Analyzing heterogeneity in Alzheimer disease using multimodal normative modeling on imaging-based ATN biomarkers

INTRODUCTION: Previous studies have applied normative modeling on a single neuroimaging modality to investigate Alzheimer disease (AD) heterogeneity. We employed a deep learning-based multimodal normative framework to analyze individual-level variation across ATN (amyloid-tau-neurodegeneration) imaging biomarkers. METHODS: We selected cross-sectional discovery (n = 665) and replication cohorts (n = 430) with available T1-weighted magnetic resonance imaging (MRI), amyloid, and tau positron emission tomography (PET). Normative modeling estimated individual-level abnormal deviations in amyloid-positive individuals compared to amyloid-negative controls. Regional abnormality patterns were mapped at different clinical group levels to assess intra-group heterogeneity. An individual-level disease severity index (DSI) was calculated using both the spatial extent and magnitude of abnormal deviations across ATN. RESULTS: Greater intra-group heterogeneity in ATN abnormality patterns was observed in more severe clinical stages of AD. Higher DSI was associated with worse cognitive function and increased risk of disease progression. DISCUSSION: Subject-specific abnormality maps across ATN reveal the heterogeneous impact of AD on the brain. Highlights: Normative modeling examined AD heterogeneity across multimodal imaging biomarkers. Heterogeneity in spatial patterns of gray matter atrophy, amyloid, and tau burden. Higher within-group heterogeneity for AD patients at advanced dementia stages. Patient-specific metric summarized extent of neurodegeneration and neuropathology. Metric is a marker of poor brain health and can monitor risk of disease progression.