, MSA patients exhibited the highest probability of ranking first for NfL level elevations (CSF: SUCRA = 0.998; blood: SUCRA = 0.925). Age significantly influenced the SMD of the comparison between MSA and PD in CSF NfL (β = -0.15; p = 0.016).

CONCLUSIONS

CSF and blood NfL levels in PD and APS are higher than those in controls, and all APS categories show higher levels than PD, suggesting that NfL levels may serve as a potential biomarker for the differential diagnosis between PD and APS. However, caution is warranted when using NfL as a diagnostic biomarker for PD. Significant differences in NfL levels are also observed between certain APS categories. Patients with MSA exhibit the highest NfL levels among PD and related disorders.