Investigating TMS–evoked potentials as a biomarker in the Alzheimer’s dementia spectrum

The use of biomarkers in Alzheimer’s disease (AD) has been fundamental for early diagnosis. Currently, biomarkers in use for clinical purposes assess the presence or quantify molecular markers of the disease, i.e., ß-amyloid or Tau protein, or quantify the medial-temporal atrophy caused by the disease. Neuroimaging techniques such as structural, functional and diffusion magnetic resonance imaging and positron-emission tomography have been essential in showing how Alzheimer’s disease pathology spreads within resting-state networks, ultimately impairing their functioning. However, neuroimaging techniques provide indirect measures that do not capture the physiological status of the affected cerebral tissues. Neurophysiological techniques, such as transcranial magnetic stimulation (TMS) and electroencephalography (EEG), are established techniques that can be used in combination to capture both the status of a target cortex and its connections through the brain through TMS-evoked potentials (TEPs). Therefore, TEPs have gained momentum as a possible novel AD biomarker. In the last decade, a specific five-phase framework for the development of novel AD biomarkers has been developed, with the goal of standardizing the steps needed to bring a measure from research to clinical practice. Phase 1 for TEPs, concerning the rationale of using them as a biomarker in AD, could be considered completed, while most of the research is now focusing on phase 2. In this phase, the ability of a measure to distinguish between healthy elderly individuals and AD patients is assessed, together with the reliability and replicability of the measure. In this thesis, we address several aims of phase 2 by testing whether early TEP responses could be used to differentiate between healthy elderly, prodromal, late-onset, and early-onset AD. Then, we test the sensitivity of TEPs to different preprocessing pipelines to assess their robustness. Third, we review the current literature on TEP reliability and describe which tests are missing for this measure to enter clinical practice. Finally, we propose a tool to promote replicability in noninvasive brain stimulation paradigms, such as TMS–EEG. We conclude that despite a solid rationale for the employment of TEPs in clinical practice, several methodological issues need to be addressed before TEPs can gain clinical utility.