Elsevier

The Lancet Neurology

Volume 10, Issue 9, September 2011, Pages 829-843
The Lancet Neurology

Review
Functional network disruption in the degenerative dementias

https://doi.org/10.1016/S1474-4422(11)70158-2Get rights and content

Summary

Despite advances towards understanding the molecular pathophysiology of the neurodegenerative dementias, the mechanisms linking molecular changes to neuropathology and neuropathological changes to clinical symptoms remain largely obscure. Connectivity is a distinctive feature of the brain and the integrity of functional network dynamics is crucial for normal functioning. A better understanding of network disruption in the neurodegenerative dementias might help bridge the gap between molecular changes, pathological changes, and symptoms. Recent findings on functional network disruption as assessed with resting-state or intrinsic connectivity functional MRI and electroencephalography and magnetoencephalography have shown distinct patterns of network disruption across the major neurodegenerative diseases. These network abnormalities are somewhat specific to the clinical syndromes and, in Alzheimer's disease and frontotemporal dementia, network disruption tracks the pattern of pathological changes. These findings might have practical implications for diagnostic accuracy, allowing earlier detection of neurodegenerative diseases even at the presymptomatic stage, and tracking of disease progression.

Introduction

Historically, clinicians have identified patients with neurodegenerative dementias on the basis of their clinical symptoms. In recent years, advances in basic science have allowed researchers to recategorise these diseases on the basis of molecular phenotype—ie, the toxic, misfolded disease protein aggregates that are identified in the brain post mortem, such as amyloid β (Aβ) and hyperphosphorylated tau in Alzheimer's disease; tau, TAR DNA-binding protein of 43 kDa (TDP-43), or fused in sarcoma (FUS) in frontotemporal dementia; and α-synuclein in Parkinson's disease and dementia with Lewy bodies.1 These pathological changes are thought to be early events in a cascade that begins at the synaptic and neuronal levels and ultimately leads to the clinical syndrome. Within this temporal window, quantifiable biological, imaging, and physiological markers of pathology have been identified that can be thought of as in-vivo intermediate phenotypes. Such surrogate markers of pathology can improve understanding of disease pathophysiology—ie, indicate links between the molecular phenotype and clinical symptoms—and have the potential to allow earlier, more accurate diagnosis and monitoring of disease progression. In Alzheimer's disease, PET amyloid ligands enable in-vivo mapping of cerebral Aβ deposition,2 whereas structural MRI findings have been shown to relate to hyperphosphorylated-tau-mediated neurodegeneration.3 These biomarkers have recently been incorporated into the new diagnostic criteria for Alzheimer's disease.4, 5 In disorders such as Parkinson's disease, frontotemporal dementia, and dementia with Lewy bodies, structural biomarkers have been used to elucidate disease pathophysiology by showing patterns of atrophy associated with histopathology on the one hand,6, 7, 8 and clinical symptoms on the other (table 1).8, 9

Localisation-based approaches (such as in-vivo mapping of molecular changes and neurodegeneration) have helped build much of the present knowledge of disease pathophysiology. However, these approaches are less suited to investigation of neuronal or synaptic dysfunction, which is thought to underlie cognitive and functional deficits. Because brain functions rely on the integrity of dynamic communication between interconnected brain regions and circuits, a network perspective accounting for such interactions has the potential to provide new and meaningful intermediate phenotypes of pathology (table 1). Prevalent views on the relation between symptoms and pathological changes in Alzheimer's disease help illustrate this notion (figure 1). In typical Alzheimer's disease, the progression of symptoms occurs in a stereotyped order that relates to the topographic progression of hyperphosphorylated tau:10 episodic memory loss takes place first (hippocampus and medial temporal lobe, and posterior cingulate cortex), followed by semantic memory loss (lateral temporal cortex) and aphasic, apraxic, and visuospatial symptoms (frontal, temporal, and parietal neocortex), and finally by motor and visual deficits (sensorimotor and occipital cortex). Although atypical variants exist,11 this orderly progression might be indicative of an incremental spread throughout interconnected regions within large-scale networks, and, ultimately, a spread into adjacent or upstream regions.

The brain can be thought of as a complex neural network consisting of structurally and functionally interconnected regions at many scales (panel 1).12 At the macroscopic level, neural networks can be assessed non-invasively in health and disease with functional MRI (fMRI) and neurophysiological techniques (electroencephalography [EEG] and magnetoencephalography [MEG]).13, 14 The aim of our Review is to provide a comprehensive overview of findings on functional network disruption in the most prevalent neurodegenerative dementias. Although several reviews have addressed functional network disruption in Alzheimer's disease and in psychiatric disorders,15, 16, 17, 18, 19, 20 we summarise studies across many neurodegenerative dementias. By including frontotemporal dementia, dementia related to Parkinson's disease, and dementia with Lewy bodies, we highlight functional network similarities and differences in disorders that share common mechanisms (toxic protein aggregation and neuronal loss) but have distinct clinical phenotypes. Towards this aim, we review resting-state task-free functional imaging and neurophysiological studies. Because our primary goal is to review functional methods that are broadly applicable across neurodegenerative diseases, we have omitted task-activation studies, which require the design of disease-specific experiments (see Dickerson, 2007, for a review of task-activation studies in Alzheimer's disease21), as well as studies of grey-matter structural covariance.22, 23

Section snippets

Techniques to assess network integrity

fMRI, EEG, and MEG techniques enable researchers to assess large-scale neural networks at different spatial and temporal resolutions. Functional connectivity between brain regions can be measured at a spatial resolution of 2–3 mm with fMRI and about 5–30 mm with EEG or MEG. fMRI and neurophysiological techniques contrast most sharply in their temporal resolutions, which differ by three orders of magnitude (seconds vs milliseconds). Structural connectivity within networks can be measured at a

Functional networks and clinical impairment

Imaging and lesion studies have provided valuable information on the functional anatomy of the brain, and localisation principles are vital to the clinical neurologist. However, as we outlined in our introduction, localisation-based perspectives often do not explain the complex inter-relation between neurodegenerative pathological changes and clinical symptoms. Even focal lesions such as stroke (eg, strategic infarction), brain tumour, or traumatic brain injury can cause widespread disturbance

Conclusions and future directions

Brain connectivity studies allow questions to be addressed that have so far escaped a convincing answer. For example, what is the mechanism whereby, in Alzheimer's disease, the deposition of Aβ and hyperphosphorylated tau takes place in largely distinct but highly interconnected hub regions? Why does damage spread to the whole network? Similar questions apply to α-synuclein in dementia with Lewy bodies and tau, TDP-43, and FUS in frontotemporal dementia. Several working models for network-based

Search strategy and selection criteria

References for this Review were identified through searches of PubMed with the search terms “network”, “network dysfunction”, “connectivity”, “resting state functional MRI”, “electroencephalography”, “magnetoencephalography”, “diffusion tensor imaging”, “tractography”, “dementia”, “neurodegenerative disorders”, “frontotemporal dementia”, “Alzheimer”, “mild cognitive impairment”, “Parkinson”, “Lewy bodies dementia”, “stroke”, and “tumour” from 1986 until June, 2011. Furthermore, we identified

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