Amygdala-predominant α-synuclein pathology exacerbates hippocampal neuron loss in Alzheimer's disease

Misfolded -synuclein (Syn) protein accumulates in 43-63% of individuals with symptomatic Alzheimers disease (AD). Two main patterns of co-morbid Syn pathology have been identified: caudo-rostral and amygdala-predominant, with the latter being more common in AD. Syn pathology has been shown to interact with DNA-binding protein 43 (TDP-43) and abnormally phosphorylated Tau protein (pTau). These proteins tend to accumulate in the amygdala, yet the specific role of amygdala-predominant Syn pathology in the progression of AD and hippocampal degeneration remains unclear. In this cross-sectional study, we analyzed 291 autopsy brains from both demented and non-demented elderly individuals neuropathologically. Neuronal density in the CA1 region of the hippocampus was assessed using hematoxylin-stained sections for all cases. We semi-quantitatively evaluated Syn pathology severity in six brain regions and stratified the cases into the two spreading patterns. In 99 AD cases, we assessed limbic-predominant age-related TDP-43 neuropathological changes (LATE-NC), CA1 pTau density, and cerebral amyloid angiopathy (CAA). Structural equation modeling analysis was conducted based on the assessed pathological parameters in AD patients. We identified an association between the amygdala-predominant Syn pathology pattern and decreased neuronal density in the CA1 region. AD patients with an amygdala-predominant Syn pattern exhibited the most severe pTDP-43 pathology among all groups, while those with the caudo-rostral pattern had the lowest severity of AD-related pathological changes including CAA type 1. Our model revealed that the relationship between Syn pathology and CA1 neuron loss is mediated through pTau and LATE-NC. Our results indicate that amygdala-predominant Syn pathology, in contrast to Syn pathology with a caudo-rostral pattern, significantly contributes to hippocampal neuron loss, potentially by accelerating TDP-43 and pTau pathologies. This finding, along with observed neuropathological differences between AD patients with these two Syn spreading patterns, underscores the need for precise stratification of patients. The stratification should consider not only the molecular and morphological identity of co-pathologies but also the distribution pattern of the respective co-pathologies.