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Special Review

Cerebrospinal Fluid Amyloid Beta,

Tau Levels, Apolipoprotein, and 1H-
MRS Brain Metabolites in Alzheimer’s
Disease: A Systematic Review
Albert Dayor Piersson, MSc, Mazlyfarina Mohamad, PhD, Fadilah Rajab, DPhil,
Subapriya Suppiah, MD, MRAD

Background: There is compelling evidence that neurochemical changes measured by proton magnetic resonance spectroscopy (1H-
MRS) occur at different phases of Alzheimer’s disease (AD). However, the extent to which these neurochemical changes are associated
with validated AD biomarkers and/or apolipoprotein (APOE) e4 is yet to be established.
Objective: This systematic review analyzed the available evidence on (1) neurochemical changes; and (2) the relations between brain
metabolite and validated cerebrospinal fluid biomarkers, and/or APOE in AD.
Methods: PubMed, Cochrane, Scopus, and gray literature were systematically screened for studies deemed fit for the purpose of the cur-
rent systematic review.
Results: Twenty four articles met the inclusion criteria. Decreased levels of N-acetyl aspartate (NAA), NAA/(creatine) Cr, and NAA/(myo-
inositol) ml, and increased ml, ml/Cr, Cho (choline)/Cr, and ml/NAA were found in the posterior cingulate cortex/precuneus. Increased ml
is associated with increased tau levels, reduced NAA/Cr is associated with increased tau. ml/Cr is negatively correlated with Ab42, and
ml/Cr is positively correlated with t-tau. NAA and glutathione levels are reduced in APOE e4 carriers. APOE e4 exerts no modulatory effect
on NAA/Cr. There is interaction between APOE e4, Ab42, and ml/Cr.
Conclusion: NAA, ml, NAA/Cr, NAA/ml and ml/Cr may be potentially useful biomarkers that may highlight functional changes in the clini-
cal stages of AD. The combinations of ml and tau, NAA/Cr and Ab42, and NAA/Cr and tau may support the diagnostic process of differen-
tiating MCI/AD from healthy individuals. Large, longitudinal studies are required to clarify the effect of APOE e4 on brain metabolites.
Keywords: Proton magnetic resonance spectroscopy; cerebrospinal fluid; Amyloid beta; Tau; Apolipoprotein; Alzheimer’s disease.
© 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.

INTRODUCTION of progression of the condition, monitoring its progression, as

well as evaluating the efficacy of treatment, and prognosis (1).

I
dentification of robust and reliable biomarkers correlated
The pathophysiological hallmark of AD which include beta-
with clinical presentation are essential for providing early
amyloid (Ab) and tau proteins are critical measures which can
diagnostic capability of differentiating Alzheimer’s disease
be determined from biological fluids, particularly from cerebro-
(AD) from other types of dementia at an early stage. Biomarkers
spinal fluid (CSF). CSF measures of Ab42 and tau proteins are
can be invaluable for providing accurate diagnosis and prediction
currently the most widely established biomarkers of AD, specifi-
cally reduced CSF Ab42 (2) which indicates brain Ab amyloid-
Acad Radiol 2020; &:1–17 osis (1). On the other hand, increased level of CSF tau is not
From the Diagnostic Imaging and Radiotherapy Programme, Universiti specific to AD and is thought to indicate neuronal injury (1).
Kebangsaan Malaysia, Kuala Lumpur 50300, Malaysia (A.D.P., M.M.); Depart-
ment of Imaging Technology & Sonography, School of Allied Health Sciences, Interestingly, there are studies that firmly suggest that alterations
University of Cape Coast, Cape Coast, Ghana (A.D.P.); Biomedical Science in CSF Ab take place much earlier (3,4), hence CSF Ab42/40
Programme, Center for Healthy Aging and Wellness, Universiti Kebangsaan
Malaysia, Kuala Lumpur 50300, Malaysia (F.R.); Centre for Diagnostic Nuclear
ratio offers a better advantage in predicting the risk of AD (5).
Imaging, Universiti Putra Malaysia, Selangor 43400, Malaysia (S.S.). Received Positron emission tomography (PET) is also capable of provid-
April 12, 2020; revised May 9, 2020; accepted June 3, 2020. Address corre- ing measures of Ab and tau and is particularly advantageous in
spondence to: A.D.P. e-mail: mazlyfarina@ukm.edu.my
its ability to detect regional deposition of Ab that is believed to
© 2020 The Association of University Radiologists. Published by Elsevier Inc.
All rights reserved. precede clinical symptoms and neocortical structural changes
https://doi.org/10.1016/j.acra.2020.06.006

1
 ARTICLE IN PRESS
PIERSSON ET AL
(2). Furthermore, genetic testing to identify the presence of apo-
lipoprotein epsilon 4 (APOE e4), has also been utilized as a bio-
marker for AD (6). Several studies suggest the association
between APOE e4 allele and reduced measures of CSF Ab42
concentrations in a gene dose-dependent fashion (7,8).
Despite emerging tests and techniques to manage AD, neuro-
imaging techniques remain as an indispensable tool capable of
revealing not only structural changes in the brain of AD patients
and other dementia types, but also the functional alterations that
occur in vivo. One of the main advantages of imaging bio-
markers is that they are capable of providing an insight into the
topographic distribution of pathologic changes, which is not
possible with fluid biomarkers. Neuroimaging techniques cur-
rently identified to be capable of this task include PET and mag-
netic resonance imaging (MRI). The disadvantage of PET is that
it involves the use of ionizing radiation. Alternatively, MRI is
able to reveal information on macrostructural integrity of both
gray and white matter, using high-resolution two-dimensional
or three-dimensional T1-weighted images. Proton magnetic res-
onance spectroscopy (1H-MRS), advanced MRI technique,
stand out as a unique technique that is capable of yielding infor-
mation on measures of selected metabolites in vivo, and other
functional information.
There are some common 1H-MRS metabolites that are
frequently assessed as biomarkers of neurological disease pro-
cesses. One of the most studied metabolites, N-Acetyl Aspar-
tate (NAA), is present in relatively high concentrations in
viable brain cells and almost exclusively present in the central
nervous system (9). As NAA is synthesized in neurons, its lev-
els reflect the viability and density of the neurons, whereas
the decrease in its levels indicates loss of integrity of the neu-
rons (10). Decreased NAA in the gray matter (GM) of the
parietal lobes has been observed in AD (11). Choline (Cho)
that is often referred together with Creatine (Cr), a more
constant metabolite, is frequently elevated in pathology and
indicative of cell membrane breakdown (10). In the spectrum
of neuroinflammatory cascade leading to neurocognitive
decline among AD subjects, the elevation of myo-inositol
(mI), a metabolite that mediates the transduction of cell sig-
nals via regulation of neurotransmitters and steroid hormones
(12) is noted to precede the reduction of NAA. This is noted
as early as in the MCI phase of the disease in line with the
predementia continuum (13). In fact, mI has been noted to
be elevated in APOE e4 carriers who did not have any
demonstrable amyloid pathology (13). Another metabolite
that is abnormally elevated in AD is glutamate (Glu). Gluta-
mate excitotoxicity, a condition when prolonged elevation
of extracellular Glu causes exocytosis pathways to become
activated leading to necrosis of the neurons (14). Conversely,
glutathione (GSH) another metabolite considered to have
antioxidant properties is thought to be involved in neuronal
death when depleted.
In a recent systematic review, the authors suggest that there
are certain specific 1H-MRS metabolites and their ratios that
may serve as potential biomarkers of impaired function of the
brain in individuals with AD (15). However, the study did
2
Academic Radiology, Vol &, No &&, && 2020
not incorporate the use of CSF and/or APOE biomarkers. It
has been widely suggested that the combination of potentially
useful neuroimaging and fluid biomarkers leads to improve-
ment in accuracy, sensitivity, and specificity of making an
early diagnosis of AD and other types of dementia. It is also
likely that multiple biomarkers can contribute to improve-
ments in predicting those who may convert from cognitively
normal state to MCI, or progress from MCI to AD. In view
of the lack of formal synthesis of studies integrating CSF Ab,
tau, and/or APOE genotype, with neurochemical changes in
individuals with cognitive decline, the current systematic
review provides a summary of available evidence on altera-
tions in 1H-MRS metabolites and their ratios, alterations in
CSF Ab, tau, levels, association between CSF Ab, tau, and
1
H-MRS metabolites, association between APOE genotype
and 1H-MRS metabolites, and association between CSF Ab,
tau, APOE genotype, and 1H-MRS metabolites.
METHODS
Information Sources and Search Strategy
A systematic search was conducted to identify eligible studies
from the following widely sourced electronic databases—
PubMed, Cochrane, and Scopus. The initial search was con-
ducted to source all publications till July 17, 2019. An update
of the search was further carried out till December 5, 2019.
Gray literature search was also conducted. To broaden the
scope of the search, all relevant studies were further cross-ref-
erenced for potentially eligible studies through their bibliog-
raphy. The search was carried out in accordance with the
Patient, measurement Instrument, Comparison, Outcome
(PICO) framework. Using Boolean operators, i.e., “AND”
and “OR,” the following search terms were entered in the
search engines of the above listed electronic databases—
(“Proton Magnetic Resonance Spectroscopy,” “Proton MR
Spectroscopy,” “MRS,” “MRSI,” “1H-MRS,” OR “brain
metabolites”) with (“Mild Cognitive Aging,” “MCI,” “Alz-
heimer’s disease,” “AD,” and “Dementia’’) as well as (“Cere-
brospinal fluid,” “CSF”) AND (“Genotype,” “Genotyping,”
“Apolipoprotein” OR “APOE”) AND (Healthy cognitive
aging” OR “Normal cognitive aging”) AND (“amyloid
beta” OR “Ab”) AND (“tau”).
Study Selection
Articles identified were required to fulfill the following crite-
ria: (1) human participants; (2) participants not afflicted with
any systemic disease (P; patient population); (3) 1H-MRS
included with either CSF and/or genotyping (I; diagnostic
instrument); (4) studies which featured cognitive aging; (5)
articles published in English; and (6) and full text of original
studies. Studies that failed to satisfy these criteria were elimi-
nated.
Initial screening involved the selection of articles premised
on the titles and abstracts. Following this exercise, whole text
 ARTICLE IN PRESS
Academic Radiology, Vol &, No &&, && 2020
Figure 1. Flowchart for study screening process.
of studies deemed to be potentially fit for the review were
then obtained. If the abstract of the studies were found to
provide insufficient information, the whole text was
obtained. The next phase involved critical evaluation of full
text of studies that satisfied the inclusion criteria (Fig 1). Both
phases of the screening exercise were undertaken by A.D.P.
(a PhD candidate) and supervised independently by M.M.
Data Items and Collection
Details extracted from each article are presented in Tables 1
and 2. Table 1 contains the following information—patient
group, control group, magnetic field strength, parameters,
pulse sequence, and voxel size. Table 2 includes the follow-
ing—metabolite measures, brain regions for metabolite meas-
ures, CSF measures, genotype measures, main findings,
remarks, and neuropsychological measures.
Risk of Bias in Individual Studies
Methodological quality of each study was undertaken by
using the Newcastle-Ottawa Scale (NOS) specifically
A SYSTEMATIC REVIEW
designed for case-control and cohort studies. There are three
subcategories of this quality assessment tool—selection, com-
parability, and exposure/outcome. To minimize bias, A.D.P.
and M.M. evaluated the quality assessment of each study.
After completion of the quality assessment comparison of the
results were done to reach consensus in case the scores allo-
cated to a study was different. A score of one point was allo-
cated to each item on the NOS, particularly for the Selection
and Exposure/Outcome categories, whereas a score of two
was allocated to the Comparability category. Item 9 of the
NOS was substituted with a self-designed subcategory,
“MRI data quality” since the default item did not suit the
theme of the current systematic review (16). Hence the maxi-
mum score on the modified NOS is 9 (Table 3).
Based on the study design evaluated in this review and the
methodological quality, a level of evidence (LOE) was
assigned in keeping with the Dutch Institute for Healthcare
Improvement (CBO) classification design (Table 4). Further-
more, after studies were pooled for comparison of study
designs and aims, a strength of conclusion was allotted to
account for the study designs of the eligible studies, as well as
risk of bias (Table 5).
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PIERSSON ET AL Academic Radiology, Vol &, No &&, && 2020

TABLE 1. Study Demographics and 1H-MRS Imaging Parameters

Authors Patient Group Control Group MRI Field TR/TE (ms) Pulse Voxel Size
Strength
(Tesla)

(17) 25 AD (74.3 § 7.3 years; 27 older controls (70.2 § 6.7; 3.0 2000/35 PRESS 9 cm3
m=40%) m = 44%)
27 younger control (41.0 § 10.6;
m = 85%)
(18) None 15 older individuals (f = 5; 55-75 3.0 1500/68 PRESS 15.7 cm3
years)
(19) None 30 young individuals (20-40 3.0 4000/85 SPECIAL 8 cm3
years)
151 older individuals (60-85
years)
(20) None 594 ( 60 years; m = 343) 3.0 2000/30 PRESS 8 cm3
(21) 14 aMCI (76-86 years; m = 9) 16 (74-83 years; m = 16) 3.0 5000/28 sLASER 8 cm3
(22) 53 MCI; 21 AD; 7 DLB n = 200 1.5 2000/25 PRESS 8 cm3
(13) 49 SCI 156 Normal (negative) CSF Ab42 3.0 2000/30 PRESS 8 cm3
88 MCI (n = 156)
59 Abnormal (positive) CSF Ab42
(23) 11 aMCI patients between 66 n = 16 3.0 2000/32 PRESS 6.4 £ 3.2 cm
and 88 years old
(24) None 57 children (12.45 § 3.4 1.5 1500/35 PRESS 8 cm3
years)
48 parents (37.5 § 6.78 years)
9 control children (9.77 § 0.83)
7 control parents (34.57 § 6.02)
(25) 15 patients with aMCI n = 21 (mean = 70.5; SD = 4.0; 3.0 1800/68 PRESS 9 cm3
(mean = 74.2; SD = 9.6; male = 14)
male = 11).
(26) 8 MCI; 13 Probable AD; 2 n = 17 3.0 2000/30 PRESS 8 cm3
DLB; 2 Progressive visual
(27) 34 DLB (73 § 7 years; m = 29) 148 (77 § 6 years; m = 80) 1.5 2000/30 PRESS 8 cm3
20 DLB: Low Probability of
AD (72 § 5 years; m = 19)
35 AD (79 § 11 years; m = 17)
(28) None 112 (50-86 years) 3.0 1600/30 PRESS 10.8 cm3
(29) 42 MCI-non-converter (NC) 93 (74.6 § 10.2 years; m = 39) 1.5 2000/25 PRESS 8 cm3
(78.9 § 7.5 years; m = 19)
25 MCI-converter (C) (77.4 §
7.1 years; m = 7)
44 AD (80.6 § 7.3 years;
m = 18)
8 DLB (74.0 § 5.3 years;
m = 5)
(30) 19 AD (72.2 § 7.5 years; 17 (67.9 § 6.6 years; m = 7) 3.0 2500/135 PRESS 8 cm3
m = 4)
(31) None 1,156 1H-MRS participants (74- 3.0 2000/30 PRESS 8 cm3
83 years; m = 594)
749 non-MRS participants (75-
84 years; m = 371)
(32) 71 aMCI (74.6 § 6.4; m = 28) 35 (70.3 § 7.8; m = 12) 1.5 2000/35 PRESS 8 cm3
(33) None 311 MRS participants (78.6-79.7 3.0 2000/30 PRESS 8 cm3
years; m = 172)
1,236 non-MRS participants (80-
80.6 years; m = 587)
(34) None 23 (69.4 § 6.9 years; m = 11) 4.0 2000/15 STEAM 8 cm3
(continued)

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TABLE 1. (Continued)

Authors Patient Group Control Group MRI Field TR/TE (ms) Pulse Voxel Size
Strength
(Tesla)

(35) 7 aMCI ( 80 years) 13 ( 80 years) 1.5 2000/30 PRESS 8 cm3

30 AD ( 80 years)
(36) 91 single-domain (SD)- aMCI 100 (71-81 years; m = 56) 1.5 2000/30 PRESS 8 cm3
(71-83 years; m = 51)
32 multiple-domain aMCI (72-
83 years; m = 30)
20 naMCI (66-80 years;
m = 13)
(37) 49 aMCI (78.0 § 8.5 years; 85 (79.1 § 7.2 years; m = 38) 1.5 2000/30 PRESS 8 cm3
m = 22)
60 AD (77.1 § 7.2 years;
m = 27)
(38) 18 MCI (82.0 § 5.4 years; 67 (80.8 § 7.1 years; m = 26) 1.5 2000/30 PRESS 8 cm3
m = 10)
33 AD (79.8 § 6.0 years;
m = 18)
(39) 21 MCI (82.6 § 5.2 years; 63 (80.4 § 6.9 years; m = 28) 1.5 2000/135 PRESS 8 cm3
m = 12)
21 AD (79.7 § 6.3 years;
m = 12)

TR, Repetition time; TE, Echo time; ms, millisecond; PRESS, Point REsolved Spectroscopy Sequence; SPECIAL, SPin-ECho full Intensity
Acquired Localized; STEAM, Stimulated Echo Acquisition Mode; sLASER, semi-localization by adiabatic selective refocusing; aMCI, amnestic
mild cognitive impairment; SCI, subjective cognitive impairment.
Most studies (n = 13) obtained 1H-MRS data on 3.0 T MRI system, followed by 1.5 T and 4.0 T. Although all the eligible studies utilized a sin-
gle-voxel technique, most commonly used spatial localization technique and voxel size were PRESS and 8 cm3 respectively.

RESULTS to study design adopted, i.e., case-control and cohort studies.

Study Selection
The search process of eligible studies is structurally shown in a
flowchart (Fig 1). A total of 240 articles were identified from
the initial search. After eliminating duplicates, a total of 223
articles were left. Further screening coupled with a hand
search of the reference list of all potentially relevant articles
resulted in a total of 24 eligible articles.
Study Characteristics
The characteristics of each study can be found in the evidence
table (Table 1). Articles were categorized on the basis of the
effect of fluid biomarkers on 1H-MRS metabolites. Six stud-
ies investigated the effect of CSF biomarkers on metabolite
alterations (13,17,22,26,29,30), 11 studies evaluated the effect
of APOE on 1H-MRS metabolite alterations (18-
20,13,22,23,24,25,28,38,39), and 4 studies explored the
combination of CSF biomarkers, APOE genotyping, and
1
H-MRS metabolite alterations (13,22,26,29).
RISK OF BIAS AND LEVEL OF EVIDENCE
Table 2 shows the risk of bias of each study and the level of
evidence. All eligible studies were assigned a LOE of B due
The scores for the methodological quality varied between 5
of 9 and 9 of 9, indicating moderate to good performance.
Syntheses of Results
Quantification of 1H-MRS Detected by Regions of Interest
The PCC/precuneus was the most commonly investigated
region as revealed in 18 studies (17-22,25,27,28-30,33-39).
The hippocampus was investigated in four studies for mea-
surement of 1H-MRS metabolites (23,24,30,24). Other
regions of interest investigated for level of metabolites
included frontal lobe (27), occipital lobe (27,32,39), parietal
lobe (30,32), temporal lobe (39), ACC (34), and inferior pre-
cunei (35,37).
Alterations of Single Metabolites and Their Ratios
Single Metabolites.—Two studies (18,19) reported the level of
GSH in the PCC/precuneus. Chiang et al reported decreased
GSH in cognitively normal older individuals (18). Suri et al
compared young and older cognitively normal individuals,
and also found that GSH level decreased in the same brain
region of older individuals compared to the young age group
(19). In conclusion, there is moderate evidence that GSH lev-
els decrease in the PCC/precuneus of cognitively normal
older individuals.

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 PIERSSON ET AL
TABLE 2. Evidence Table of Eligible Studies
1
Study H-MRS Brain Regions CSF Markers Genotyping Main Findings Remarks Neuropsychological
Metabolites Studied Studied Measures

(17) NAA, ml, Cr, Posterior cingulate Aβ42, p‐Tau181P, None ↑Glc, Lac and Asc, but ↑ Glc in the precuneus Glc differenti- CDR global score, CDR-
Gpc, Pch, Ala, cortex (PCC)/ and t‐tau ↓NAA in AD participants. ated AD from elderly individuals. sob, ADAS-Cog, and
GABA, Glc, precuneus Patient group demonstrated a Correla- MMSE
Glu, Gln, Glx, tion between mI and t-tau, p‐Tau181P,
GSH, Lac, and Clinical Dementia Rating.
NAAG, Scy,
Tau, and Asc,
(18) GSH PCC/precuneus None APOE ↓GSH Association between ↓GSH levels and BDI-II, BAI, and RBANS.
↑brain amyloidosis in the parietal and
temporal regions, after adjusting for
APOE ε4.
(19) Asp, GPC, PCh, PCC/precuneus None APOE ↓NAA/Cr and ↑ml/NAA in No evidence of APOE effect with age on MoCA

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Cr, PCr, Glc, the older group. the metabolite measures.
Tau, Gln, Glu, ↑mI and ↑Cr, but ↓glutathi- No difference in mI/Cr, NAA/Cr and mI/
GSH, mI, NAA, one and ↓Glu in older NAA between those with APOE.
NAAG. participants
(20) mI/Cr, NAA/mI PCC None APOE ε4 ↑mI/Cr, and ↓NAA/mI No evidence of APOE ε4 effect on Not indicated
baseline metabolite ratios and rate of
Aβ deposition.
(21) Glu, Glu/mI, mI, PCC None APOE ε4 ↓Glu, ↓Glu/mI, ↓NAA, and No difference in Cho level comparing Not indicated.
choline (Cho), ↑mI controls to aMCI.
NAA mI, Cho, and NAA showed no statistical
difference between aMCI and control.
↑ APOE ε4 carriers in aMCI.

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No information on correlation between
APOE ε4 and metabolites.
APOE ε4 carriers in patient group
(71.0%) > control group (25.0%).
(22) NAA/Cr, ml/Cr, PCC Aβ40, Aβ42, and p- APOE ε4 ↓NAA/mI in the entire No correlation evident between the CDR and MMSE
Cho/Cr, and tau patient group. NAA/mI and Aβ42 and p-tau.
NAA/mI ↑mI/Cr in homozygous ɛ4 allele carriers.
↓NAA/ml in subjects with two copies of
the ɛ4 allele.
No difference in NAA/Cr between those
with and without the ɛ4 allele.
No information on the correlation
between APOE, CSF biomarkers, and
metabolites.
Information not clear on the proportion-
ate number of APOE ε4 carriers in
both groups.
(continued on next page)
 Academic Radiology, Vol &, No &&, && 2020
TABLE 2. (Continued)
1
Study H-MRS Brain Regions CSF Markers Genotyping Main Findings Remarks Neuropsychological
Metabolites Studied Studied Measures

(13) NAA, Cho, and PCC/ precuneus Aβ42, t-tau, and p- APOE ɛ4 ↑ ml/Cr and ml/NAA in ↓CSF Aβ42 was associated with MMSE
ml tau amyloid-positive cogni- ↑ mI/Cr, and ↓ NAA/Cr in the entire
tively healthy cohort.
participants Correlation between ↑CSF tau and
↓NAA/Cr.
↑ mI/Cr correlated with decreased CSF
Aβ42 in the cognitively healthy group.
Correlation between NAA/Cr and t-tau
in Aβ42+ MCI participants.
↑mI/Cr in cognitively normal ε4 carriers
with normal Aβ42 levels.
APOE ε4 ↑mI/Cr in right

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(23) NAA/Cr, mI/Cr Hippocampus None No correlation between cognition and CDR
and mI/NAA hippocampus. mI/Cr in right hippocampus in APOE
ε4 and non-carriers.
The difference in NAA/Cr and mI/NAA
from bilateral hippocampus, as well
as mI/Cr in left hippocampus was
insignificant.
(24) NAA/Cr, Cho/ Hippocampus None APOEε4 ↓NAA/Cr in children APOE ε4 carrier parents showed nega- Not indicated
Cr, and mI/Cr cohort irrespective of tive correlation between BMI and ml/
APOE status. Cr in the right hippocampal mI/Cr;
↓NAA/Cr significant in left but positive correlations were observed
hippocampus of APOE with NAA/mI.
E4 parents than in
children
(25) NAA, Glx, and PCC None APOE ε4 ↓NAA, GABA, and Glx in ↓NAA in APOE ε4 carriers. CERAD-Plus, MMSE,
GABA. APOE ε4 allele carriers. Patient group exhibited more APOE ε4 Boston naming test,
Levels of Cho, Cr, and mI carriership compared to control sub- Figure copy and recall,
were indifferent across jects (patient group = 15%; control Recall and recognition,
cohorts. group = 11%). Verbal learning, Letter
fluency, Trail making
tests A and B, Letter flu-

A SYSTEMATIC REVIEW
ency, Category, RAVLT,
WMSR, and Stroop test.

(continued on next page)

 PIERSSON ET AL
TABLE 2. (Continued)
1
Study H-MRS Brain Regions CSF Markers Genotyping Main Findings Remarks Neuropsychological
Metabolites Studied Studied Measures

(26) NAA/Cr, Cho/ PCC p-tau APOE ε4 ↓NAA/Cr and ↓NAA/mI in Evidence of inverse relationship Not indicated
Cr, mI/Cr, and the intermediate- to between p-Tau, NAA/Cr and NAA/mI.
NAA/mI high-likelihood group. No information on the correlation
↑mI/Cr. between APOE and metabolites.
No information on the correlation
between APOE, CSF biomarkers, and
metabolites.
APOE ε4 carriers were more in the
patient group compared to control
subjects (patient group = 6%; control
group = 58%)
APOE ε4 ↓NAA/Cr in occipital of ↑APOE ε4 prevalence in all dementia

(27) NAA/Cr, Cho/ Frontal, posterior None
Cr, mI/Cr cingulate, and DLB.
occipital ↓NAA/Cr in frontal, poste-
rior cingulate and occip-
ital of AD.
↑NAA/Cr in frontal lobe of
DLB with low-probability
of AD compared to AD.
↑Cho/Cr of posterior cin-
gulate in AD and DLB.
↑Cho/Cr of frontal lobe in
DLB with low probability
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Not indicated
groups.
No information on the correlation
between APOE and metabolites.
APOE ε4 in patient group (DLB = 47.0%;
DLB - Low Probability AD = 55.0%;
AD = 49.0%) > control group
(n = 26.0%)

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of AD.
↑mI/Cr of posterior cingu-
late in AD and DLB.
↑mI/Cr of frontal lobe in
AD.
↑mI/Cr of occipital lobe in
DLB with low probability
of AD.
(28) NAA/Cr, Cho/ PCC/Precuneus None APOE E4 ↑Cho/Cr ↑ml/Cr Elderly carriers of APOE ε4 demon- MMSE
Cr, ml/Cr strated ↑Cho/Cr and mI/Cr relative to
APOE ε3 homozygotes.
No significant effects of APOE on NAA/
Cr and mI/Cr.
There was significant modulatory effect
on Cho/Cr .
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 Academic Radiology, Vol &, No &&, && 2020
TABLE 2. (Continued)
1
Study H-MRS Brain Regions CSF Markers Genotyping Main Findings Remarks Neuropsychological
Metabolites Studied Studied Measures

(23) NAA/Cr, ml/Cr, PCC Aβ42, p-tau and p- APOE ε4 ↓NAA/Cr in the following No significant correlation between Not indicated
Cho/Cr, and tau/Aβ42 order: DLB, AD, MCI-C, NAA/Cr and p-tau or p-tau/Aβ42.
NAA/mI and MCI-NC. No information on the correlation
↓NAA/mI in the following between APOE and metabolites.
order: DLB, AD, MCI-C, No information on the correlation
and MCI-NC. between APOE, CSF biomarkers and
↑ml/Cr in MCI-C. metabolites.
APOE ε4 carriers in the patient group
(MCI-NC = 47.0%; MCI-C = 54.5%;
AD = 40.9%; DLB = 50.0%) > control
group (27.2%)

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(30) NAA/Cr, Cho/ Hippocampus, Aβ42, t-tau, and p- None AD showed ↓NAA/Cr in ↓NAA/Cr on hippocampus was found to BDI-II, MMSE, RAVLT, and
Cr, and mI/Cr PCC, and parietal tau181P hippocampus PCC, and be associated with ↑Aβ42. ROCF
lobe. parietal lobe. Association between ↓parietal NAA/Cr
↓Cho/Cr in PCC and hip- and ↑t-tau and p-tau181P.
pocampus. mI/Cr in parietal lobe correlated with t-
↓ml/Cr in PCC. tau and NAA/mI.
↑ml/Cr in the hippocam-
pus and parietal lobe.
(31) NAA/Cr, NA/mI, PCC None APOE ε4 ↓NAA/Cr and ↓NAA/mI. NAA/Cr predicted MCI in controls. WMSR Logical Memory,
Cho/Cr, and ↑mI/Cr Same participants in the study by Kant- VR subtests, RVLT, Lan-
mI/Cr arci et al [33]. guage tests, Category
↑APOE ε4 in MRI/MRS study partici- fluency, Trail Making
pants. Test part B, WAIS-RDS
No information on correlation between subtest, WAIS-RPC sub-
APOE ε4 and metabolites. set, and BD subset.
(32) NAA, NAA/Cr, Posteromedial pari- None APOE ε4 ↓NAA/Cr in posteromedial No information on the correlations MMSE, BDRS, CDT, GDS,
NAA.ml, ml/ etal cortex and parietal cortex and between APOE ε4 and metabolites. and RAVLT delayed
Cr, and Ch/Cr occipital lobe occipital lobe among No information on APOE ε4 status of recall.
converters. control subjects.
↑NAA in occipital lobe
among converters

A SYSTEMATIC REVIEW
(33) NAA/Cr, ml/Cr, PCC None APOE ε4 ↓NAA/Cr Association between ↑PiB retention WMSR Logical Memory,
and Cho/Cr. ↑mI/Cr and ↑mI/Cr. VR subtests, RVLT, Lan-
↑Cho/Cr No information on the correlation guage tests, Category
between APOE ε4 and metabolites fluency, Trail Making
Test part B, WAIS-RDS
subtest, WAIS-RPC sub-
set, and BD subset.
(continued on next page)
 PIERSSON ET AL
TABLE 2. (Continued)
1
Study H-MRS Brain Regions CSF Markers Genotyping Main Findings Remarks Neuropsychological
Metabolites Studied Studied Measures

(34) NAA, Glu, Cho, Anterior cingulate None APOE ε4 ↓NAA/Cr, ↓NAA/Cho, All subjects were healthy. MMSE, CVLT, verbal flu-
and Cr. cortex (ACC) and ↓Glu/Cr, and Body mass index was a confounding ency, ROCF, and WAIS
PCC. ↓Glu/Cho in ACC factor.
No information on the correlation
between APOE ε4 and metabolites
(35) NAA/Cr, NAA/ Bilateral PCC and None APOE ε4 ↓NAA/Cr but ↑mI/Cr Association between ↓NAA/Cr and Not indicated
mI, Cho/Cr, inferior precunei ↑Braak stage, ↑neuritic plaque score,
and ml/Cr. and ↑likelihood of AD.
APOE ε4 in patient group (AD = 56%) >
control group (45.0%).
No information on the correlation

ARTICLE IN PRESS
between APOE ε4 and metabolites.
(36) NAA/Cr, ml/Cr, Hippocampus and None APOE ε4 ↑mI/Cr in SD-aMCI APOE ε4 more prevalent in all-MCI WMSR Logical Memory,
and Cho/Cr. PCC group. VR subtests, RVLT, Lan-
No information on the correlation guage tests, Category
between APOE ε4 in patient group fluency, Trail Making
(SD-aMCI = 45.0%; MD-aMCI = 41.0%; Test part B, WAIS-RDS
naMCI = 40.0%) > control group subtest, WAIS-RPC sub-
(n = 26.0%). set, and BD subset.
(37) NAA/Cr, ml/Cr, Bilateral PCC and None APOE ε4 ↓NAA/Cr in aMCI and AD. APOE ε4 in the patient group (all CDR-sob, DRS, and
and Cho/Cr. inferior precunei ↓Cho/Cr in stable aMCI. aMCI = 51.0 %; AD = 60.0%) > control MMSE
group (18.0%).
No information on the correlations

Academic Radiology, Vol &, No &&, && 2020

between APOE ε4 and metabolites.
(38) NAA/Cr, NAA/ PCC None APOE ε4 ↓NAA/Cr in AD ↓NAA/Cr in APOE ε4 carrier patients AVTOT and DRSTOT
mI, and mI/Cr ↓NAA/mI in AD than MCI than in APOE ε4 carrier control group.
compared to control ↓NAA/mI in APOE ε4 carrier patients
↑mI/Cr in AD than MCI than in APOE ε4 carrier control group.
↑mI/Cr in APOE ε4 carrier patients than
in APOE ε4 carrier control group.
APOE ε4 most common in MCI and AD
groups (patient group = 46%; control
group = 13%).
APOE ε4 not associated with NAA/Cr,
NAA/ml, and mI/Cr.
(continued on next page)
 Academic Radiology, Vol &, No &&, && 2020
TABLE 2. (Continued)
1
Study H-MRS Brain Regions CSF Markers Genotyping Main Findings Remarks Neuropsychological
Metabolites Studied Studied Measures

(39) NAA/Cr, Cho/ Superior temporal None APOE ε4 ↓NAA/Cr in AD compared
Cr, and mI/Cr lobe, PCC, and to MCI and control in left
medial occipital superior temporal and
lobe the posterior cingulate
volumes.
↑mI/Cr in PCC of MCI and
AD participants.
↑Cho/Cr in PCC in AD
compared to MCI and
control.
MCI and AD had highest number of MMSE, DRS, WAIS,
APOE ε carriers. WMSR-I and II
No correlation between APOE status
and the metabolite ratios.
Correlation between ↑NAA/Cr in medial
occipital region of AD and APOE ∊4
carrier status.
APOE ε4 carriers in the patient group
(MCI = 31.2%; AD = 57.9%) > control
group (n = 16.3%).

Aβ42, Amyloid-beta1-42; p‐Tau181p, phosphorylated Tau; t‐Tau, total Tau; NAA, N-acetylaspartate; ml, myoinositol; Cr, Creatine; Gpc, Glycerophosphocholine; Pch, Phosphocholine, Ala, Ala-

ARTICLE IN PRESS
nine, GABA, Gamma‐Amino Butyric Acid; Glc, Glucose; Glu, Glutamate; Gln, Glutamine, Glx, Glu-Gln; GSH, Glutathione; Lac, Lactate; mI, myoinositol; NAAG, N‐Acetyl‐Aspartyl‐glutamate;
Scy, Scyllo‐inositol; Tau, Taurine; Asc, Ascorbate; aMCI, amnestic mild cognitive aging; DLB, dementia with Lewy bodies; ↑, increased; ↓, decreased; AVTOT, Auditory Verbal Learning Test;
ADAS-Cog, Alzheimer's Disease Assessment Scale-cognitive subscale; BAI, Beck Anxiety Inventory; BDI-II, Beck Depression Inventory-II; BDRS, Blessed Dementia Rating Scale; BD, Block
Design subtest; CVLT, California Verbal Learning Test; CDR, Clinical Dementia Rating; CDR-sob, CDR sum-of-boxes; CDT, Clock drawing test; CERAD, Consortium to Establish a Registry for
Alzheimer's Disease test; DRS, Dementia Rating Scale; DRSTOT, Dementia Rating Scale Total Score; GDS, Geriatric Depression Scale; MMSE, Mini-Mental State Examination; MoCA, Montreal
Cognitive Assessment; RAVLT, Rey Auditory Verbal Learning test; ROCF, Rey Osterrieth Complex Figure; VR, Visual Reproduction; SCI, Subjective Cognitive Impairment; WAIS-RDS, Wechsler
Adult Intelligence Scale–Revised Digit Symbol; WAIS-RPC, Wechsler Adult Intelligence Scale–Revised Picture Completion subset; WMSR, Wechsler Memory Scale Revised.
SCI and MCI patients showed abnormal (positive) for Aβ42 (13). Kantarci et al (39) also acquired a TE of 30 ms to determine the mI level in the PCC. Age shown in median (interquartile range)
(21,31,24).

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PIERSSON ET AL Academic Radiology, Vol &, No &&, && 2020

TABLE 3. Methodological Quality of Studies

Study 1 2 3 4 5 6 7 8 9 Total Score LOE

(17) + + - + + + + + + 8/9 B
(18) + - + + + + + - - 6/9 B
(19) + + + + + + + + - 8/9 B
(20) + + - - + + + + - 6/9 B
(21) + + + + - - + + - 6/9 B
(22) + + + + + + + + - 8/9 B
(13) + + + + + + + + + 9/9 B
(23) + + - + + + + + - 7/9 B
(24) + + + + + + + + - 8/9 B
(25) + + + - + + + - - 6/9 B
(26) + + + + + + + + - 8/9 B
(27) + + + + + + + / + 8/9 B
(28) + - + - + + + - - 5/9 B
(29) + + + + - - + + - 6/9 B
(30) + + + + + + + + + 9/9 B
(31) + + + + + + + + - 8/9 B
(32) + + + + + + + + + 9/9 B
(33) + + - - + + + - - 5/9 B
(34) + + - - + - + / + 5/9 B
(35) + + + + + + + + + 9/9 B
(36) + + + + + + + + - 8/9 B
(37) + + + + + + + + - 8/9 B
(38) + + + + + - + + - 7/9 B
(39) + + + + + + + + - 8/9 B

LOE, level of evidence; -, score not fulfilled; +, score fulfilled; /, answer is not clear.
NOS Scale: (Items 1-4 classified under Selection category). 1 = Is the case definition adequate?; 2 = Representativeness of the cases;
3 = Selection of controls; 4 = Definition of controls; (Items 5 and 6 under Comparability category) 5 = Study controls for age or sex; 6 = Study
controls for any additional factor; (Items 7, 8, and modified 9 under Exposure category) 7 = Ascertainment of exposure; 8 = Same method of
ascertainment for cases and controls; 9 = Visual inspection of the MRI data quality.

TABLE 4. LOE, in Accordance with the 2005 Classification TABLE 5. Strength of Conclusion (Modified Table)
System of the Dutch Institute for Healthcare Improvement
CBO (www.cbo.nl) Conclusion was based on

1 A study type of LOE A1 or at least 2 independent

Intervention
A1 Systematic review of at least 2 independent from
each other conducted studies of evidence level A2
A2 Randomized double-blinded comparative clinical
research of good quality and efficient size
B Comparative research, but not with all characteris-
tics as mentioned for A2. This includes also
patient-control research and cohort research
C Not comparative research
D Experts’ opinion
For the NAA level, three studies (17,21,25) reported a
decrease in the PCC/precuneus. Modrego et al also found
decreased NAA in the posteromedial parietal cortex (32). On
the other hand, NAA was found to be increased in the occip-
ital lobe (32). In conclusion, there is moderate evidence that
NAA is decreased in the PCC/precuneus (strength of conclu-
sion 2), and some evidence that NAA is increased in the
occipital lobe (strength of conclusion 3).
studies of LOE A2
2 1 study type of LOE A2 or at least 2 independent
studies of LOE B
3 1 study type of LOE B or C
4 Experts’ opinion/Inconclusive/inconsistent find-
ings between various studies
Three studies analyzed ml levels in the PCC/precuneus
(19,21,25). Two studies observed increased ml in the PCC/
precuneus (19,21) whereas one study demonstrated no differ-
ence (25). In conclusion, there is moderate evidence that ml
is increased in the PCC (strength of conclusion 2).
Without any contrary evidence, two studies also reported
decreased Glu in the PCC/precuneus (19,21). One study
(25) found that both GABA and Glx decreased in the PCC.
One study found that Glc, Lac, and Asc increased in the
PCC/precuneus (17). One study found that the level of Cho
was not different in the PCC across the cohorts (25). In con-
clusion, there is moderate evidence that the level of Glu in
the PCC/precuneus is decreased in healthy older individuals

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and aMCI patients (strength of conclusion 2). In addition,
there is some evidence that GABA and Glx are reduced in
the PCC of APOE e4 allele carriers, and that Glc, Lac, and
Asc are increased in the PCC/precuneus in patients with AD
(strength of conclusion 3). There is also some evidence that
Cho level remains unchanged in the PCC (strength of con-
clusion 3).
similar biomarkers—Ab42, t-tau, and p-tau (13,17,29,30);
however, Waragai et al also included tau/Ab42 (29). One
study focused on Ab40, Ab42, t-tau, and p-tau (22) and the
other investigated only p-tau (26). It is important to note that
the study conducted by Murray et al was an autopsy-based
study, and so immunochemical markers were used to deduce
the accumulation of p-tau (26).

Metabolite Ratios
Creatine (Cr) is widely considered to be fairly stable; hence it CSF Ab, p-tau, and t-tau and Metabolite Alterations
is used as an internal reference. Alterations in the level of
Six studies investigated the relationship between brain metab-
NAA/Cr were reported in 14 studies. Decreased NAA/Cr
olites and CSF biomarkers (13,17,26,22,29,30). Two studies
was reported in all the 14 studies (19,24,26,27,29-35,37-39)
reported that mI correlated positively with CSF tau levels
while one of them (27) also reported its increase. In another
(17,30). In conclusion, moderate evidence shows that ml and
vein, two studies found no significant difference in NAA/Cr
CSF tau levels are positively correlated (strength of conclu-
between patients and control group (22,23). Since most of
sion 2).
the eligible articles demonstrate decreased NAA/Cr com- Only one study established a relationship between
pared to only 3 presenting contrary findings, it can be con-
increased mI/Cr and decreased CSF Ab42 specifically in cog-
cluded that there is more efficacious clarity to support
nitively healthy participants (13). It therefore appears that
findings of decreased levels of NAA/Cr (strength of conclu-
there is some evidence of negative correlation between ml/
sion 2).
Cr and CSF Ab42 (strength of conclusion 3).
Multiple studies reported decreased NAA/ml in the PCC
Two studies found that decreased NAA/Cr was associated
(20,22,26,29,31,38). In conclusion, there is moderate evi-
with decreased CSF Ab42 (13,30), while one study found no
dence that NAA/ml is decreased in the PCC (strength of
difference (29). There is moderate scientific evidence regard-
conclusion 2). ing the relationship between NAA/Cr and CSF Ab42
Several studies also reported increased level of ml/Cr
(strength of conclusion 2).
(13,20,22,23,26,27-31,33,35,36,38,39). Contrarily, Bittner et
Three studies found an association between reduced levels
al reported decreased ml/Cr in the PCC (18); and no differ-
of NAA/Cr and increased tau levels (13,26,30), contrarily,
ence in ml/Cr was reported by Yin et al (23). There appears
one study found no significant correlation between NAA/Cr
to be moderate evidence that ml/Cr levels are increased, since
and p-tau or p-tau/Ab42 (29). The evidence for the relation-
there are more studies supporting this finding (strength of
ship between NAA/Cr and tau levels seems ambiguous.
conclusion 2).
However, it can be deduced that there is moderate evidence
Increased Cho/Cr was found in four studies (27,28,33,39) for a negative correlation between the two biomarkers
but also found to be decreased in two studies (30,37).
(strength of conclusion 2).
Decreased Cho/Cr level was found in the hippocampus (30),
One study reported on the inverse relationship between p-
bilateral posterior cingulate gyri (30,37) and inferior precunei
tau and NAA/ml was found in one study (26). Another single
(37). Evidence for the level of Cho/Cr is ambiguous. How-
study found that there was no significant relationship
ever, there appears to be more support for its increased level
between NAA/ml and CSF Ab42 or CSF-p-tau (22). It can
(strength of conclusion 2).
be concluded that there is inconclusive evidence regarding
Increased ml/NAA in the PCC/precuneus was also
the relationship between NAA/ml and Ab42 or p-tau
reported in two studies (13,19), while one study found no (strength of conclusion 3).
difference in mI/NAA from bilateral hippocampus (23). The
Bittner et al showed that there is positive relationship
evidence regarding the level of ml/NAA is ambiguous. Nev-
between PCC mI/Cr and CSF t-tau (18). It can therefore be
ertheless, increased ml/NAA appears to be more prevalent in
postulated that ml/Cr and t-tau are positively correlated in
the PCC/precuneus compared to the hippocampus (strength
the PCC (strength of conclusion 3).
of conclusion 2).
There is also some evidence of decreased levels of Glu/Cr,
Glu/Cho, NAA/Cho (34), and Glu/ml (21) ratios in AD
(strength of conclusion 3).
APOE GENOTYPING
Since APOE, particularly the e4 allele is established as the
Quantification of CSF Levels of Ab40, Ab42, t-tau, and p-
main genetic risk factor for AD (6), its evaluation has been of
tau Proteins
interest in several cognitive aging studies. A total of 22 studies
Only six studies evaluated CSF biomarkers together with evaluated the APOE genotype of participants (13,18-29,31-
brain metabolites (13,17,22,26,29,30). Four studies explored 33,34-39).

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APOE Effects on 1H-MRS Metabolites did not show any statistical correlation. In conclusion, there is
1 some evidence of the interaction among APOE e4, CSF
The effects of APOE genotype on H-MRS metabolites
Ab42, and ml/Cr (strength of conclusion 3).
were assessed in 11 studies (13,18-20,22-25,28,38,39).
One study reported an association between decreased GSH
levels and increased brain amyloidosis in the temporal and
parietal regions, after adjusting for APOE e4 carrier (18). A DISCUSSION
partial relationship may be suggested between GSH and
The current systematic review provides a summary of avail-
APOE e4 carrier (strength of conclusion 4).
able evidence regarding alterations in 1H-MRS metabolites
Only one study reported decreased level of NAA in APOE
and their ratios, CSF Ab and tau levels, and relations between
e4 carriers (25). In conclusion, there is some evidence that
these biomarkers, APOE genotype and 1H-MRS metabo-
NAA level is decreased in APOE e4 carriers (strength of con-
lites, and between CSF Ab, tau, APOE genotype, and 1H-
clusion 3).
MRS detected metabolites. Most studies applied in vivo sin-
Five studies showed the lack of APOE e4 modulatory
gle-voxel 1H-MRS, as this technique is not only easy to
effect on NAA/Cr (19,22,28,38,39), while one of these stud-
acquire but also less technically demanding compared to the
ies also reported a correlation between increased NAA/Cr
multi-voxel 1H-MRS. Overall, the studies included investi-
and APOE e4 carrier status (38). In conclusion, there is mod-
gated a wide range of regional structures involved in the
erate evidence that APOE e4 has no modulatory effect on
development of AD, with the most commonly studied
NAA/Cr (strength of conclusion 2). This is because there are
regions for metabolite changes being the PCC/precuneus
more studies supporting this finding as opposed to only one
(17-22,25,27,28-30,33-39), followed by the hippocampus
study which gave a contradictory findings.
(23,24,30,24), and occipital lobe (27,32,39). The PCC/pre-
Regarding the relationship between APOE e4 and NAA/
cuneus is an important region which plays a critical role
ml, one study reported a correlation between BMI and right
within the default mode network, serving as a node for struc-
hippocampal NAA/ml in APOE e4 parents (11), while the
ture-functional connectivity (40). In the early course of AD,
other reported that APOE e4 status did not modify the associ-
this region does not only demonstrate cortical thinning (41),
ation between decreased NAA/mI and rate of Ab accumula-
but also reveal reduced glucose metabolism (42), and histo-
tion (20). For direct relationship between APOE e4 and
pathologic changes (43).
NAA/ml, one study found decreased NAA/ml in participants
Importantly the most studied metabolites, NAA and ml
with two copies of the ɛ4 allele (22), while the other found
demonstrated alteration in their levels, with the former being
that APOE e4 status showed no significant differences in
decreased and the latter being increased in the PCC/precu-
NAA/mI (38). In view of the conflicting findings, there is no
neus during the course of AD. Localized reduced levels of
full consensus regarding the effect of APOE e4 on NAA/ml
NAA in itself is indicative of neuronal malfunctioning either
(strength of conclusion 4).
as a result of decrease in density of neurons, neuronal cell loss,
Four studies found no effect of APOE on ml/Cr
or neuronal impairment (44). There is evidence that demen-
(19,28,38,39), while two studies found an association
tias i.e. AD are associated with gliosis and therefore demon-
between increased ml/Cr and APOE e4 (22,23). In addition,
strates increased mI (45), and may act as a biomarker of
three studies (20,23,24) did not show a clear relationship path
microglial proliferation (46). Although other metabolites
between APOE e4 and ml/Cr. In conclusion, there is incon-
such as GSH, Glu, GABA, Glx, Glc, Lac, Asc, and Cho may
clusive evidence regarding the effect of APOE e4 on ml/Cr
be valuable as potential biomarkers, further studies are
(strength of conclusion 4).
required to validate their role in the developmental stages of
Regarding the relationship between APOE e4 and Cho/
AD. Interesting results regarding changes in metabolite ratios
Cr, one study reported a significant modulatory effect of
were found in several studies predominantly involving MCI
APOE on Cho/Cr (28), while the other found no correlation
and AD. NAA/Cr, thought to be a marker of synaptic integ-
between APOE status and Cho/Cr (39). In conclusion, the
rity due to its association with synaptic vesicle immunoreac-
evidence for the effect of APOE e4 on Cho/Cr is inconclu-
tivity (26) is largely reduced in AD relative to controls
sive (strength of conclusion 4).
considering the consistent direction of change found across
most studies, and irrespective of the brain region analyzed.
Decreased NAA/ml and increased ml/NAA were observed
APOE and CSF Ab, tau, p-tau Effects on 1H-MRS
in the PCC/precuneus, contrary to the report of no signifi-
Another crucial evaluation from this review was to investigate cant difference in the level of ml/NAA in bilateral hippo-
how both CSF biomarkers and APOE genotyping jointly campi. There is relatively large evidence which supports the
correlated with brain metabolite alterations. Four studies observation of increased levels of ml/Cr and Cho/Cr in the
investigated the levels of CSF biomarkers together with PCC/precuneus of AD patients relative to MCI and controls.
APOE genotyping (13,22,26,29). However, only one study There is also some evidence showing decreased levels of Glu/
reported evidence of increased ml/Cr in healthy e4 carriers Cr, Glu/Cho, NAA/Cho, and Glu/ml in AD, albeit less fre-
who also had normal CSF Ab42 levels (13), while the others quently studied.

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A number of studies reported a significant relationship
between 1H-MRS detected brain metabolites with CSF bio-
markers and APOE e4. Overall, it seems plausible to suggest
that the relationship between ml and CSF tau levels, NAA/
Cr and CSF Ab42, and NAA/Cr and tau are the biomarkers
that may prove valuable in differentiating individuals in the
clinical stages of MCI and AD from healthy participants;
however, the latter relationship may be mainly useful for dif-
ferentiating between dementia and healthy controls. It has
been suggested that cognitively normal older individuals with
reduced CSF Ab42 demonstrate disruption of functional net-
works (47,48) and reduced brain volume (49,50), consistent
with the patterns exhibited in AD. Furthermore, increased
CSF tau thought to indicate neuronal injury (1) have been
shown to be closely associated with increased fMRI func-
tional connectivity between brain regions that are spatially
connected, not only in cognitively normal elderly individuals,
but also in AD or those with vascular cognitive impairment
(51,52). Together, these findings support the hypothesis that
increased tau deposition is related to neural activity and inter-
regional functional connectivity. It may therefore be sug-
gested that the decreased NAA/Cr and increased ml/Cr
exhibited in the PCC/precuneus of AD patients may be the
consequence of disruptions in both structural and functional
connectivity with concomitant cognitive impairment.
It is not surprising to find large number of APOE e4 car-
riers in the patient groups compared to healthy controls,
which is consistent with the well-grounded fact that APOE
e4 is associated with the increased risk of developing AD.
There is reasonable evidence to demonstrate that NAA levels
are decreased in APOE e4 carriers, and overwhelming sup-
port for the lack of APOE e4 modulatory effect on NAA/Cr
in the PCC (19,22,28,38,39). Presently, there are conflicting
reports regarding the relationship between APOE e4 and
other metabolites and their ratios. Furthermore, there is
limited evidence to confirm a relationship between
APOE e4, CSF Ab42, and mI/Cr in the asymptomatic
stages of AD.
CONCLUSION
The current study demonstrate that NAA and ml as single
biomarkers, and ml/Cr and NAA/Cr metabolite ratios are
the most reliable metabolite biomarkers for differentiating
patients with MCI and AD from healthy individuals.
Increased ml/NAA ratio may also be used to differentiate
patients with AD from cognitively normal individuals. While
NAA/ml and Cho/Cr may be reliably used to differentiate
different types of dementia from healthy individuals, they
may not be specific for differentiating MCI and AD from
cognitively normal individuals. The combination of ml and
tau may be utilized for differentiating AD from healthy con-
trols. Meanwhile, the combination of NAA/Cr with Ab42
may suffice for differentiating MCI from healthy controls.
NAA/Cr combined with tau may not only be useful for dif-
ferentiating other types of dementia from healthy cognitively
A SYSTEMATIC REVIEW
normal individuals, but may also have a role in differentiating
MCI and AD from healthy individuals. It can therefore be
suggested that these relationships may also prove useful in
predicting conversion from asymptomatic to symptomatic
phases of AD. It can also be confirmed that NAA levels
decrease in APOE e4 carriers and APOE e4 has no modula-
tory effect on NAA/Cr, while the effect of APOE e4 on
other metabolite ratios remain inconclusive. The association
between APOE e4, CSF Ab, tau, and the metabolites also
remain inconclusive. Nevertheless, it is worth to note that
the combination of biomarkers may be more effective than a
single biomarker in differentiating MCI and AD from cogni-
tively healthy individuals.
Strengths and Limitations
The multimodal combination of CSF Ab, tau, and APOE
e4 with 1H-MRS detected brain metabolite changes for
the investigation of cognitive impairment, particularly pre-
clinical, MCI and AD is required for cognitive neurosci-
ence research, and may provide robust biomarkers capable
of early diagnosis, prediction, and prognosis within clinical
settings. The current systematic review summarizes the
integration of these biomarkers in cognitive aging
research. It should be noted that the methodological qual-
ity of the studies included was moderate to good, with a
level of evidence B as most studies included were case-
control and cohort studies.
It is however important to emphasize that the following
study limitations have to be taken into account when
interpreting the results. Notably, only eligible studies pub-
lished in English were included. An important limitation
is the relatively small sample size in most studies, which is
typical of brain imaging studies. Also, a substantial number
of the studies did not report on the visual inspection of
the MRI data quality, which is crucial in MRI studies
(16). As such, parameters such as the sequence, location,
voxel size, repetition time, echo time, and the post-proc-
essing methods can lead to disparities among the out-
comes of different studies (15). Also, the exclusion of 1H-
MRS studies that did not include either CSF or genotype
markers was a clear-cut limitation, as many of such studies
provided important information but did not fit into the
inclusion criteria. Furthermore, the current systematic
review did not consider studies that provided information
on macro- or microstructural MRI findings. In addition,
studies employing other functional neuroimaging methods
i.e. fMRI, PET, electroencephalography, and magnetoen-
cephalography are currently not included. This is because
they were beyond the scope of the current study. It is
also important to mention that a few of the studies
employed other neuroimaging methods which in one
way or the other might have affected the outcome of
such studies. There are relatively few studies investigating
the relationship between 1H-MRS and fluid biomarkers.
Further studies are required to establish their contribution
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 ARTICLE IN PRESS
PIERSSON ET AL
to diagnostic work-up of individuals at risk or with AD.
Finally, evidence of correlation between variables as indi-
cated in some of the studies should not be interpreted as
being a causal relationship. Hence, no conclusions can be
established on the causality of the relations observed.
FUTURE DIRECTIONS
Further research employing 1H-MRS should consider
including analysis of fluid biomarkers and APOE status of
study participants. Importantly, information on results of cor-
relation analysis between 1H-MRS metabolites and fluid bio-
markers should be one of the topmost priorities in future
research. Future studies may also consider clarifying the effect
of APOE e4 on brain metabolites, and to unravel how altera-
tions of brain metabolites are affected by APOE e4 and CSF
biomarkers. It would also be interesting to explore the com-
bination of similar biomarkers from blood plasma with
APOE e4 and other neuroimaging techniques to provide fur-
ther insight into understanding the structural, and functional
changes underlying MCI and AD. Future studies may also
consider a larger sample size with a focus on longitudinal
design to validate the results.
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