Distinct Patterns of Hippocampal Pathology in Alzheimer's Disease with Transactive Response DNA‐binding Protein 43.

Objective: Age‐related dementia syndromes are often not related to a single pathophysiological process, leading to multiple neuropathologies found at autopsy. An amnestic dementia syndrome can be associated with Alzheimer's disease (AD) with comorbid transactive response DNA‐binding protein 43 (TDP‐43) pathology (AD/TDP). Here, we investigated neuronal integrity and pathological burden of TDP‐43 and tau, along the well‐charted trisynaptic hippocampal circuit (dentate gyrus [DG], CA3, and CA1) in participants with amnestic dementia due to AD/TDP, amnestic dementia due to AD alone, or non‐amnestic dementia due to TDP‐43 proteinopathy associated with frontotemporal lobar degeneration (FTLD‐TDP). Methods: A total of 48 extensively characterized cases (14 AD, 16 AD/TDP, 18 FTLD‐TDP) were analyzed using digital HALO software (Indica Labs, Albuquerque, NM, USA) to quantify pathological burden and neuronal loss. Results: In AD/TDP and FTLD‐TDP, TDP‐43 immunoreactivity was greatest in the DG. Tau immunoreactivity was significantly greater in DG and CA3 in AD/TDP compared with pure AD. All clinical groups showed the highest amounts of neurons in DG, followed by CA3, then CA1. The AD and AD/TDP groups showed lower neuronal counts compared with the FTLD‐TDP group across all hippocampal subregions consistent with the salience of the amnestic phenotype. Interpretation: We conclude that AD/TDP can be distinguished from AD and FTLD‐TDP based on differential regional distributions of hippocampal tau and TDP‐43. Findings suggest that tau aggregation in AD/TDP might be enhanced by TDP‐43. ANN NEUROL 2023;94:1036–1047 [ABSTRACT FROM AUTHOR]