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4. DISCUSSION

4.5 General conclusions

In conclusion, fMRI has a clear potential in a clinical setting. Despite the limitations of our findings, fMRI should not be dismissed in favor of markers of neuropathology in future studies.

Instead, additional efforts towards a better standardization of preprocessing should be undertaken, as well as validation in bigger cohorts, so that the utility of fMRI can be recognized in a clinical setting. Indeed, the use of task-based and RS fMRI to characterize brain networks brings additional information that can be very valuable in the context of early diagnosis. Crucially, fMRI can inform us about compensation mechanisms, early in the course of the disease, prior to the appearance of behavioral impairment. This way, it can potentially be a good predictor of time to conversion, and can help us to better understand the inter-individual variability for the response to treatment. Moreover, we are eager to see the relationship between task and RS fMRI being investigated across the AD spectrum in larger cohorts. Furthermore, a longitudinal analysis could show whether the strength of this link is stable across time, and along a disease continuum.

We stress the urgency of finding a multimodal marker that could be used for screening, and/or to identify patients with MCI who will convert in AD. The integration of information coming from multiple modalities is essential to ascertain as much as possible the early diagnosis, but also the prognosis of an individual. The combination of several modalities (e.g., fMRI coupled with markers of neuropathology and/or neurodegeneration) can also improve our understanding of interindividual variability in terms of function, behavior and disease (Yeo and Eickhoff 2016).

Concomitant with a longitudinal design, multimodality will allow to advance our understanding

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of mechanisms of neural plasticity and cognitive reserve, in order to better understand the « lag » between the first signs of neuropathology and the first clinical symptoms.

Our conclusions are limited by the possible heterogeneity in the aetiology of MCI patients, who may not necessarily go on to develop AD (Petersen, Doody et al. 2001). Unfortunately, we lacked biomarkers to ascertain the prognosis of our MCI cohort. However, our strict inclusion criteria (only the amnestic subtype) and long follow-up (8 years for some of our participants!) has allowed us to dismiss alternative prognoses. Our sample size is relatively small, especially when compared with multisite datasets such as ADNI. However, even such cohorts might not be large enough to properly assess the extent of heterogeneity that exists across individuals. We may need to wait for studies with several thousands of patients to start seeing an integrative picture of a complex disease such as AD.

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