#79 Axel Montagne, Ph.D. on Blood-Brain Barrier Dysfunction in Alzheimer’s Disease and Dementia

Posted on February 27th 2023 (about 2 years)

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Dr. Axel Montagne is a chancellor's fellow and group leader at the UK Dementia Research Institute at the University of Edinburgh Centre for Clinical Brain Sciences. His group aims to understand how, when, and where critical components of the blood-brain barrier become dysfunctional preceding dementia and in the earliest stages of age-related cognitive decline. With this knowledge, they hope to develop precise treatments targeting brain vasculature to protect brain function.

More importantly, his work and that of his colleagues provide a critical lens through which to view the contributions of vascular dysfunction (or, conversely, vascular health – if we choose to preserve it) as a critical common thread in dementia and neurodegeneration.

In this episode, Dr. Montagne and I discuss:

  • What dementias have in common
  • The importance of preserving small blood vessels (in the brain)
  • Changes in the blood-brain barrier in aging that cause "leaking"
  • Predicting cognitive decline early with biomarkers – an opportunity for intervention?
  • Why targeting amyloid isn’t enough
  • The impact of the APOE4 genotype on brain vasculature
  • The cause of white matter damage in the brain
  • Why the loss of omega-3 transport affects pericytes
  • The role of exercise in prevention of blood-brain barrier dysfunction
  • Why high heart rates during exercise preserve brain function
  • The role of exercise in preserving vision health
  • Why leaky vessels damage myelin and the brain
  • Can you have more than one type of dementia?
  • Does the breakdown of the blood-brain barrier cause “type 3 diabetes"?
  • Why omega-3 may prevent detachment of pericytes
  • Why a hepatitis drug restored cognition in APOE4 mice
  • Why blood-brain barrier disruption results in the accumulation of amyloid-beta
  • Why lifetime hypertension increases dementia risk
  • Effects of obesity on blood-brain barrier leakage

(For more timestamps, please click the timeline tab.)

Identifying a common threat in cognitive decline

"Many studies back from 20-30 years ago show that when you look at postmortem brain tissue samples of people that died from Alzheimer's disease, you can see a lot of vascular problems in every single case." - Axel Montagne, Ph.D. Click To Tweet

Biomarkers of blood-brain barrier breakdown and vascular injury

Rather than thinking about dementia as the amyloid-beta plaques and tau tangles characteristic of Alzheimer's disease or altered brain glucose metabolism (colloquially referred to as "type 3 diabetes"), what if we could instead find an underlying and unifying pathology involved in most dementias?

Alzheimer's disease, cerebral small vessel disease, and vascular dementia are the three most prevalent forms of dementia and can present simultaneously, exacerbating the associated cognitive losses. Although some treatments for dementia are available, they are limited and only moderately effective at slowing the insidious decline accompanying the condition – and carry many serious side effects. A fresh look at identifying and addressing the root causes of dementia has therefore taken on greater importance. The health of the blood vessels that comprise the blood-brain barrier may be one of the most critical and early pathological features of Alzheimer's disease and other dementias.

More than half of all dementias begin with the breakdown of the blood-brain barrier

Scientists now know that roughly half of all dementias start with the breakdown of the smallest vessels in the brain and subsequent leakiness of the blood-brain barrier.[1] Biomarkers of blood-brain barrier dysfunction can be measured before other pathological hallmarks of Alzheimer's disease, including amyloid plaques and tau tangles. Roughly three decades ago, researchers observed an interesting phenomenon in the post-mortem brain tissue of some people with Alzheimer's disease: a propensity for vascular dysfunction – a broad term that describes the loss of normal endothelial tone and permeability.

These losses promote the deterioration and disease of small blood vessels in the brain, ultimately compromising the blood-brain barrier, the brain's primary defense to keep the brain clear of pathogens, toxins, immune factors, and other blood components found in circulation. Breakdown of the blood-brain barrier also disrupts blood flow to the brain, decreasing the brain's supply of oxygen and glucose.

Blood-brain barrier leakage affects the brain region involved in learning and memory

The learning and memory region of the brain, the hippocampus, is leakier than normal in people that are older versus young, and we know that this region leaks the earliest in dementia as well. Click To Tweet

The loss of blood-brain barrier integrity is a feature of normal aging and typically begins in the hippocampus, the part of the brain that is crucial for memory (in particular, the consolidation of short-term memories to long-term memories), learning, and spatial navigation.[2] Consequently, the hippocampus is the first brain region to exhibit blood-brain barrier breakdown in dementia. This "leakiness" is observable in brain imaging studies, which can detect differences between young and old people's vessels – even if the latter are cognitively healthy.

In the research setting, the presence of blood-brain barrier leakiness, along with various blood and cerebrospinal biomarkers, can predict future cognitive decline. Interestingly, leaky vessels aren't always co-located with amyloid-beta and tau protein accumulation, suggesting that these pathological events may be independent pathways for the development of dementia – and that a "cocktail approach" of simultaneously addressing a leaky barrier and amyloid-beta might be productive.

The major genetic risk factor for Alzheimer's disease, APOE4, promotes earlier breakdown of the blood-brain barrier

"If you target the vessels, it can have a big impact on neuronal function and cognition."- Axel Montagne, Ph.D. Click To Tweet

APOE4 isoform-specific CypA-MMP9 activation

A variant of the APOE gene called APOE4 is the primary genetic risk factor for late-onset Alzheimer's disease. Carrying one copy of APOE4 increases a person's Alzheimer's disease risk two- to threefold; carrying two copies increases a person's risk as much as 15-fold. People with two copies of APOE4 have 2.7 times as many amyloid oligomers in their brains as people with two APOE3 alleles.

Biomarkers of and contributors to the process of blood-brain barrier breakdown, MMP9 and cyclophilin A, are elevated in the cerebrospinal fluid of people carrying the APOE4 allele. Evidence suggests APOE4 competes with amyloid-beta for binding to a receptor called LRP1, which typically participates in amyloid clearance. Binding to LRP1 results in a release of proteins, including MMP9 and cyclophilin A, that degrade the tight junctions that hold endothelial cells that comprise the blood-brain barrier, thus leading to breakdown and increased permeability.

High Levels of cyclophilin A are implicated in many diseases, including neurodegenerative and cardiovascular diseases.[3] This should give us pause because APOE4 carriers have nearly four times more MMP9 and cyclophilin A than non-carriers. However, the good news is that studies in mice that carry APOE4 have shown that inhibiting the action of cyclophilin A partially restores vascular function and cognition.

Degeneration of brain capillary pericytes leads to neurodegeneration and leaks in the blood-brain barrier

"If the pericytes are not there; you can easily assume that your blood flow will be disturbed. They are there to constrict and dilate vessels, so when they detach, not only do you have the leakage of the barrier, but you also have some blood flow problems."- Axel Montagne, Ph.D. Click To Tweet

Integral to the pathophysiology of cerebral small vessel disease and neurodegenerative diseases involving the loss of blood-brain barrier integrity is the detachment and loss of pericytes. These specialized endothelial cells cover as much as 80 percent of the surface area of brain capillaries in the cortex and hippocampus of the human brain and wrap around the smallest vessels that make up the blood-brain barrier.

Pericytes have several critical functions:

  • Regulating vascular blood flow via vasoconstriction and dilation.
  • Providing structural support to small blood vessels.
  • Participating in regulating transcytosis in endothelial cells as part of the neurovascular unit, which makes up the blood-brain barrier.

Aging contributes to neuroinflammation, causing endothelial cells to adopt a pro-inflammatory phenotype, which is thought to ultimately drive the detachment of pericytes and contribute to the breakdown of the blood-brain barrier and the pathophysiology of various dementias, including Alzheimer's disease. In fact, it is the detachment of pericytes that enables the physical entry of immune cells_ into the brain. As pericytes detach, they shed a cell-surface protein called platelet-derived growth factor receptor-beta, or PDGFR-beta. Soluble PDGFR-beta is detectable in the cerebrospinal fluid and plasma of cognitively normal older adults and is more pronounced in people with early Alzheimer's disease, suggesting it may be an early biomarker of the disease.[4]

Preventing toxic proteins originating in blood from entering the brain

As the blood-brain barrier breaks down, whether as a part of aging or neurodegenerative disease, immune cells, inflammatory cytokines, toxic proteins, and red blood cells gain access to the brain from the blood and contribute to cognitive dysfunction. 

Examples include:

  • Plasminogen - A clot-busting protease that is associated with neurotoxicity, calcium-induced excitotoxicity, microglia activation, and neuronal laminin degradation, leading to neuroinflammation. 
  • (Pro-)thrombin - A neurotoxic clotting protein that activates microglia by upregulating pro-inflammatory pathways, such as NF-kB, and promoting further blood-brain barrier degradation and neuronal apoptosis.[5]
  • Auto-antibodies - Immune cells that target neuronal receptors and synaptic proteins, driving neuroinflammation.[6]
  • Albumin - A protein derived from the blood that, in the setting of a leaky blood-brain barrier, enters the brain where it can drive inflammation and mediate excitotoxicity.[7]
  • Fibrinogen - A protein that plays a role in blood clotting; see section below.

Fibrinogen, a protein found in the blood, is toxic to the brain.

"It shouldn't be in the brain at all, but we start seeing this extravascular deposition of fibrinogen, which means that, for it to cross, you must have some degree of breakdown of the blood-brain barrier." - Axel Montagne, Ph.D. Click To Tweet

One example of neurotoxicity originating from plasma proteins is fibrinogen, a protein produced in the liver that plays roles in blood clot formation and is crucial for survival. But fibrinogen should not be in the brain. Disruption of the blood-brain barrier allows fibrinogen to leak into the brain. Its deposition is toxic to neurons and oligodendrocytes (myelin-producing cells) and leads to inflammation and white matter disease, a common feature of Alzheimer's disease.

Fibrinogen also activates the microglia, the brain’s resident immune cells. When inflammatory signals activate microglial cells, they switch from protecting the blood-brain barrier to attacking it. This promotes a vicious cycle of blood-brain barrier dysfunction and neurotoxicity. Chronic activation of microglia causes neuroinflammation and increases dementia risk.

Strategies of prevention for dementia

"We need to exercise no matter what. If you want to stay healthy in terms of brain function, yeah, no other choice."- Axel Montagne, Ph.D. Click To Tweet

While we await potential breakthroughs in targeting elements of the neurovascular unit in the blood-brain barrier directly with stem cell therapeutics, gene therapies, and other cutting-edge techniques, there are things we can do now to better support vascular health and thereby help maintain the integrity of the blood-brain barrier.

Omega-3 fatty acids

"As we age and with dementia, Mfsd2a, the receptor for omega-3 is reduced on the blood vessels. And where there is a reduction of Mfsd2a on blood vessels, we see pericyte loss."- Axel Montagne, Ph.D. Click To Tweet

MFSD2A is essential for blood-brain barrier integrity and DHA transport

Omega-3s, especially the marine-derived eicosapentaenoic acid, EPA, and docosahexaenoic acid, DHA, exert potent anti-inflammatory effects on the body's cells via the action of metabolic byproducts called specialized pro-resolving mediators, or SPMs. Specific classes of SPMs, such as resolvins, protectins, and maresins, have been independently shown to promote blood-brain barrier repair and downregulate neuroinflammation in the context of various neurological diseases, including dementia. These SPMs help lower inflammation, including that induced by the presence of fibrinogen.[8] [9]

The omega-3 fatty acid DHA may play a direct role in maintaining blood-brain barrier integrity. Mfsd2a, a transmembrane protein found exclusively on the endothelial cells that line blood vessels on the blood-brain barrier, is the sole means by which lysophospholipid DHA is delivered to the brain. In animal studies where Mfsd2a is defective or absent (which can occur with age or genetic predisposition), this reduces the brain's DHA levels by more than fifty percent and causes the blood-brain barrier to break down. This suggests that DHA plays a vital role in maintaining blood-brain barrier integrity.

Aerobic exercise

"If you don't make sure that your heart is pumping at a high rate regularly during the week, those tiny vessels that are even smaller than your hair in terms of diameter will start to collapse." - Axel Montagne, Ph.D. Click To Tweet

Aerobic exercise stands out as a potent tool against age-related vascular dysfunction. Exercise improves endothelial function and increases the density and overall function of brain capillaries, which comprise roughly 90 percent of the brain's vasculature. Exercise intensity may be necessary for this effect. Vigorous exercise increases vascular endothelial growth factor, resulting in increased capillary density and the sprouting of new capillaries from existing blood vessels at the blood-brain barrier.

Exercise also increases brain-derived neurotrophic factor (BDNF) at the endothelial cells that comprise the blood-brain barrier, strengthening them. The shear force of blood flow during vigorous exercise is a signal that boosts BDNF production in the brain, suggesting vigorous exercise, in particular, may be a powerful tool to prevent neurodegenerative disease.[10]

A good rule of thumb for determining your exercise intensity: It should be challenging to maintain a conversation, make you sweat, and, ideally, elevate your heart rate to 80 percent of your estimated maximum. When factors like these align, you're achieving a vigorous intensity in your exercise.

Blood pressure

"When people have hypertension, they tend to have more microbleeding in the basal ganglia. A few studies show that hypertension also triggers blood-brain barrier leakage and pericyte loss."- Axel Montagne, Ph.D. Click To Tweet

Nearly half of all adults in the United States have high blood pressure, defined as having a systolic pressure of 130 mmHg or higher or a diastolic pressure of 80 mmHg or higher. Maintaining early healthy blood pressure is critical to ensuring the proper functioning of blood vessels in the brain and blood-brain barrier integrity. Cumulative exposure to high blood pressure damages blood vessels and increases dementia risk. Aerobic exercise and sauna use have robust blood pressure-lowering effects.

Selected publications for this episode

Articles:

Episodes:

About Dr. Axel Montagne

People mentioned in this episode

  • Joanna Wardlaw, MD
  • Berislav Zlokovic, MD, PhD
  • Tony Wyss-Coray, PhD
  • Katerina Akassoglou, PhD
  • William A. Banks, MD
Show References  ▸

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