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CSF Tau and Amyloid-Beta Predict Cerebral Synucleinopathy in Autopsied Lewy Body Disorders

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CSF Tau and Amyloid-Beta Predict Cerebral Synucleinopathy in Autopsied Lewy Body Disorders ARTICLE CSF tau and amyloid-beta predict cerebral synucleinopathy in autopsied Lewy body disorders David J. Irwin, MD, MTR, Sharon X. Xie, PhD, David Coughlin, MD, Naomi Nevler, MD, Correspondence Rizwan S. Akhtar, MD, PhD, Corey T. McMillan, PhD, Edward B. Lee, MD, PhD, David A. Wolk, MD, Dr. Irwin Daniel Weintraub, MD, Alice Chen-Plotkin, MD, John E. Duda, MD, Meredith Spindler, MD, dirwin@pennmedicine. Andrew Siderowf, MD, MSCE, Howard I. Hurtig, MD, Leslie M. Shaw, PhD, Murray Grossman, MD, upenn.edu and John Q. Trojanowski, MD, PhD Neurology® 2018;90:1-9. doi:10.1212/WNL.0000000000005166 Abstract RELATED ARTICLE Objective Editorial To test the association of antemortem CSF biomarkers with postmortem pathology in Lewy Alzheimer disease body disorders (LBD). biomarkers and synucleinopathy Methods Page XXX Patients with autopsy-confirmed LBD (n = 24) and autopsy-confirmed Alzheimer disease (AD) (n = 23) and cognitively normal (n = 36) controls were studied. In LBD, neuropathologic criteria defined Lewy body α-synuclein (SYN) stages with medium/high AD copathology (SYN + AD = 10) and low/no AD copathology (SYN − AD = 14). Ordinal pathology scores for tau, β-amyloid (Aβ), and SYN pathology were averaged across 7 cortical regions to obtain a global cerebral score for each pathology. CSF total tau (t-tau), phosphorylated tau at thre- β onine181, and A 1-42 levels were compared between LBD and control groups and correlated with global cerebral pathology scores in LBD with linear regression. Diagnostic accuracy for postmortem categorization of LBD into SYN + AD vs SYN − AD or neocortical vs brainstem/ limbic SYN stage was tested with receiver operating curves. Results ff β SYN + AD had higher CSF t-tau (mean di erence 27.0 ± 8.6 pg/mL) and lower A 1-42 (mean difference −84.0 ± 22.9 g/mL) compared to SYN − AD (p < 0.01, both). Increasing global cerebral tau and plaque scores were associated with higher CSF t-tau (R2 = 0.15–0.16, p < 0.05, β 2 – both) and lower A 1-42 (R = 0.43 0.49, p < 0.001, both), while increasing cerebral SYN scores β 2 β were associated with lower CSF A 1-42 (R = 0.31, p < 0.001) and higher CSF t-tau/A 1-42 ratio 2 β fi (R = 0.27, p = 0.01). CSF t-tau/A 1-42 ratio had 100% speci city and 90% sensitivity for SYN + β fi AD, and CSF A 1-42 had 77% speci city and 82% sensitivity for neocortical SYN stage. Conclusions β β Higher antemortem CSF t-tau/A 1-42 and lower A 1-42 levels are predictive of increasing cerebral AD and SYN pathology. These biomarkers may identify patients with LBD vulnerable to cortical SYN pathology who may benefit from both SYN and AD-targeted disease-modifying therapies. From Penn Frontotemporal Degeneration Center (D.J.I., N.N., C.T.M., M.G.), Alzheimer’s Disease Core Center (D.A.W., J.Q.T.), Department of Neurology (D.J.I., D.C., R.S.A., C.T.M., D.A. W., D.W., A.C.-P., M.S., A.S., H.I.H., M.G.), Penn Morris K. Udall Parkinson’s Disease Research Center of Excellence (D.J.I., R.S.A., C.T.M., D.W., A.C.-P., J.E.D., M.G., J.Q.T.), Center for Neurodegenerative Disease Research (L.M.S., J.Q.T.), Translational Neuropathology Research Laboratory (E.B.L.), Department of Pathology and Laboratory Medicine (E.B.L., L.M.S., J.Q.T.), and Department of Biostatistics and Epidemiology Perelman School of Medicine (S.X.X.), University of Pennsylvania; and Parkinson’s Disease Research, Education and Clinical Center (D.W., J.E.D.), Michael J. Crescenz VA Medical Center, Philadelphia, PA. Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. Copyright © 2018 American Academy of Neurology 1 Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited. GLOSSARY Aβ = β-amyloid; AD = Alzheimer disease; AUC = area under the curve; CI = confidence interval; DLB = dementia with Lewy bodies; LBD = Lewy body disorders; PD = Parkinson disease; PDD = Parkinson disease with dementia; p-tau = phosphorylated tau; ROC = receiver operating curve; SYN = α-synuclein; t-tau = total tau. Roughly 40% of all patients with Lewy body disorders Standard protocol approvals, registrations, (LBD) (i.e., Parkinson disease [PD], PD with dementia and patient consents [PDD]; dementia with Lewy bodies [DLB]) have sufficient All procedures were performed with informed consent under amyloid plaque and tau tangle pathology for a concomitant institutional review board approval. – diagnosis of Alzheimer disease (AD) at autopsy.1 6 Fur- thermore, increasing levels of cerebral tau and amyloid CSF collection and analysis pathology in postmortem brains of patients with LBD are CSF was collected under standard operating procedures and associated with shorter survival, rapider time to develop analyzed with a Luminex xMAP immunoassay platform dementia in relation to onset of motor parkinsonism, and (Luminex, Austin, TX) to measure CSF t-tau, p-tau (phos- 2 β 8 higher burden of cortical α-synuclein (SYN) pathology. phorylated at threonine-181), and A 1-42 as described. Thus, AD copathology has significant consequences in LBD, and antemortem identification of this patient sub- Neuropathologic examination group has important implications for prognosis and clinical Autopsy procedures were performed as previously de- 11 management in LBD.7 CSF levels of the protein con- scribed with sampling of fresh brain tissue according to fi ff stituents of AD neuropathology (i.e., total tau [t-tau], a standardized atlas and xed in 10% neutral bu ered for- β β phosphorylated tau [p-tau], and -amyloid [A 1-42]) have malin or 70% ethanol with 150 mmol/L NaCl overnight, 8 ffi been extensively studied in the context of AD, but CSF processed, and embedded in para n for sectioning. For μ biomarker work in LBD is largely restricted to living neuropathologic diagnosis, 6- m sections were cut and cohorts without postmortem validation. Furthermore, stained with immunohistochemistry with established anti- fi neuroimaging modalities to visualize cerebral SYN pa- bodies speci c for hyperphosphorylated tau (PHF-1), SYN β thology during life are lacking, and CSF SYN analytes are (SYN303), A (Nab228), and phosphorylated TDP-43 yet to be validated,9 so in vivo measures that predict ce- (p409-410) and chemically stained with the amyloid- fl rebral SYN pathology are urgently needed. binding dye Thio avin-S to detect neuritic plaques. Expert neuropathologists (E.B.L., J.Q.T.) applied currently validated 12,13 Here, we test the hypothesis that AD CSF biomarkers mea- diagnostic criteria to assign Braak tau, Thal amyloid, ’ sured during life predict postmortem cortical severity of both Consortium to Establish a Registry for Alzheimer sDisease AD-associated tau tangles and Aβ plaques, as well as SYN neuritic plaque, and SYN Lewy body stages, as well as the fi Lewy pathology, in a cohort of 24 patients with autopsy- nal diagnosis for each case. confirmed LBD. We find evidence of a direct association of β β CSF A 1-42 and CSF t-tau/A 1-42 ratio with cerebral SYN We categorized patients with medium- or high-level AD as Lewy pathology. having AD copathology (SYN + AD) and patients with no or low-level AD pathology as those without significant AD copathology (SYN − AD) according to neuropathologic cri- Methods teria12 as described.1,2 Alternative analyses compared patients with low/medium/high AD copathology (n = 18) to SYN Patients with no AD (n = 6). Patients were followed up in clinical cores of the Penn Udall Center for Parkinson’s Disease Research, Frontotemporal To obtain a continuous measure of global neuropathologic Degeneration Center, or Alzheimer’s Disease Core Center severity for tau-positive tangles, amyloid-positive plaques, and and selected from the Penn Integrated Neurodegenerative SYN-positive Lewy bodies/Lewy neurites, we calculated an Disease Database10 as of April 1, 2017, to identify patients average of ordinal scores (i.e., 0 = rare/none, 1 = mild, 2 = with an antemortem clinical diagnosis of LBD (PD, PDD, moderate, 3 = severe) obtained at autopsy using diagnostic DLB), autopsy confirmation through the Penn Center for criteria in 7 cortical regions. Briefly, the medial temporal lobe Neurodegenerative Disease brain bank of SYN pathology severity was calculated by averaging the ordinal scores in the (brainstem, limbic, or neocortical stage), and baseline ante- amygdala, hippocampal entorhinal cortex, and cornu mortem CSF samples for study. We included reference ammonis/subiculum regions. The global cerebral scores were cohorts with available CSF data and age-matched normal derived from the average of ordinal scores in the medial cognition (n = 36) or autopsy-confirmed AD neuropathology temporal lobe, superior/midtemporal lobe, angular cortex, without SYN copathology (n = 23) (table e-1, links.lww.com/ midfrontal cortex, and anterior cingulate gyrus as described.1,2 WNL/A257). We also calculated a global subcortical score for SYN 2 Neurology | Volume 90, Number 12 | March 20, 2018 Neurology.org/N Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited. pathology from sections of medulla, substantia nigra, non- nigral midbrain, pons, striatum, globus pallidus, and thalamus. Table 1 Autopsy-confirmed LBD cohort clinical, demographic, and neuropathologic data Statistical analysis SYN 2 AD SYN + AD p 2 Demographics were compared between groups by use of χ (n = 14) (n = 10) Value analysis for categorical data and cerebral neuropathology Clinical phenotype, n scores with the Mann-Whitney U test. CSF analyte meas- urements did not have a normal distribution and thus were PD 10 0.1 – natural log transformed for analysis.
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