Astrocyte reactivity across the AD continuum measured by [18F]SMBT-1 and its relationship with the Aβ burden

Abstract Purpose Astrocytes colocalize with fibrillar amyloid-β (Aβ) plaques in postmortem Alzheimer’s disease (AD) brain tissue; however, their spatiotemporal dynamics in vivo remain poorly understood. This multicenter study aimed to investigate the progression of astrocyte reactivity across the AD continuum, including healthy controls (HC), mild cognitive impairment (MCI), and AD, using the novel monoamine oxidase B (MAO-B)-specific PET tracer [ 18 F]SMBT-1, while exploring its association with cognitive performance and amyloid burden. Methods A total of 91 participants (35 HC, 44 MCI, 12 AD) underwent [ 18 F]SMBT-1 PET, amyloid PET, T1-weighted MRI, and standardized neuropsychological assessments. Standardized uptake value ratios (SUVRs) were calculated based on [ 18 F]SMBT-1 PET data using four reference regions for subgroup comparisons stratified by Aβ status. Results [ 18 F]SMBT-1 uptake was significantly elevated in amyloid-positive MCI (MCI+) and AD groups compared with amyloid-negative HC (HC−) in the frontal, temporal, and posterior cingulate regions. Notably, astrogliosis patterns distinguished MCI subtypes: MCI+ individuals exhibited a widespread AD-like pattern, whereas the MCI− group showed a distinct profile. Furthermore, the uptake in symptomatic MCI+ individuals was significantly higher than that in asymptomatic HC+ individuals. Regional SMBT-1 uptake also strongly correlated with greater Aβ burden and worse cognitive scores. Conclusion This study demonstrates that [ 18 F]SMBT-1 is a promising tool for characterizing the spatial pattern and magnitude of reactive astrogliosis across the Aβ-defined AD continuum. Our findings further suggest that astrogliosis may represent an important mechanistic link between amyloid pathology and cognitive impairment, supporting its potential relevance in therapeutic development. Clinical trial registration Japan Registry of Clinical Trials (jRCT) jRCTs031210602, registered Feb. 07, 2022. URL for the trial registry https://jrct.mhlw.go.jp/en-latest-detail/jRCTs031210602 .