Four distinct trajectories of tau deposition identified in Alzheimer’s disease

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Alzheimer’s disease (AD) is characterized by the spread of tau pathology throughout the cerebral cortex. This spreading pattern was thought to be fairly consistent across individuals, although recent work has demonstrated substantial variability in the population with AD. Using tau-positron emission tomography scans from 1,612 individuals, we identified 4 distinct spatiotemporal trajectories of tau pathology, ranging in prevalence from 18 to 33%. We replicated previously described limbic-predominant and medial temporal lobe-sparing patterns, while also discovering posterior and lateral temporal patterns resembling atypical clinical variants of AD. These ‘subtypes’ were stable during longitudinal follow-up and were replicated in a separate sample using a different radiotracer. The subtypes presented with distinct demographic and cognitive profiles and differing longitudinal outcomes. Additionally, network diffusion models implied that pathology originates and spreads through distinct corticolimbic networks in the different subtypes. Together, our results suggest that variation in tau pathology is common and systematic, perhaps warranting a re-examination of the notion of ‘typical AD’ and a revisiting of tau pathological staging.

Original languageEnglish
Pages (from-to)871-881
Number of pages11
JournalNature Medicine
Issue number5
StatePublished - May 2021

Bibliographical note

Funding Information:
The authors thank M. Chakravarty, B. Misic, P. Bellec, P. Rosa-Neto, A. Dagher, E. Hamel and W. Seeley for feedback during the composition of this manuscript. J.W.V. acknowledges support from the government of Canada through a tri-council Vanier Canada Graduate Doctoral fellowship from the McGill Centre for Integrative Neuroscience and the Healthy Brains, Healthy Lives initiative, and from the National Institutes of Health (NIH) (no. T32MH019112). A.L.Y. is supported by a Medical Research Council Skills Development Fellowship (MR/T027800/1). N.P.O. is a UK Research and Innovation Future Leaders Fellow (no. MR/S03546X/1). N.P.O. and D.C.A. acknowledge support from the UK National Institute for Health Research University College London Hospitals Biomedical Research Centre, and D.C.A. acknowledges support from the Engineering and Physical Sciences Research Council grant no. EP/ M020533/1. M.J.G. is supported by the Miguel Servet program (no. CP19/00031) and a research grant (no. PI20/00613) of the Instituto de Salud Carlos III-Fondo Europeo de Desarrollo Regional. R.L.J. acknowledges support from the NIH (no. K99AG065501). This project received funding from the European Union’s Horizon 2020 research and innovation programme under grant no. 666992. The BioFINDER studies are supported by the Swedish Research Council (no. 2016-00906), the Knut and Alice Wallenberg Foundation (no. 2017-0383), the Marianne and Marcus Wallenberg Foundation (no. 2015.0125), the Strategic Research Area MultiPark (Multidisciplinary Research in Parkinson’s disease) at Lund University, the Swedish Alzheimer’s Foundation (no. AF-939932), the Swedish Brain Foundation (no. FO2019-0326), the Swedish Parkinson Foundation (no. 1280/20), the Skåne University Hospital Foundation (no. 2020-O000028), Regionalt Forskningsstöd (no. 2020-0314) and the Swedish Federal Government under the ALF agreement (no. 2018-Projekt0279). The Tau PET study in Gangnam Severance Hospital was supported by a grant from the Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education (nos. NRF2018R1D1A1B07049386 and NRF2020R1F1A1076154) and a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute funded by the Ministry of Health and Welfare, Republic of Korea (grant no. HI18C1159). We also thank B. L. Miller, H. J. Rosen, M. Gorno Tempini and W. Jagust for supporting the UCSF tau-PET studies, which were funded through the following sources: National Institute on Aging (NIA) no. R01 AG045611 (G.D.R.), no. P50 AG23501 (B.L.M., H.J.R., G.D.R.), no. P01 AG019724 (B.L.M., H.J.R., G.D.R.). The precursor of 18F-flortaucipir was provided by AVID Radiopharmaceuticals. The precursor of 18F-flutemetamol was sponsored by GE Healthcare. The precursor of 18F-RO948 was provided by Roche. Data collection and sharing for this project were funded by ADNI (NIH grant no. U01 AG024904) and Department of Defense ADNI (award no. W81XWH-12-2-0012). ADNI is funded by the NIA, the National Institute of Biomedical Imaging and Bioengineering and through generous contributions from the following: AbbVie, Alzheimer’s Association; Alzheimer’s Drug Discovery Foundation; Araclon Biotech; Bioclinica; Biogen; Bristol Myers Squibb; CereSpir; Cogstate; Eisai; Elan Pharmaceuticals; Eli Lilly and Company; EUROIMMUN; F. Hoffmann-La Roche and its affiliated company Genentech; Fujirebio; GE Healthcare; IXICO; Janssen Alzheimer Immunotherapy Research Development; Johnson & Johnson Pharmaceutical Research Development; Lumosity; Lundbeck; Merck; Meso Scale Diagnostics; NeuroRx Research; Neurotrack Technologies; Novartis Pharmaceuticals Corporation; Pfizer; Piramal Imaging; Servier; Takeda Pharmaceutical Company; and Transition Therapeutics. The Canadian Institutes of Health Research is providing funds to support ADNI clinical sites in Canada. Private sector contributions are facilitated by the Foundation for the National Institutes of Health ( The grantee organization is the Northern California Institute for Research and Education, and the study is coordinated by the Alzheimer’s Therapeutic Research Institute at the University of Southern California. ADNI data are disseminated by the Laboratory for Neuro Imaging at the University of Southern California. Finally, we thank all participants of this study and the families and caregivers of the patients included for their support in volunteering data for this study. Data used in the preparation of this article were obtained from the Alzheimer’s Disease Neuroimaging Initiative (ADNI) database ( As such, the investigators within the ADNI contributed to the design and implementation of ADNI and/or provided data but did not participate in analysis or writing of this report.

Publisher Copyright:
© 2021, The Author(s), under exclusive licence to Springer Nature America, Inc.

ASJC Scopus subject areas

  • Biochemistry, Genetics and Molecular Biology (all)


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