The relevance of magnetic resonance imaging in the era of Alzheimer’s disease biomarkers - Editorial

Sep 29, 2026

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Brain magnetic resonance imaging (MRI) provides detailed anatomical information that supports evaluation of neurodegenerative diseases, particularly Alzheimer’s disease (AD), by identifying patterns of atrophy. Because atrophy is a final common pathway and not highly specific, validated complementary tests have been developed to quantify β-amyloid, neuritic plaques, and tau, including amyloid and tau PET, cerebrospinal fluid measures, and plasma assays. The 2018 and 2024 Alzheimer’s Association diagnostic criteria consider MRI evaluation nonspecific for diagnosis.

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Editorial

MRI and atrophy in Alzheimer’s disease

Limitations of MRI specificity

Complementary biomarker tests

Diagnostic criteria in 2018 and 2024

Evidence from visual atrophy scales study

Clinical implications and screening use

Article published online: 2025-02-17 Editorial 1 The relevance of magnetic resonance imaging in the era of Alzheimer’s disease biomarkers Marcio Luiz Figueredo Balthazar 1 1 Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brazil. Arq. Neuro-Psiquiatr. 2025;83(1):s00451801863 . Brain magnetic resonance imaging (MRI) has revolutionized how we view neurological diseases, with a level of anatomical detail that has yet to be surpassed by anyother method. In several neurodegenerative diseases, and speciﬁcally in Alzheimer’s disease (AD), instead of acting to rule out other potential causes, such as cerebrovascular, tumors, or inﬂammatory diseases, MRI has come to play an essential role in identifying patterns of atrophy. Different visual scales of atrophy have been incorporated into clinical practice, and, in AD, scales of mesial temporal atrophy such as that proposed by Scheltens 1 and of atrophy of the entorhinal cortex and transentorhinal region (ERICA), proposed by Enkirch, have been frequently used, with reasonable accuracy, as tools to support clinical diagnostic decisions.2 However, the evolution of both research and diagnostic criteria has highlighted the importance of a more accurate diagnosis regarding the pathophysiology of the disease since atrophy is the ﬁnal common pathway of different neurodegenerative processes and, therefore, is not very speciﬁc. Thus, complementary tests that quantify β-amyloid peptide, neuritic plaques, and tau protein have been validated, such as amyloid positron emission tomography (PET), tau PET, the dosage of these proteins in the cerebrospinal ﬂuid and, more recently and still in the validation process, in the plasma. Thus, in the latest diagnostic criteria of the Alzheimer’s Association of 2018 and 2024, the MRI evaluation was considered nonspeciﬁc for the diagnosis.3,4 In the paper “Diagnosing preclinical and clinical Alzheimer’s disease with visual atrophy scales in clinician practice”, Socher et al. retrospectively evaluated the speciﬁcity, sensitivity, accuracy, and positive and negative predictive values of the medial temporal atrophy (MTA) and ERICA scales according to the amyloid PET (11-C PiB) result and clinical diagnosis (cognitively normal, mild cognitive impairment, and Alzheimer’s disease dementia).5 They found that the sensitivity of the ERICA score in the AD group according to amyloid PET status was 77.7%, with an accuracy of 67.7%. MTA sensitivity was 40.7%, and the score speciﬁcity Address for correspondence Marcio Luiz Figueredo Balthazar ([email: mbalth@unicamp.br](email: mbalth@unicamp.br)) received December 16, 2024 accepted December 19, 2024 DOI [https://doi.org/](https://doi.org/)[ ](https://doi.org/)10.1055/s-0045-1801863 . ISSN 0004-282X. was 50% for clinical diagnosis. In mild cognitive impairment (MCI), both the ERICA and MTA scores achieved similar performances with an accuracy of 􀀁 50%, with no differences in the visual analysis of cerebral atrophy. The ERICA score achieved moderate sensitivity at 70%, and the MTA score was more speciﬁc at 74%.5 Considering the group with normal cognition, both ERICA and MTA scores achieved low sensitivities in this study, but the MTA score had a greater speciﬁcity (91%) than the ERICA score (60%). The authors conclude that clinicians could use this visual analysis, mainly the ERICA score, to screen for AD inpatients with clinical dementia but not in asymptomatic or early stages without dementia.5 Although the sensitivity, speciﬁcity, and accuracy values of the scales in this study were relatively low, their use may still be essential in clinical practice. It is common to ﬁnd changes in these scales, even in people with initial symptoms. Furthermore, it is possible to quantify the volume of these structures more precisely using software (usually paid) available on the internet that deﬁnes, for example, the percentile in which a patient is

FAQs

Why is MRI important in Alzheimer’s disease evaluation?

MRI is important because it offers high anatomical detail and can identify characteristic patterns of atrophy, including mesial temporal atrophy and entorhinal cortex-related regions.

Why is MRI considered nonspecific in recent Alzheimer’s diagnostic criteria?

Atrophy is described as a final common pathway across different neurodegenerative processes, making it insufficiently specific for determining Alzheimer’s pathophysiology on its own.

How do visual atrophy scales perform compared with biomarker-based findings?

In the cited study, ERICA showed higher sensitivity in the AD group than MTA, while performance varied by clinical category; the authors conclude visual analysis, mainly ERICA, can help screen for AD in clinical dementia but not reliably in asymptomatic or early nondemented stages.

Sep 29, 2026

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