ISSN# 1545-4428 | Published date: 19 April, 2024
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At-A-Glance Session Detail
   
Alzheimer's Disease II
Digital Poster
Neuro
Wednesday, 08 May 2024
Exhibition Hall (Hall 403)
16:45 -  17:45
Session Number: D-126
No CME/CE Credit

Computer #
4040.
17CSF Mimicking Phantom based Evaluation of CSF Flow using Phase Contrast and Diffusion Imaging on a Highly Efficient Head Only Gradient System
Brock Jolicoeur1, James Rice2, Leonardo Rivera-Rivera3, Alejandro Rold Roldán-Alzate4, and Kevin Johnson5
1Medical Physics, University of Wisconsin-Madison, Madison, WI, United States, 2Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, United States, 3Medical Physics, Alzheimer's Disease Research Center, University of Wisconsin-Madison, Madison, WI, United States, 4Mechanical Engineering, Radiology, University of Wisconsin-Madison, Madison, WI, United States, 5Medical Physics, Radiology, University of Wisconsin-Madison, Madison, WI, United States

Keywords: Alzheimer's Disease, Velocity & Flow, cerebrospinal fluid, low-venc

Motivation: Accurate characterization of CSF flow dynamics is necessary for understanding of brain metabolite clearance pathways.

Goal(s): To compare PC and DWI techniques for slow CSF flow velocity at 3T in a clinical scanner and a heald-only high performance gradient system using high fidelity ventricle phantoms.  

Approach: Flow pump experiments were performed on silicone phantom at each of the scanners using varying Vencs.

Results: Greater velocity-to-noise ratio (VNR) gains and diffusion sensitivity were observed from scans collected on the high performance gradient system

Impact: Generating physiologically realistic cerebral ventricles phantom and leveraging high performance gradient systems can enable low CSF flow assessment for studying brain waste clearance pathways.

4041.
18Whole-brain high-resolution myelin water fraction mapping within 6 min using the accelerated BMC-mcDESPOT (aBMC-mcDESPOT) method.
Jonghyun Bae1, Zhaoyuan Gong1, John P Laporte1, Alex Guo1, Mary E Faulkner1, and Mustapha Bouhrara1
1National Institute on Aging, National Institute of Health, Baltimore, MD, United States

Keywords: Alzheimer's Disease, Relaxometry, Accelerated imaging, Myelin water fraction, BMC-mcDESPOT

Motivation: Our previous works demonstrate the unique capability of BMC-mcDESPOT MRI method which provided myelin water fraction(MWF) mapping to infer myelination. However, the BMC-mcDESPOT protocol consists of multiple imaging sequences, leading to the total acquisition time of 17min.

Goal(s): In this study, we test the feasibility of accelerating the acquisition by under-sampling in both the Fourier and in the data domain.

Approach: We acquired fully-sampled BMC-mcDESPOT dataset, followed by under-sampled BMC-mcDESPOT dataset with compressed sensing. Further acceleration was achieved retrospectively in the data domain by selecting two flip-angles (aBMC-mcDESPOT). 

Results: Our results showed that derived MWF maps using BMC-mcDESPOT and aBMC-mcDESPOT were virtually similar.

Impact: We proposed the accelerated BMC-mcDESPOT (aBMC-mcDESPOT) analysis, which drastically reduces acquisition time for accurately measuring MWF. This critical advancement in multicomponent relaxometry will allow greater integration of MWF imaging in clinical investigations for cerebral myelination in aging and neurodegenerative diseases.

4042.
19Preliminary Diffusion MRI Findings in Hippocampal Subregions of People with Subjective Cognitive Decline
Ryn Flaherty1, Yu Veronica Sui1, Arjun V. Masurkar1, Mark C. Eldaief2,3, Henry Rusinek1, and Mariana Lazar1
1New York University School of Medicine, New York, NY, United States, 2Massachusetts General Hospital, Boston, MA, United States, 3Harvard University, Cambridge, MA, United States

Keywords: Alzheimer's Disease, Data Analysis, hippocampus, subjective cognitive decline

Motivation: Hippocampal subregions are differentially impacted by early Alzheimer’s pathology and may differ in their roles in information processing. However, differences in microstructure in hippocampal subregions have not been investigated in SCD.

Goal(s): To investigate how hippocampal subregions (anterior, medial, and posterior) are affected in SCD.

Approach: Anatomical and diffusion imaging was used to extract diffusion tensor and diffusional kurtosis imaging metrics from hippocampal subregions.

Results: Reduced fractional anisotropy, decreased kurtosis, and increased mean diffusivity were found in SCD compared with a control group for the examined regions. The pattern of change varied across hemispheres and along the anterior-posterior axis.   

Impact: These data suggest heterogeneous pathological changes in the hippocampal microstructure in SCD indicative of neurodegeneration. These findings may inform future research on biomarker development for early AD detection.

4043.
20Sex-specific entorhinal cortex functional connectivity in cognitively normal older adults with amyloid-β pathology
Liang Gong1 and Chunhua Xi2
1Neurologu, Chengdu Second People's Hospital, Chengdu, China, 2Neurolog, The Third Affiliated Hospital of Anhui Medical University, Hefei, China

Keywords: Alzheimer's Disease, Alzheimer's Disease

Motivation: The sex-specific brain alteration in cognitively normal older adults with amyloid-β pathology was unclear.

Goal(s): This study aimed to investigate the impact of sex and APOE genotype on the functional connectivity of the entorhinal cortex (ERC) in cognitively normal older adults with amyloid-β pathology. 

Approach: Using a large sample from the A4 study, the authors performed a comprehensive analysis comparing demographic information, cognitive performance, volumetric MRI data, and ERC functional connectivity. 

Results: Results revealed sex-specific differences in ERC connectivity, with males showing higher connectivity in the sensorimotor network and females exhibiting higher connectivity in the default mode, executive control, and reward networks.

Impact: This study sheds light on the influence of sex and APOE genotype on the functional connectivity of the entorhinal cortex in cognitively normal older adults with amyloid-β pathology.  

4044.
21Large-scale dynamic functional connectivity alterations in subjective cognitive decline: a rs-fMRI study on 5T MRI
Futao Chen1,2, Lixian Zou2, Xiang Fan3, Guanxun Cheng3, Ye Li2, Dong Liang2, Xin Liu2, Hairong Zheng2, and Bing Zhang1
1Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China, 2Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China, 3Department of Radiology, Peking University Shenzhen Hospital, Shenzhen, China

Keywords: Alzheimer's Disease, Alzheimer's Disease, 5TMRI, Dynamic Functional Connectivity, Independent Component Analysis

Motivation: Subjective cognitive decline (SCD) is considered to be the best window period for early diagnosis and intervention of Alzheimer’s disease (AD). However, large-scale dynamic functional connectivity (DFC) alterations in this stage remain unclear.

Goal(s): To assess alterations in large-scale DFC in SCD patients on 5T MRI.

Approach: With a sliding-window approach and k-means clustering based on independent component analysis, rs-fMRI of high spatial-temporal dimension was used to evaluate large-scale DFC properties in SCD and normal control (NC) on 5T MRI.

Results: Four distinct functional states were identified. DFC properties were statistically significantly different between SCD and NC in state 2 and state 3.

Impact: Our study is the first successful attempt in fMRI of high spatio-temporal dimension on 5T MRI datasets. Altered temporal properties in large-scale DFC may serve as sensitive neuroimaging biomarkers for the preclinical detection of individuals with incipient AD.

4045.
22One year aerobic exercise improved fitness, cognition, reduced arterial stiffness and brain vascular reactivity to CO2 in amnestic MCI
Suhaas Penukonda1,2, Takashi Tarumi3,4, Min Sheng2,5, Tsubasa Tomoto3,4, Munro C. Cullum6,7, Rong Zhang3,8, Hanzhang Lu2,9, and Binu P. Thomas2,10
1Department of Biomedical Engineering, University of Texas at Dallas, Dallas, TX, United States, 2Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX, United States, 3Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, United States, 4National Institute of Advanced Industrial Science and Technology, Tsukuba, Japan, 5The Hospital for Sick Children, Toronto, ON, Canada, 6Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, United States, 7Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States, 8Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States, 9Department of Radiology and Radiological Science, John Hopkins University School of Medicine, Baltimore, MD, United States, 10Department of Bioengineering, University of Texas at Arlington, Arlington, TX, United States

Keywords: Alzheimer's Disease, Alzheimer's Disease, Cerebrovascular Reactivity, Aerobic Exercise, Cardiorespiratory Fitness, Carotid Artery Stiffness

Motivation: The benefits of long-term aerobic exercise (AE) on brain function in amnestic mild cognitive
impairment (aMCI) patients is not fully understood.

Goal(s): This study assesses long-term benefits of AE on cerebrovascular reactivity (CVR) in aMCI in
relation to cognition, cardiorespiratory fitness and carotid arterial stiffness.

Approach: 27 aMCI patients were assigned randomly to either AE or stretching and toning (ST) groups.
CVR MRI, cardiorespiratory fitness, cognition, carotid arterial stiffness using ultrasound were
measured before and one-year after AE or ST intervention.

Results: One-year intervention improved fitness and cognition, decreased arterial stiffness and CVR in
the AE group, not different in the ST group.

Impact: Long-term aerobic exercise (AE) intervention in amnestic MCI patients improved cardiorespiratory fitness and cognition, reduced arterial stiffness and cerebrovascular reactivity(CVR), suggesting that long-term AE improves cognition and vasculature; CVR reduction is suggestive of vascular adaptations to long-term AE.

4046.
23Imaging of microvascular pulsatility using Fourier velocity encoding
Eric Wong1, Thomas Liu1, Conan Chen1, Ryan Barnes1, and Divya Bolar1
1University of California, San Diego, La Jolla, CA, United States

Keywords: Alzheimer's Disease, Velocity & Flow

Motivation: Vascular pulsatility has been hypothesized to be an important component in the etiology of microvascular damage in dementia. There are currently no well established methods for non-invasive mapping of pulsatility at the microvascular scale.

Goal(s): To provide a simple and robust means of mapping microvascular pulsatility in the brain.

Approach: We use Fourier velocity encoding to measure the velocity spectrum in each voxel, with retrospective gating to the cardiac cycle, producing quantitative metrics of pulsatility.

Results: Our preliminary data shows a clear modulation of microvascular flow across the cardiac cycle, with a spatial distribution that is consistent with vascular geometry.

Impact: In this work we demonstrate a simple and robust method for imaging vascular pulsatility in the brain. This provides a new metric for studying the role of pulsatility in dementia, and a potential new biomarker for microvascular damage.

4047.
24Cerebral Blood Flow in Midlife Obesity: Associations with Visceral and Subcutaneous Abdominal Adipose Tissue
Mahsa Dolatshahi1, Paul Commean1, Weiying Dai2, Caitlyn Nguyen1, LaKisha Lloyd1, Sara Hosseinzadeh Kassani1, Bettina Mittendorfer3, Claude Sirlin4, Tammie Benzinger1, Joseph E. Ippolito1, John C. Morris1, and Cyrus A. Raji1
1Washington University in St. Louis, Saint Louis, MO, United States, 2Computer Science, State University of New York at Binghamton, Binghamton, NY, United States, 3Missouri state university, Columbia, MO, United States, 4University of California San Diego, La Jolla, CA, United States

Keywords: Alzheimer's Disease, Perfusion, adiposity, obesity

Motivation: Understanding the role of midlife obesity in Alzheimer disease (AD) risk is key to AD prevention.

Goal(s): We aimed to investigate the association between obesity and abdominal visceral and subcutaneous adipose tissue (VAT, and SAT) and brain perfusion, altered early in AD.

Approach: For this aim, we performed brain and abdominal MRI scans to compare absolute cerebral blood flow (CBF), derived from pCASL sequence, between the obese vs. non-obese, the high- vs. low-VAT and high- vs. low-VAT groups.

Results: A lower whole-brain CBF was observed in the obese vs. non-obese and high-VAT vs. low-VAT, but not between high- and low-SAT groups.

Impact: Lower brain perfusion in individuals with obesity and higher VAT, especially in AD-related areas like middle temporal cortex, highlights midlife visceral obesity’s role in AD development. Future studies should explore the association of AD neuroimaging markers with body mass components.

4048.
25Exploring Pathology Along the White Matter Tract near Hyperintense Vasogenic Edema through Multiparametric MRI and Diffusion
Youssef Z Wadghiri1,2, Jelle Veraart1,2, Sean Murray3, Jakub Szabo3, Suleiman Khan3, Hannah Goldman1,2, Muhammad Soliman3, Michael Llanos3, Charles V. Kingsley4, Jody Swain4, Stanton Bradley Gray5, William Donald Hopkins5, Thomas Wisniewski3, and Henrieta Scholtzova3
1Radiology, NYU Grossman School of Medicine, New York, NY, United States, 2Bernard and Irene Schwartz Center for Biomedical Imaging & Center for Advanced Imaging Innovation and Research (CAI2R), NYU Grossman School of Medicine, New York, NY, United States, 3Neurology, NYU Grossman School of Medicine, New York, NY, United States, 4Small Animal Imaging Facility, MD Anderson Cancer Center, Houston, TX, United States, 5Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX, United States

Keywords: Alzheimer's Disease, Alzheimer's Disease, Vasogenic edema, white matter hyperintensities.

Motivation: There is a critical need for neuroimaging methodologies that can characterize the neuropathological changes associated with cerebral amyloid angiopathy (CAA) in Alzheimer’s disease (AD).

Goal(s): Our goal was to explore CAA-associated pathology using multiparametric MRI including diffusion MRI.

Approach: A combination of MRI techniques and histopathology was employed to evaluate and characterize the underlying neuropathological changes in a squirrel monkey model of AD.

Results: Unique pathology was found to be present along normal appearing white matter tracts using conventional MRI near areas of hyperintense vasogenic edema.

Impact: Given the prominence of CAA in human AD cases and the critical need for a more proximate model of AD pathology, our study evaluated the feasibility of advanced neuroimaging methodologies characterizing neuropathological changes in squirrel monkeys that develop spontaneous CAA.

4049.
26Longitudinal brain MRI and tauPET provide novel insights for Alzheimer’s Disease trial planning
Michal R Tomaszewski1, Yuchuan Wang1, Bradley T Christian2, Sterling C Johnson3, Christopher C Rowe4, W Joseph Herring1, and Eric D Hostetler1
1Translational Imaging, Merck & Co., Inc., West Point, PA, United States, 2Department of Medical Physics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, United States, 3Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, United States, 4Department of Nuclear Medicine and Centre for PET, Austin Health, Heidelberg, Australia

Keywords: Alzheimer's Disease, Alzheimer's Disease, Drug Discovery

Motivation: Anatomical MRI plays an important role in Alzheimer’s Disease drug trials, yet the information it provides may not be fully utilized. 

Goal(s): Regional brain volume and its atrophy in conjunction with amyloid- and tau-PET can provide valuable information about disease progression and treatment response.

Approach: Local brain atrophy was quantified and correlated with PET biomarkers.

Results: Significant correlation was reported between atrophy and baseline tau-PET in the medial-temporal region as well as robust associations with disease stage and amyloid burden. These findings can be used to understand disease development and therefore capture modulation in pathology with anti-tau and other therapies in trials.

Impact: Understanding the relationships between brain volumetrics, disease severity and tau burden, including significant correlation between medial-temporal atrophy and tauPET presented in this study allows for efficient measurement of treatment response in AD trials.

4050.
27In Vivo Measurement of Regional Brain Nicotinamide Adenine Dinucleotide (NAD) by 31P MR Spectroscopic Imaging at 1.5 T
Fernando Arias-Mendoza1,2,3, Kavindra Nath2, Ravi Srinivasan3, and Lin Z. Li1
1Britton Chance Laboratory of Redox Imaging, Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States, 2Molecular Imaging Section, Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States, 3Advanced Imaging Research, Inc., Cleveland, OH, United States

Keywords: Alzheimer's Disease, Alzheimer's Disease, MR Spectroscopy, NAD indices

Motivation: Our incentive is to validate the clinical translation of the nicotinamide adenine dinucleotide (NAD) indices as biomarkers in aging and neurodegenerative diseases in clinically accessible 1.5T MR scanners. 

Goal(s): We aimed to demonstrate the feasibility of the noninvasive assessment of the NAD indices in the human brain using 31P magnetic resonance spectroscopic imaging at 1.5 T. 

Approach: We used advanced data processing, including principal component analysis, and performed simulations to support quantifying the brain NAD indices using low magnetic fields. 

Results: Our results demonstrate that total NAD is reliably measured under our conditions, making it a potential metabolic biomarker for aging and neurodegeneration.

Impact: Brain nicotinamide adenine dinucleotide is a potential biomarker and therapeutic target in aging and neurodegeneration. Its noninvasive measurement by 31P magnetic resonance spectroscopic imaging on highly accessible 1.5T clinical scanners will facilitate its biomarker development and treatment utility.

4051.
28In vivo tau and diffusion correlation in Alzheimer’s disease
Aziz M. Ulug1,2, Richard Watts3, Robert K. Haxton1, Robert Melton Jr.1, and Sebastian Magda1
1Cortechs Labs, Inc, San Diego, CA, United States, 2Institute of Biomedical Engineering, Bogazici University, Istanbul, Turkey, 3University of Canterbury, Christchurch, New Zealand

Keywords: Alzheimer's Disease, Aging

Motivation: To investigate the microstructural changes caused by tau deposits in Alzheimer's disease.

Goal(s): Use diffusion imaging in vivo to detect microstructural changes related to tau deposits.

Approach: We used MR diffusion and PET tau images in conjunction with native space segmentation maps from T1-weighted images to explore correlations between tau deposits and diffusion maps in a group of  patients with Alzheimer’s disease.

Results: There is decreased diffusion in gray matter with increasing tau deposits in Alzheimer's patients which may be used for non-invasive monitoring of disease progression.

Impact: Diffusion MRI may provide a proxy measure of tau deposits in gray matter and may decrease the need for repeated radioactive tracer use for monitoring Alzheimer's disease progression.

4052.
29Memory impairment in AD association with Dentate Gyrus atrophy: A pilot study using the Uniform Data Set Neuropsychological Battery and 7T MRI
Oluwatobi Folorunsho Adeyemi1,2, Ishani Hari3, Olivier Mougin4, Penny Gowland4, Richard Bowtell4, and Akram Hosseini3
1Physics, University of Nottingham, NOTTINGHAM, United Kingdom, 2Physics, University of Abuja, Abuja, Nigeria, 3Neurology, Nottingham University Hospital, Nottingham, United Kingdom, 4Physics, University of Nottingham, Nottingham, United Kingdom

Keywords: Alzheimer's Disease, Alzheimer's Disease

Motivation: The research study is primarily motivated by the need to understand the relationship between Alzheimer's disease (AD), hippocampal structure, and cognitive function.

Goal(s): To evaluate whether the atrophy of specific hippocampal subfields correlates with cognitive decline in individuals with Alzheimer's disease?

Approach: 36 participants (19 with AD) were scanned at 7T. Hippocampal sub-field volumes obtained by segmentation of high-resolution TSE images were compared to the neuropsychological test scores. 

Results: In AD participants, hippocampal volume correlated with memory category cue and recognition memory scores. In analysis of hippocampal subfield volumes, the dentate gyrus volume significantly correlated with recognition and cued memory scores.

Impact: These findings matter because they provide crucial insights into the relationship between hippocampal subfield atrophy and cognitive decline in AD. It has the potential to improve the accuracy of diagnosis, targeted treatments, and the understanding of the neurobiology of AD. 

4053.
30Association of Brain Diffusion-Tensor Parameters with Risk of Alzheimer’s Disease-Related Cognitive Decline
Yihao Guo1, Tao Liu1, Weiyuan Huang1, Huijuan Chen1, Xiaoyue Zhou2, and Feng Chen1
1Hainan General Hospital, Haikou, China, 2MR Research Collaboration, Siemens Healthineers, Shanghai, China, Shanghai, China

Keywords: Alzheimer's Disease, Alzheimer's Disease, Cognitive decline

Motivation: Diffusion-tensor parameters of projection and association neural fibers associated with glymphatic function may be able to predict the development of Alzheimer’s Disease (AD). 

Goal(s): To study the association between diffusion-tensor parameters and cognition in patients with AD, and investigate whether diffusion-tensor parameters relate to cognitive decline.

Approach: Linear regression models were performed to examine associations between diffusion-tensor parameters and cognition. linear mixed-effects models were used to evaluate the association between the baseline ALPS index and cognitive decline.

Results: There was a positive association between ALPS index and cognition. Higher ALPS index levels were associated with less cognitive decline over time.

Impact: Higher ALPS index levels are associated with lower risk of AD-related changes. These findings suggest that ALPS index derived from diffusion-tensor parameters may provide useful AD progression or treatment biomarkers.

4054.
31Diamagnetic susceptibility and relationship to amyloid burden in Alzheimer’s Disease
Felisha Ma1, Mert Sisman2, Laya Ashouri3, Mackenzie Logan1, Trey Hedden1, Sara Binder1, Bradley Delmen1, Priti Balchandani1, and Akbar Alipour1
1BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States, 2Cornell University, Ithaca, NY, United States, 3Urmia University of Medical Science, Urmia, Iran (Islamic Republic of)

Keywords: Alzheimer's Disease, Alzheimer's Disease

Motivation: Alzheimer's disease (AD) is a progressive neurological disorder affecting cognitive functions, memory, and behavior, primarily in older adults. It's marked by abnormal protein deposits, including beta-amyloid plaques and tau tangles in the brain, causing nerve cell dysfunction and death.

Goal(s): Positron Emission Tomography (PET) detects beta-amyloid but has limitations. High-resolution MRI imaging can detect beta-amyloid, focusing on diamagnetic properties associated with electron density.

Approach: Quantitative susceptibility mapping (QSM) is particularly effective at 7 Tesla MRI, offering high sensitivity and better neuroanatomy details.

Results: The study utilized 7T MRI to measure beta-amyloid's diamagnetic susceptibility in AD patients using separated QSM technique.

Impact: In this study we leveraged the high susceptible sensitivity of 7T MRI to measure the diamagnetic susceptibility of beta-amyloid aggregated in the brain of Alzheimer's disease patients using separated quantitative susceptibility mapping.

4055.
32Gray-White Matter Boundary Z-Score and Its Volume as Imaging Biomarkers of Alzheimer’s Disease
Geon-Ho Jahng1, Yunan Tian2, Jang-Hoon Oh3, Hak Young Rhee4, Soonchan Park1, Chang-Woo Ryu1, and Wook Jin1
1Radiology, Kyung Hee University Hospital at Gangdong, Seoul, Korea, Republic of, 2Kyung Hee University, Seoul, Korea, Republic of, 3Radiology, Kyung Hee University Hospital, Seoul, Korea, Republic of, 4Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea, Republic of

Keywords: Alzheimer's Disease, Alzheimer's Disease, gray-white matter boundary

Motivation: Alzheimer's disease (AD) presents typically gray matter atrophy and white matter abnormalities in neuroimaging.

Goal(s): Exploring gray-white matter boundary Z-score (gwBZ) and its tissue volume (gwBTV) between patients with Alzheimer’s disease (AD), amnestic mild cognitive impairment (MCI), and cognitively normal (CN) elderly participants.

Approach: Three-dimensional T1-weight images of a total of 227 participants were acquired to calculate gwBZ and gwBTV, prospectively.

Results: Both gwBZ and gwBTV were reduced in AD, were positively correlated with cognitive function, and could accurately discriminate AD from CN .

Impact: gwBZ and gwBTV could be a useful tool for monitoring AD progression and diagnosis.