A 2-Step Cerebrospinal Algorithm for the Selection of Frontotemporal Lobar Degeneration Subtypes
Open accessAbstract
Importance: Cerebrospinal fluid (CSF) core Alzheimer disease (AD) biomarkers have shown an excellent capacity for the in vivo detection of AD. Previous studies have shown that CSF levels of phosphorylated tau (p-tau) also correlate with tau pathology in frontotemporal lobar degeneration (FTLD) after accounting for AD copathology. Objective: To develop an algorithm based on core AD CSF measures to exclude cases with AD pathology and then differentiate between FTLD-tau and FTLD transactive response DNA-binding protein of approximately 43kDa (FTLD-TDP). Design, Setting, and Participants: A case-control study at the University of Pennsylvania. Participants were selected from a database of 1796 patients included between 1992 and 2016 with different neurodegenerative diseases with available CSF. Three patient cohorts were included: a cohort of patients with sporadic, autopsy-confirmed FTLD and AD (n = 143); a cohort of patients with frontotemporal degeneration (FTD) with TDP-associated or tau-associated mutations (n = 60); and a living cohort of patients with syndromes highly predictive of FTLD (progressive supranuclear palsy and FTD-amyotrophic lateral sclerosis; n = 62). Main Outcomes and Measures: Cerebrospinal fluid values of amyloid β1-42 (Aβ1-42), total tau (t-tau), and p-tau obtained using the INNO-BIA AlzBio3 (xMAP; Luminex) assay or INNOTEST enzyme-linked immunosorbent assay transformed using a previously validated algorithm. Sensitivities and specificities for differentiating AD from FTLD groups were calculated. Results: This autopsy cohort included FTLD-tau (n = 27; mean [SD] age at onset, 60.8 [9.7] years), FTLD-TDP (n = 13; mean [SD] age at onset, 62.4 [8.5] years), AD (n = 89, mean [SD] age at onset, 66.5 [9.7] years); and mixed FTLD-AD (n = 14, mean [SD] age at onset, 70.6 [8.5] years).The p-tau/Aβ1-42 ratio showed an excellent diagnostic accuracy to exclude AD cases in the autopsy cohort with single neurodegenerative pathologies (area under the curve [AUC], 0.98; 95% CI, 0.96-1.00). Cerebrospinal fluid p-tau levels showed a good AUC (0.87; 95% CI, 0.73-1.00) for discriminating pure FTLD-TDP from pure FTLD-tau. The application of an algorithm using cutpoints of CSF p-tau to Aβ1-42 ratio and p-tau allowed a good discrimination of pure FTLD-TDP cases from the remaining FTLD-tau and mixed FTLD cases. The diagnostic value of this algorithm was confirmed in an independent cohort of living patients with progressive supranuclear palsy and FTD-amyotrophic lateral sclerosis (AUC, 0.9; 95% CI, 0.81-0.99). However, the algorithm was less useful in FTD cases carrying a pathogenic mutation (AUC, 0.58; 95% CI, 0.38-0.77) owing to elevated p-tau levels in TDP-associated mutation carriers. Conclusions and Relevance: Alzheimer disease CSF core biomarkers can be used with high specificity for the in vivo identification of patients with pure FTLD-TDP and FTLD-tau when accounting for comorbid AD and genetic status.
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Plasma biomarkers are powerful diagnostic and prognostic clinical tools.
“Plasma biomarkers are powerful diagnostic and prognostic clinical tools. 1”
From Plasma Tau and Neurofilament Light in Frontotemporal Lobar Degeneration and Alzheimer Disease (2021) · cites this paper as [1]
The Biofluid Collection and Analysis and Discussion sections describe cerebrospinal fluid (CSF) biomarkers and their diagnostic use in distinguishing neurodegenerative pathologies. The Discussion also notes that CSF neurofilament light correlates with disease progression, but the paper does not establish that plasma biomarkers are diagnostic or prognostic clinical tools. Page numbers are unavailable in our copy. (LLM, conf=0.83)
Experimental — accuracy not yet measuredBoth t-tau and NfL may be useful for the diagnosis and prognosis of FTLD.
“The combination of CSF t-tau and NfL discriminated between early onset AD and FTLD, 9 and both analytes may be useful for the diagnosis and prognosis of FTLD.1,[10][11][12]”
From Plasma Tau and Neurofilament Light in Frontotemporal Lobar Degeneration and Alzheimer Disease (2021) · cites this paper as [1]
The Discussion (page unavailable) says NfL is elevated in FTD and correlates with disease progression, supporting its potential prognostic use, but cautions that it lacks disease specificity. The paper uses t-tau among biomarkers that help exclude AD in FTLD-related syndromes; it does not establish t-tau as a prognostic marker for FTLD. (LLM, conf=0.86)
Experimental — accuracy not yet measuredElevated CSF total tau and phosphorylated tau are regarded as markers of neurodegeneration and tau pathology in Alzheimer disease and are used clinically to raise diagnostic certainty; with CSF Aβ42 they are recommended in the Alzheimer's Association Appropriate Use Criteria for CSF testing in AD diagnosis.
“Elevated CSF levels of t-tau and p-tau are considered markers of neurodegeneration and tau pathology in AD and are used in the clinical setting to increase the diagnostic certainty of AD, 1 and together with CSF Aβ42 recommended for diagnostic use in the Alzheimer's Association Appropriate Use Criteria for CSF testing in the diagnosis of AD. 35”
From Plasma Tau and Neurofilament Light in Frontotemporal Lobar Degeneration and Alzheimer Disease (2021) · cites this paper as [1]
Split into 2 atoms — 1 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredPatients were included if they had either a post mortem neuropathologic diagnosis or an in vivo CSF analyte profile suggestive of the underlying neuropathology based on cutoffs previously validated in autopsy series.
“Patients were included if they had either a post mortem neuropathologic diagnosis or an in vivo CSF analyte profile suggestive of the underlying neuropathology based on cutoffs previously validated in autopsy series.”
From Automatic classification of AD pathology in FTD phenotypes using natural speech (2024) · cites this paper as [29]
The Autopsy Cohort and Statistical Analysis sections (pages not provided) describe neuropathologically diagnosed patients and CSF cutoffs derived from the autopsy cohort; the Validation section applies the algorithm to living patients. The paper therefore supports the basis for an in vivo CSF profile, but it does not establish the claimed either/or inclusion rule: its living validation cohort was selected by clinical syndrome, not by a qualifying CSF profile. (LLM, conf=0.83)
Experimental — accuracy not yet measuredCo-occurring AD pathology is a frequent clinical FTD manifestation.
“which is a frequent clinical FTD manifestation [90].”
Lower CSF p-tau could discriminate FTD-TDP from FTD-tau in sporadic pure FTD cases after excluding AD.
“Lower CSF p‐tau could discriminate FTD‐TDP from FTD‐tau in sporadic pure FTD cases after excluding AD.”
From New developments of biofluid‐based biomarkers for routine diagnosis and disease trajectories in frontotemporal dementia (2022) · cites this paper as [67]
Many biomarker studies in FTD may be confounded by co-occurring secondary AD pathology.
“Of note, many biomarker studies in FTD may be confounded by co‐occurring secondary AD pathology.”
From New developments of biofluid‐based biomarkers for routine diagnosis and disease trajectories in frontotemporal dementia (2022) · cites this paper as [67]
The value of CSF tau measurements is limited to pure cases of FTLD (e.g., without copathologies).
“Other studies have shown that the value of CSF tau measurements is limited to pure cases of FTLD (e.g., without copathologies).”
From New developments of biofluid‐based biomarkers for routine diagnosis and disease trajectories in frontotemporal dementia (2022) · cites this paper as [67]
The performance of CSF p-tau181 to discriminate between FTD pathological subtypes (FTLD-tau vs. FTLD-TDP) was considerably reduced when mutation carriers were analyzed separately (AUCs of 0.87 in sporadic pure cases vs. 0.58 in genetic cases).
“the performance of CSF p‐tau181 to discriminate between FTD pathological subtypes (i.e., FTLD‐tau vs. FTLD‐TDP) was considerably reduced when mutation carriers were analyzed separately (AUCs of 0.87 in sporadic pure cases vs. 0.58 in genetic cases). 61 , 67”
From New developments of biofluid‐based biomarkers for routine diagnosis and disease trajectories in frontotemporal dementia (2022) · cites this paper as [67]
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- Authors
- Lleó, A., Irwin, D. J., Illán-Gala, I., McMillan, C. T., Wolk, D. A., Lee, E. B., Van Deerlin, V. M., Shaw, L. M., Trojanowski, J. Q., & Grossman, M.
- Affiliations
- Universitat Autònoma de Barcelona (ES)
- University of Pennsylvania Health System (US)
- Department of Neurology, Institut d’Investigacions Biomèdiques Sant Pau, Hospital de Sant Pau, Universitat Autònoma de Barcelona and Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas, Barcelona, Spain.
- University of Pennsylvania (US)
- Alzheimer’s Disease Core Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Corresponding author
- Grossman, Murray
- ORCID
- Venue
- JAMA Neurology
- Publisher
- American Medical Association (AMA)
- Published
- 2018-06-01
- Volume
- 75
- Issue
- 6
- Pages
- 738
- ISSN
- 2168-6149 (ISSN-L)
- PMC
- PMC5885205
- OpenAlex
- W2794239764
- Cited by
- 71
- References
- 40
- Citations by year
- 2026: 3 · 2025: 8 · 2024: 7 · 2023: 9 · 2022: 13 · 2021: 6 · 2020: 9 · 2019: 11 · 2018: 5
- FWCI
- 6.10
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Neurology (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Wyncote Foundation
- National Institutes of Health
- Instituto de Salud Carlos III
- National Institute on Aging (P30AG010124, P01AG017586, K01AG043503)
- National Institute of Neurological Disorders and Stroke (K23NS088341)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Health Sciences › Medicine › Physiology › Alzheimer's disease research and treatments
- Health Sciences › Medicine › Neurology › Amyotrophic Lateral Sclerosis Research
- Keywords
- frontotemporal lobar degeneration, FTLD-tau, FTLD-TDP, Alzheimer's disease, cerebrospinal fluid biomarkers, phosphorylated tau, amyloid-beta 42, diagnostic algorithm, differential diagnosis, progressive supranuclear palsy, tau mutations, neurodegeneration
- MeSH terms
- Aged, Aged, 80 and over, Algorithms, Female, Humans, Male, Peptide Fragments, Biomarkers, Case-Control Studies, Databases, Factual, Amyloid beta-Peptides, tau Proteins, Frontotemporal Lobar Degeneration
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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