Prediction of the Clinical SUV Ratio in Amyloid PET Imaging Using a Biomathematic Modeling Approach Toward the Efficient Development of a Radioligand

Agreement between early-phase amyloid-PET and pulsed arterial spin labeling in a memory clinic cohort

Relative cerebral blood flow (rCBF), assessed using pulsed arterial spin labeling (pASL) MRI, and the standardized uptake value ratio (SUVr) in early-phase amyloid-PET (ePET) are used as proxies for brain perfusion. These methods have the potential to streamline clinical workflows and reduce the burden on patients by eliminating the need for additional procedures. While both techniques have shown good agreement with the gold standard for glucose metabolism assessment, F-fluorodeoxyglucose-PET, a direct comparison between them has yet to be fully clarified. This retrospective study aimed to compare perfusion-like data from pASL (rCBF) and ePET (SUVr) in a memory clinic cohort. We included 46 subjects (69 ± 8 years; 37 women) from the Geneva Memory Center (cognitively impaired-CI n = 29; cognitively unimpaired-CU n = 17), with available pASL and ePET. We evaluated the association between rCBF and SUVr values across 18 cortical and subcortical regions using linear regression and the within-subject coefficient of variation (wsCV). Regional differences between CU and CI groups were assessed using linear regression model corrected for age. We observed significant association between rCBF and SUVr in precuneus (β = 0.69, wsCV = 16.9), angular gyrus (β = 0.64, wsCV = 19.4), and hippocampus (β = 0.23, wsCV = 16.1). Additionally, significant differences in rCBF between CU and CI were also observed in the posterior cingulate, precuneus, calcarine, hippocampus, and composite (p < 0.05), while SUVr showed significant differences only in the hippocampus. Our findings indicate weak to moderate local correlations between the two techniques. However, both exhibited differing regional perfusion levels in CU and CI groups, with rCBF showing more regional differences between cognitive stages in comparison with SUVr. KEY MESSAGES: rCBF is assessed through pASL MRI and SUVr through ePET, both serving as proxies of brain perfusion. Weak to moderate associations between rCBF and SUVr were found in a number of brain regions. rCBF and SUVr differences between cognitive stages were observed mostly in cortical and subcortical regions respectively. Both techniques were able to identify AD perfusion-like differences expected in cognitively impaired vs unimpaired.

Amyloid-PET of the white matter: Relationship to free water, fiber integrity, and cognition in patients with dementia and small vessel disease

White matter (WM) injury is frequently observed along with dementia. Positron emission tomography with amyloid-ligands (Aβ-PET) recently gained interest for detecting WM injury. Yet, little is understood about the origin of the altered Aβ-PET signal in WM regions. Here, we investigated the relative contributions of diffusion MRI-based microstructural alterations, including free water and tissue-specific properties, to Aβ-PET in WM and to cognition. We included a unique cohort of 115 participants covering the spectrum of low-to-severe white matter hyperintensity (WMH) burden and cognitively normal to dementia. We applied a bi-tensor diffusion-MRI model that differentiates between (i) the extracellular WM compartment (represented via free water), and (ii) the fiber-specific compartment (via free water-adjusted fractional anisotropy [FA]). We observed that, in regions of WMH, a decrease in Aβ-PET related most closely to higher free water and higher WMH volume. In contrast, in normal-appearing WM, an increase in Aβ-PET related more closely to higher cortical Aβ (together with lower free water-adjusted FA). In relation to cognitive impairment, we observed a closer relationship with higher free water than with either free water-adjusted FA or WM PET. Our findings support free water and Aβ-PET as markers of WM abnormalities in patients with mixed dementia, and contribute to a better understanding of processes giving rise to the WM PET signal.

A Historical Review of Brain Drug Delivery

The history of brain drug delivery is reviewed beginning with the first demonstration, in 1914, that a drug for syphilis, salvarsan, did not enter the brain, due to the presence of a blood-brain barrier (BBB). Owing to restricted transport across the BBB, FDA-approved drugs for the CNS have been generally limited to lipid-soluble small molecules. Drugs that do not cross the BBB can be re-engineered for transport on endogenous BBB carrier-mediated transport and receptor-mediated transport systems, which were identified during the 1970s-1980s. By the 1990s, a multitude of brain drug delivery technologies emerged, including trans-cranial delivery, CSF delivery, BBB disruption, lipid carriers, prodrugs, stem cells, exosomes, nanoparticles, gene therapy, and biologics. The advantages and limitations of each of these brain drug delivery technologies are critically reviewed.

18F-FDG PET, the early phases and the delivery rate of 18F-AV45 PET as proxies of cerebral blood flow in Alzheimer's disease: Validation against 15O-H2O PET

INTRODUCTION

Dual-biomarker positron emission tomography (PET), providing complementary information on cerebral blood flow and amyloid-β deposition, is of clinical interest for Alzheimer's disease (AD). The purpose of this study was to validate the perfusion components of early-phase ¹⁸F-florbetapir (eAV45), the ¹⁸F-AV45 delivery rate (R1), and ¹⁸F-FDG against ¹⁵O-H₂O PET and assess how they change with disease severity.

METHODS

This study included ten controls, 19 amnestic mild cognitive impairment, and 10 AD dementia subjects. Within-subject regional correlations between modalities, between-group regional and voxel-wise analyses of covariance per modality, and receiver operating characteristic analyses for discrimination between groups were performed.

RESULTS

FDG standardized uptake value ratio, eAV45 (0-2 min) standardized uptake value ratio, and AV45-R1 were significantly associated with H₂O PET (regional Pearson r = 0.54-0.82, 0.70-0.94, and 0.65-0.92, respectively; P < .001). All modalities confirmed reduced cerebral blood flow in the posterior cingulate of patients with amnestic mild cognitive impairment and AD dementia, which was associated with lower cognition (r = 0.36-0.65, P < .025) and could discriminate between patient and control groups (area under the curve > 0.80). However, eAV45 was less sensitive to reflect the disease severity than AV45-R1 or FDG.

DISCUSSION

R1 is preferable over eAV45 for accurate representation of brain perfusion in dual-biomarker PET for AD.

Evaluation of the Feasibility of Screening Tau Radiotracers Using an Amyloid Biomathematical Screening Methodology

The purpose of this study is to evaluate the feasibility of extending a previously developed amyloid biomathematical screening methodology to support the screening of tau radiotracers during compound development. 22 tau-related PET radiotracers were investigated. For each radiotracer, in silico MLogP, V _x, and in vitro K _D were input into the model to predict the in vivo K ₁, k ₂, and BP_ND under healthy control (HC), mild cognitive impaired (MCI), and Alzheimer's disease (AD) conditions. These kinetic parameters were used to simulate the time activity curves (TACs) in the target regions of HC, MCI, and AD and a reference region. Standardized uptake value ratios (SUVR) were determined from the integrated area under the TACs of the target region over the reference region within a default time window of 90-110 min. The predicted K ₁, k ₂, and BP_ND values were compared with the clinically observed values. The TACs and SUVR distributions were also simulated with population variations and noise. Finally, the clinical usefulness index (CUI) ranking was compared with clinical comparison results. The TACs and SUVR distributions differed for tau radiotracers with lower tau selectivity. The CUI values ranged from 0.0 to 16.2, with 6 out of 9 clinically applied tau radiotracers having CUI values higher than the recommend CUI value of 3.0. The differences between the clinically observed TACs and SUVR results showed that the evaluation of the clinical usefulness of tau radiotracer based on single target binding could not fully reflect in vivo tau binding. The screening methodology requires further study to improve the accuracy of screening tau radiotracers. However, the higher CUI rankings of clinically applied tau radiotracers with higher signal-to-noise ratio supported the use of the screening methodology in radiotracer development by allowing comparison of candidate radiotracers with clinically applied radiotracers based on SUVR, with respect to binding to a single target.

Biomathematical screening of amyloid radiotracers with clinical usefulness index

Introduction

To facilitate radiotracers' development, a screening methodology using a biomathematical model and clinical usefulness index (CUI) was proposed to evaluate radiotracers' diagnostic capabilities.

Methods

A total of 31 amyloid positron emission tomography radiotracers were evaluated. A previously developed biomathematical model was used to simulate 1000 standardized uptake value ratios with population and noise simulations, which were used to determine the integrated receiver operating characteristics curve (Az), effect size (Es), and standardized uptake value ratio (Sr) of conditions-pairs of healthy control–mild cognitive impaired and mild cognitive impaired–Alzheimer's disease. CUI was obtained from the product of averaged Az(Az¯), Es(Es¯), and Sr(Sr¯).

Results

The relationships of Az¯, Es¯, and Sr¯ with CUI were different, suggesting that they assessed different radiotracer properties. The combination of Az, Es, and Sr complemented each other and resulted in CUI of 0.10 to 5.72, with clinically applied amyloid positron emission tomography radiotracers having CUI greater than 3.0.

Discussion

The CUI rankings of clinically applied radiotracers were close to their reported clinical results, attesting to the applicability of the screening methodology.

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Clinical usefulness index was proposed to evaluate radiotracers' diagnostic power.

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CUI rankings of amyloid radiotracers were close to their clinical results.

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CUI allows for simultaneous and objective comparison of candidate radiotracers.