Pathology International 2017; 67: 185–193
12520
Review Article
Plaque formation and the intraneuronal accumulation of
b-amyloid in Alzheimer's disease
Reisuke H. Takahashi,1 Toshitaka Nagao1 and Gunnar K. Gouras2
1
Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan and 2Department of Experimental
Medical Science, Lund University, Lund, Sweden
Amyloid plaques and neurofibrillary tangles (NFTs) in the
brain are the neuropathological hallmarks of Alzheimer's
disease (AD). Amyloid plaques are composed of b-amyloid
peptides (Ab), while NFTs contain hyperphosphorylated
tau proteins. Patients with familial AD who have mutations
in the amyloid precursor protein (APP) gene have either
increased production of Ab or generate more aggregation-
prone forms of Ab. The findings of familial AD mutations in
the APP gene suggest that Ab plays a central role in the
pathophysiology of AD. Ab42, composed of 42 amino acid
residues, aggregates readily and is considered to form
amyloid plaque. However, the processes of plaque forma-
tion are still not well known. It is generally thought that Ab
is secreted into the extracellular space and aggregates to
form amyloid plaques. Ab as extracellular aggregates and
amyloid plaques are thought to be toxic to the surrounding
neurons. The intraneuronal accumulation of Ab has more
recently been demonstrated and is reported to be involved
in synaptic dysfunction, cognitive impairment, and the
formation of amyloid plaques in AD. We herein provide an
overview of the process of the intraneuronal accumulation
of Ab and plaque formation, and discuss its implications
for the pathology, early diagnosis, and therapy of AD.
Key words: Alzheimer's disease, b-amyloid, intraneuronal
accumulation, multivesicular body, synapse
Alzheimer's disease (AD) is the primary dementia-causing
disease and approximately 46.8 million people worldwide
had dementia in 2015.1 It is estimated that 5–7% of older
adults who are 60 years and over will be affected by AD.1
The most common early symptom in AD is difficulty in
remembering recently learned information. As the disease
Correspondence: Reisuke H. Takahashi, MD, PhD, Department of
Anatomic Pathology, Tokyo Medical University, Nishi-shinjuku 6-7-1
Shinjuku, Tokyo, 160-0023, Japan.
E-mail: takaharh@tokyo-med.ac.jp
Received 15 October 2016. Accepted for publication 2 February
2017.
© 2017 Japanese Society of Pathology and John Wiley & Sons
Australia, Ltd
doi:10.1111/pin.
advances, symptoms include disorientation, deepening con-
fusion about events, loss of motivation, failure to perform
self-care, and finally the loss of bodily functions leading to
death. In developed countries, the social and financial
burdens imposed by AD are among the greatest of any
disease. Some medications can temporarily improve the
symptoms of AD, but no medications are available to halt its
progression. Thus, although some treatments for the symp-
toms associated with AD exist, there is currently no cure.
Therefore, AD remains the subject of major ongoing
research.
In 1906, AD was first described by a psychiatrist, Alois
Alzheimer. He reported the case of a 51-year-old female
patient who presented with progressive cognitive decline.
He described the unique pathological findings in the
patient's brain, specifically the deposition of a “peculiar
substance” in an autopsy report, which is now called
plaque. Oskar Fischer considered that plaques were de-
rived from the degeneration of the neuronal processes,
while Francesco Bonfiglio suggested that they can originate
within neuronal cell bodies and terminals.2–4
Amyloid plaques and neurofibrillary tangles (NFTs) are
the two neuropathological hallmarks of AD. Cerebral atro-
phy, the loss of neurons, inflammation and amyloid angiop-
athy are also observed. There are numerous reports that
describe the loss of synapses in AD brains, which correlates
best among brain changes with cognitive decline.5–7 b-
amyloid (Ab) peptides have taken a central role in AD
research because genetic studies have indicated that they
are involved in all known forms of familial AD.8 Most
experimental therapies aim to reduce the levels of Ab
peptides in the brain. However, the molecular mechanism of
Ab neurotoxicity has not been elucidated. The fibrillar form
of Ab, protofibrils of Ab, and various soluble and insoluble
Ab oligomers have been thought to be neurotoxic and to be
involved, mainly extracellularly, in the disruption of learning
and memory.9 Evidence that has accumulated over the past
few decades suggests that the intraneuronal accumulation
186 R. H. Takahashi et al.
of Ab peptides plays an important role in the development
of AD.10–14
The amyloid precursor protein (APP) and the
production of Ab
Amyloid protein was first purified and characterized from the
vasculature in the brain of AD patients;15 the amyloid
precursor protein (APP) was subsequently cloned.16 APP is
a type I transmembrane protein and is cleaved by secre-
tases. The APP gene is localized on chromosome 21 and
its mRNA can be processed by alternative splicing to
produce three main isoforms. The 695 amino acid isoform
is predominantly found in neurons, and the 751 and 770
amino acid isoforms are preferentially expressed systemi-
cally. The Ab domain in APP is partially located within the
ectodomain and the transmembrane domain of APP as up
40–43 amino acid residue peptides (Fig. 1). The disease-
associated isoform of Ab is Ab42 and accounts for 5–10%
of the total amount of Ab that is produced.12 The initially
deposited amyloid plaques observed in AD brains are made
up of Ab42. APP is proteolytically processed by the a-, b-,
and g-secretases. Much of APP is cleaved by a-secretase
Figure 1 A schematic diagram of APP and APP fragments,
including Ab and APP b-CTFs. Ab is partially within the transmem-
brane domain and partially in the ectodomain of APP that is
exposed to the cytoplasm or the extracellular space. The sites at
which APP is cleaved by a-, b-, and g-secretases are numbered
from the N-terminus of Ab. In the non-amyloidgenic pathway APP
is mostly cleaved by a-secretase within Ab, which precludes the
production of Ab. The sequential processing of APP by b- and g-
secretases in the amyloidgenic pathway produces Ab. Representa-
tive antibodies, such as 6E10 and 4G8, recognize several amino
acid residues within Ab, and therefore detect both Ab and APP.
The MBC42 and AB5078P antibodies specifically recognize the C-
terminus of Ab42 allowing the detection of Ab42 without cross-
reacting to APP or APP b-CTF. Monoclonal antibody MBC42 was
kindly provided by Dr. Yamaguchi at Gunma University and
ployclonal antibody AB5078P was a product of Chemicon (currently
Merck Millipore; however the current clone is now different).
© 2017 Japanese Society of Pathology and John Wiley & Sons Australia, Ltd
within the Ab domain at amino acid 17, precluding the
generation of Ab, and is then released as secreted aAPP in
the non-amyloidgenic pathway. APP is also sequentially
cleaved by the b- and g-secretases at the N- and C-
terminus of the Ab domain respectively, generating Ab in
the amyloidgenic pathway.17 A greater amount of APP is
expressed in Down syndrome (DS) patients because of
their trisomy 21; AD-type pathology is known to develop
much earlier in those with DS.18 Moreover, the autosomal
dominant mutations in APP and presenillin that are associ-
ated with the familial forms of early-onset AD were shown
to increase the production of Ab and/or to generate more
aggregation-prone Ab. Based on these genetic clues, the
Ab peptide has come to be a central focus of AD research.
Ab was initially thought to be generated at the plasma
membrane and to subsequently be released as extracellular
Ab. In AD patients, it is hypothesized that secreted Ab
gradually increases in the extracellular space until it starts
to form aggregates of insoluble b-pleated amyloid fibrils,
which consist of antiparallel-pleated sheets of filaments that
are approximately 7–9 nm in diameter. It has been hypothe-
sized that these extracellular Ab fibrils exert their toxic
effects on the surrounding neurons and their processes.19
More recently, the intermediate products of Ab fibril
formation, such as lower molecular weight Ab oligomers
and protofibrils, have been suggested to be more toxic to
neurons and more disruptive to synaptic plasticity than Ab
fibrils.9 In addition, among soluble and insoluble forms of
Ab, soluble Ab correlates better with cognitive function in
the AD brain.20,21 Protofibrils are a form of soluble Ab and
such soluble pools of Ab is increasingly considered to have
major pathogenic effects.
The subcellular accumulation of Ab
It may be important to elucidate where and how Ab
accumulates and/or aggregates to understand the mecha-
nism of AD pathogenesis. Some groups have suggested
that Ab accumulation can be initiated within neurons rather
than in the extracellular space.12,22,23 It has been reported
that the intraneuronal accumulation of Ab peptides may
occur before the formation of extracellular amyloid plaques
and NFTs.12 We observed the subcellular accumulation of
Ab42 peptides in the cortex of wild-type mouse brain by
immunofluorescent labeling (Fig. 2a,b). The first biochemi-
cal evidence of endogenous intracellular Ab was reported in
1993,24 and subsequently intracellular generation and accu-
mulation were reported in a variety of subcellular loca-
tions.12,25 The generation of Ab has been described in the
endoplasmic reticulum/intermediate compartment (ER/IC),26
the Golgi apparatus,27 and endosomal/lysosomal system28
in experimental cell biology studies. It was reported that

Figure 2 The immunofluorescent staining of the brain of an 11-month-old wild-type mouse. The intracellular accumulation of Ab42
peptides is detected by antibodies (a) MBC42 and (b) AB5078P within the pyramidal neurons of wild-type mouse cortex. Ab42 peptides
accumulate in a granule/vesicular pattern in the cytoplasm around the nucleus. Scale bars: 5 mm.
APP retained in the ER/IC eliminates the production of
intracellular Ab40, but does not alter the synthesis of
intracellular Ab42.29 According to this finding, the ER/IC
may be an important site for the generation of amyloidgenic
species of Ab42. It was subsequently reported that Ab40
and Ab42 accumulate in the Golgi apparatus, and that both
Ab peptides are predominantly generated within the trans-
Golgi network (TGN) and then packaged into post-TGN
secretary vesicles for secretion.27 In addition, it was
demonstrated that the endocytic pathway is involved in the
production and release of Ab after the internalization of
APP from the cell surface by clathrin-mediated
endocytosis.30
The observation of the intraneuronal accumulation of
Ab by light and fluorescence microscopy
Although there are now numerous reports of the intra-
neuronal accumulation of Ab in the brains of human AD,
DS, and transgenic models of AD, one of the reasons why
the intraneuronal accumulation of Ab has not been a major
issue in AD research is that the intraneuronal labeling of Ab
was previously considered to be an artifact. Most investi-
gators could not easily appreciate intraneuronal Ab labeling
in the postmortem AD brain. However, not easily observing
intraneuronal Ab in brain sections does not mean that it is
absent in the neurons. The routinely short development
time for 3, 3’-diaminobenzidine (DAB)/peroxidase reactions
has been introduced to detect neuropathology in AD brains,
because this leads to clean plaque staining without back-
ground. The extraneuronal aggregates of Ab peptides in
amyloid plaques are also much more abundant than the
intraneuronal accumulation of Ab. Thus, intraneuronal
accumulation has been considered to be less important
than the extracellular deposits of Ab. Furthermore, previous
antibodies against Ab were directed against the Ab domain
of APP and could not distinguish Ab from APP or APP
© 2017 Japanese Society of Pathology and John Wiley & Sons Australia, Ltd
Intraneuronal accumulation of b-amyloid 187
fragments, such as secretase-cleaved APP C-terminal frag-
ments (CTFs). A short development time with these well-
established Ab/APP antibodies is sufficient for the detection
of plaque by immunohistochemistry. Since APP is also
more abundant than Ab in neurons; APP can be detected
using such Ab/APP antibodies, used to detect amyloid
plaques, even with a short development time. Thus, a
longer development time is required to establish appropriate
immunohistochemical procedures for detecting the intra-
neuronal accumulation of Ab.
As noted above, staining with Ab/APP antibodies has
represented a problem with regard to the acceptance of
intraneuronal Ab. It is preferable to use C-terminal end-
specific Ab antibodies directly, because they are able to
differentiate Ab from APP and APP fragments, since they
do not label the Ab domain within APP. Moreover, C-
terminal end-specific Ab antibodies allow for the differentia-
tion of Ab40 from Ab42 peptides. Ab40 peptides are the
predominantly secreted Ab species, which aggregate as
vascular amyloid in leptomeningeal arteries and cortical
arterioles.31,32 On the other hand, Ab42/43 peptides are
generated as a minor Ab species but are deposited earliest
as amyloid plaques in the brain parenchyma. Thus, a longer
DAB/peroxidase reaction time is required in order to
observe the intraneuronal accumulation of Ab, even though
these Ab42 peptides within the neurons are more apparent
than Ab40 peptides.12
Formic acid pretreatment has widely been used to
increase the staining of pathological plaques in AD brains
for antigen retrieval. However, this treatment makes the
sections more friable and can also reduce the immunoreac-
tivity of paraffin-embedded human brain tissue. Similar to
APP immunoreactivity, intraneuronal Ab, which is present in
cells at much lower levels than APP, is more difficult to
detect by immunohistochemistry when formic acid pretreat-
ment is used. Unlike formic acid, microwave treatment or
autoclave heating has been reported to enhance the
immunoreactivity of intraneuronal Ab.33 It was just over a
188 R. H. Takahashi et al.

decade ago when investigators attempted to optimize the
pretreatment conditions for the staining of intraneuronal
Ab.34,35 Formic acid was reported to have a similarly
detrimental effect to heating pretreatment on the detection
of intraneuronal Ab. The staining protocol for intraneuronal
Ab peptides in paraffin-embedded sections was optimized
in relation to heating and formic acid using AD transgenic
mouse models.34 In this specific study, formic acid was
found to be essential for the staining of aggregated intra-
neuronal Ab peptides in mouse brain tissue.
Additional concerns for the acceptance of intraneuronal
Ab are appropriate for all immunohistochemical treatments,
for example, the postmortem interval, fixation, pre-treat-
ments, detergents and blocking solutions.
The observation of the intraneuronal accumulation of
Ab by immuno-electron microscopy
Multivesicular bodies
Immuno-electron microscopy (immuno-EM) was employed
to investigate the subcellular localization of Ab within the
neurons of the brain. Pre-embedding immuno-EM demon-
strated that Ab42 normally resides in the outer membrane
of multivesicular bodies (MVBs) and small vesicles associ-
ated with endosomal organelles in the neurons of mouse
(Fig. 3a,b), rat and human (Fig. 4a,b) brains.14 MVBs are
relevant to many cellular functions, especially the trafficking
and degradation of membrane receptors.36,37 MVBs are
considered to be late endosomes, which are formed from
the membrane invaginations and buddings of the early
endosomes that produce the inner vesicles. The proper
transport of proteins to the MVB interior depends on the
specific ubiquitination of cargo, and the recognition and
sorting of ubiquitinated cargo to endosomal organelles.38
During invagination or budding, the outer MVB membrane is
thought to trap receptors in the MVB interior and to promote
their subsequent degradation in the more acidic environ-
ment of inner vesicles of MVBs and lysosomes. MVBs were
also reported to be important vesicles in retrograde trans-
port, as they can carry cargo from the neuronal terminals to
the cell body for signaling and/or degradation in lyso-
somes.39 The Ab42 labeling of endosomal organelles,
including MVBs, by immuno-EM has been reported by other
groups,40 and has also been reported by more standard
immunofluorescent and immunohistochemical microscopy
in neurons in culture36 and the brain.41
Immuno-EM revealed that Ab42 did not co-localize with
APP using either APP N- or C-terminal fragments (CTFs),
which further precludes the cross-reactivity of the Ab42
antibody to full-length APP and/or APP CTFs.14 It is
important to note that the immuno-labeling of Ab42 was not
observed in neurons of the well-established APP knockout
mouse brain.42 Further, the monoclonal Ab42 antibody,
MBC42, used prominently in the first immuno-EM study,
was shown to bind Ab42 by Western blotting, but not to
bind to Ab40, APP, or APP fragments.14
Neurodegeneration
Prior to plaque formation, Ab42 accumulation was found to
increase with aging, particularly in the endosomes and
related vesicles within the distal axons and dendrites

Figure 3 The ultrastructural localization of Ab42 in neurons of AD transgenic mouse brain. (a) Prominent gold-labeled Ab42 particles are
observed within a vesicular-form in the neuronal perikaryon in the cortex of a 13-month-old 3xTg mouse brain using the AB5078P antibody.
The gold-labeled Ab42 particles are localized inside of the plasma membrane (black arrows) of a neuron. (b) A higher magnification of the
boxed area in Fig. 3a. The higher magnification image shows the gold-labeled Ab42 particles, which are associated with the outer
membrane of an MVB (arrowheads) and small vesicles ( ) close to a mitochondrion; no gold-labeling is evident in the mitochondrion. The
plasma membrane is shown in Fig. 3a by black arrows. Abbreviations: MVB, multivesicular body; mit, mitochondrion; N, nucleus. Scale bars:
2 mm (a), 500 nm (b).

© 2017 Japanese Society of Pathology and John Wiley & Sons Australia, Ltd
 Intraneuronal accumulation of b-amyloid 189

Figure 4 The intracellular localization of Ab42 in the human AD brain observed by immuno-EM. (a) The accumulation of gold-labeled
vesicular-shaped Ab42 is evident in the subcellular region in the cortical brain area of human AD by labeling with the MBC42 antibody. (b,
c) A higher magnification immuno-EM image shows that the gold-labeled Ab42 particles are associated with the outer membrane of an MVB
(arrowheads) and small vesicles in the subcellular region (b) and in neurites (c), while no gold-labeled particles are evident in the Golgi
apparatus or the mitochondrion close to the MVB. The MVB is darker than normal in the human AD brain. A higher magnification view of the
MVB reveals the characteristic small intravesicular vesicles. Occasional gold-labeled particles are attached to the small clear vesicles, and
gold-labeled particles are also found in poorly identifiable locations. (d) In these distended processes close to the post-synaptic density ( ),
gold-labeled Ab42 particles are associated with dark fibril-like material that is reminiscent in shape of MVBs (arrowheads). Abbreviations:
MVB, multivesicular body; G, Golgi apparatus; mit, mitochondrion; N, nucleus. Scale bars: 2 mm (a), 500 nm (b–d).

(neurites), and their pre- and post-synaptic compartments,
in AD transgenic mice (Tg2576 harboring the FAD Swedish
mutation in APP). At times the marked accumulation of
Ab42 was observed in disrupted MVBs that were associ-
ated with intraneuronal pathology.14 Ab42 gold-particles
also assembled in clusters reminiscent of MVBs, an in
endosomal vesicle within the distal neurites (Fig. 4c), and
EM revealed synaptic compartments that were suggestive
of degeneration, such as distended processes and dark
fibril-like material (Fig. 4d). In the human AD brain Ab42
accumulation could also be observed, which is reminiscent
of a diffuse plaque (Fig. 5a). Within this accumulation, Ab42
gold-particles are associated with disrupted, swollen den-
drites containing electron-dense material and abnormally
stacked membranes, with the absence of normal cytoskele-
tal organelles (which are normally contained within neurites)
(Fig. 5b,c). These morphological alterations are associated
with the prominent accumulation of Ab42 within the
disrupted neurites and are consistent with abnormal synap-
tic function. While Ab42 levels rise markedly prior to and
then dramatically with plaque formation, these immuno-EM
studies provided evidence that plaque can originate as
remnants of degenerating neurites. These data were cor-
roborated as important also for the human disease by our
analogous findings in the examination of human AD biopsy
brain tissue.14
Oligomers
Soluble Ab also accumulates intracellularly, and then
appears to gradually change to insoluble Ab, which could
then impair cellular functions. Some investigators have
suggested that intracellular soluble Ab, oligomers or proto-
fibrils, are the critical neurotoxic entity in AD.43
Moreover, a subsequent immuno-EM study demonstrated
that the intraneuronal accumulation of higher molecular
weight Ab42 oligomers was invariably associated with

© 2017 Japanese Society of Pathology and John Wiley & Sons Australia, Ltd
190 R. H. Takahashi et al.
Figure 5 Ab42 accumulation reminiscent of a diffuse plaque in
the human AD brain. (a) Ab42 gold-particles are observed to
accumulate diffusely as clusters under lower magnification. The
distribution of gold-labeled Ab42 particles is similar to the diffuse
plaques observed by light microscopy in areas of brain without
neuron cell bodies, but rather distal dendrites and axons. (b, c) At
higher magnification substantial amounts of gold-labeled Ab42
particles are found within a disrupted, swollen dendrite containing
electron-dense material and abnormally-stacked membranes in the
absence of normal cytoskeletal organelles, which are indicative of
degenerative neurites. The same axons in Fig. 5a are observed
under higher magnification (b: Ax1, c: Ax2). Scale bars: 2 mm (a),
500 nm (b, c).
neuritic degeneration, even prior to plaques, in vulnerable
distal neurites and synaptic compartments in the brains of
AD transgenic mice and in human AD.44 Cumulative data
on the intraneuronal accumulation of Ab supports the
hypothesis that increased levels of Ab within the neurites
and synapses leads to their dysfunction and then destruc-
tion. After the destruction of numerous neurites and synap-
ses, amorphous remnants may be further shaped as
plaques by activated microglia.45 Microglia may contribute
to the formation of amyloid plaques and other AD
pathologies.
Intracellular Ab and microtubule proteins
Tau
Besides amyloid plaques, NFTs are the other well-known
neuropathological hallmark of AD. The relationship between
Ab and tau remains to be elucidated. It has been reported
© 2017 Japanese Society of Pathology and John Wiley & Sons Australia, Ltd
that hyperphosphorylated tau can be observed within some
of the dystrophic neurites around plaques in APP mutant
transgenic mice and in the brains of humans with AD.46,47
Dual immunofluorescence and dual immuno-EM revealed
that dystrophic neurites around plaques showed the co-
localization of hyperphosphorylated tau with Ab42.47
Tau mutant transgenic mice crossed with APP mutant
Tg2576 mice48 or tau mutant mice receiving a cerebral
injection of Ab49 both showed enhanced tau pathology. In
human AD or DS brains with early AD changes, the
intraneuronal accumulation of Ab42 in CA1 pyramidal cell
bodies preceded hyperphosphorylation of tau.12,50 In
3xTg-AD mice with mutations in APP, tau and presenilin,
the intraneuronal accumulation of Ab in the pyramidal cell
bodies preceded tau hyperphosphorylation and tau pathol-
ogy.13 Since 3xTg-AD mice develop early Ab accumulation
in the CA1 hippocampal neurons and later tau pathologies,
the distal apical dendrites in the stratum lacunosum-
moleculare (SLM) of CA1 hippocampuses were selectively
investigated by immuno-EM.47 Remarkably, an early in-
crease in Ab42 levels and phosphorylated tau staining with
the well-established antibody AT8, was observed concomi-
tantly in the SLM by dual immunofluorescence. Dual
immuno-EM confirmed that hyperphosphorylated tau was
specifically evident in CA1 distal dendrites that showed
marked accumulation of Ab42 in their post-synaptic com-
partments in the SLM.47 Tau, which normally localizes to
the axons, presents with early somatodendritic mislocaliza-
tion and hyperphosphorylation concomitant with aberrant
accumulation of Ab in post-synapses.
The implications of intraneuronal Ab include insights into
a potential link between the early pathologies of Ab and tau,
which were formerly considered to be separate.
MAP2
It has been suggested that hyperphosphorylated tau dis-
rupts microtubules, resulting in the attenuation of microtu-
bule-associated proteins (MAPs).51 The accumulation and
oligomerization of Ab42 peptides in neurons are associated
with subcellular pathology, including reduced levels or a
lack of MAPs.14,52 Since the loss of synapses is considered
to be the factor that is most correlated with the cognitive
decline in AD rather than amyloid plaques or NFTs, the
accumulation of Ab peptides within the synapses and the
associated structural alterations in MAPs is significant.6,7
We previously reported that the localized accumulation of
Ab42 peptides in dendrites is associated with early pathol-
ogy of MAP2, which is an important MAP in dendrites.53
Again taking advantage of the well-defined anatomy of the
hippocampus, we revealed the accumulation of Ab42
peptides and the concomitant reduction of MAP2 in den-
drites of Tg2576 mouse brain occurs with aging, focusing
on the SLM of the hippocampal CA1 region. The SLM

region mainly contains distal dendrites from the CA1
pyramidal cells and their associated synaptic compart-
ments. An increase in immunoreactivity of the Ab42 peptide
correlated with the decrease of MAP2 in the SLM of Tg2576
mice with aging. We revealed a similar reduction of MAP2
in the stratum radiatum (SR) region.53 In the SR region of
aging Tg2576 mice, dendrites also appeared sparser and
reduced in diameter in comparison to the same region in
age-matched wild-type mice. This is consistent with several
previous studies, which demonstrated reduced dendritic
architecture in APP mutant transgenic mice.53–56 In agree-
ment with these observations under light microscopy, we
observed a correlation between the increased accumulation
of Ab42 peptides and reduced MAP2-immunoreactivity in
the dendrites by dual-labeling immuno-EM of Ab42 peptides
and MAP. In the Tg2576 mouse brain, postsynaptic com-
partments with no appreciable Ab42 peptide labeling
showed strong MAP2 labeling; those with intermediate
Ab42 peptide labeling showed intermediate MAP2 labeling;
and those with strong Ab42 peptide labeling showed little
MAP2 labeling. We also observed the marked accumulation
of Ab42 peptides in the degenerated dendrites and axon
terminals, which lacked any clear cytoskeletal architecture.
These images support that the intracellular accumulation
of Ab42 peptides is associated with the reduction and
degeneration of microtubule proteins.
Intracellular and extracellular Ab
The intraneuronal Ab hypothesis for the pathogenesis of
AD may not yet have as wide support as the established
extracellular Ab hypothesis. The current evidence supports
the hypothesis that both extracellular and intracellular Ab
are important in the pathogenesis of AD. It was previously
reported that extracellular Ab42 led to some internalization
by neurons, followed by the marked generation of new Ab
within neurons.57 It is therefore possible that extracellular
Ab can accelerate the aggregation of intracellular Ab after
neuritic degeneration.4,58 Degenerating neurites and synap-
ses may release newly generated intracellular Ab into the
extracellular spaces, and then this AD pathology may be
propagated extracellularly to the adjacent neuronal pro-
cesses. Thus, extracellular Ab can influence intracellular
Ab, and vice versa.
CONCLUSION
It was previously stated that AD is characterized by
extracellular Ab plaques and intracellular neurofibrillary
tangles. Evidence of intraneuronal Ab, which has now been
reported by many groups, suggests that this previous
statement should be changed. As with tau aggregation, Ab
© 2017 Japanese Society of Pathology and John Wiley & Sons Australia, Ltd
Intraneuronal accumulation of b-amyloid 191
accumulation also begins intracellularly and ends up extra-
cellularly following neuritic degeneration. The early accumu-
lation of aberrant Ab within processes and synaptic
compartments is correlated with early synaptic dysfunction
in AD. Oligomerization appears to require the accumulation
of Ab in the dystrophic and degenerating neuronal pro-
cesses and synapses. Intracellular soluble Ab oligomers
may better reflect the cognitive decline in AD patients. While
it is important to determine how Ab originally accumulates,
plaques are increasingly viewed as tombstones. That
plaques eventually do not grow in size, but instead become
compact, might inhibit the extracellular spread of Ab toxicity
and/or reduce the amount of soluble oligomeric Ab that is
available to induce local damage.
AD is a complicated disease that is affected by aging and
which affects memory and synapses. Fundamental age-
related processes, such as oxidative stress and other
factors that are injurious to the brain, such as vascular
disease, appear to be important modulators of the accumu-
lation of Ab. Genetic studies also show that numerous
genes are related to AD risks, in particular apolipoprotein E
(APOE).59 Investigations to elucidate the mechanism by
which Ab accumulation impairs the synapse, neuron and
brain systems appears to be important for research into
effective therapies for AD.
ACKNOWLEDGMENTS
We appreciate the assistance of Teresa. A Milner, PhD,
with research and writing this review article. Reisuke
Takahashi has been announced as the winner of The
Japanese Society of Pathology; Pathology Research Award
in 2014.
DISCLOSURE STATEMENT
None declared
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