Increase in iron level has been reported in Alzheimer’s disease (AD) ^1,2, potentially receiving contributions from tau in tangles ¹ and amyloid-β (Aβ) plaques ³. In recent years, contribution of iron imaging using MRI is rapidly growing due its non-invasive nature and high spatial resolution. Among MRI modalities, susceptibility weighted imaging (SWI) has shown a promising reliability in visualizing iron deposits when compared to T2 or T2*-weighted images ⁴. However, the main shortcomings of measuring parenchymal iron with SWI are its qualitative measure and its sensitivity to both vascular iron (deoxygenated iron in vessels) and parenchymal iron (ferritin and hemosiderin). In the context of iron changes in AD, previous SWI studies were performed only on subjects with mild cognitive impairment (MCI) and reported non-overlapping findings with the literature ^5,6.In this study, an image processing pipeline was utilized to remove the presence of vascular iron (iron in blood vessels) and acquire a pseudo-quantitative iron estimate. A group-wise analysis was then performed to investigate the usefulness of SWI in identifying regional brain iron accumulation associated with AD.For this study, a subset of 120 cross-sectional scans comprised of 23 AD, 30 MCI and 67 healthy controls (HC) from the Australian Imaging Biomarkers and Lifestyle (AIBL) study were included (for detailed demographic information refer to Table 1).All subjects underwent an anatomical T1-weighted (T1W) and SWI. MRI data were acquired on a 3T Siemens TRIO scanner with a 12-channel head coil, where SWIs were automatically reconstructed online using the scanner system (software VB17). The 3D SWIs were obtained with 0.93×0.93 mm in-plane resolution and 1.75 mm slice thickness, repetition time/echo time of 27/20 msec, and flip angle 20°. The T1W data were parcellated into 45 gray-matter (GM) regions by segmentation propagation of an atlas database which had been previously parcellated using the Automated Anatomical Labeling (AAL) ⁷. Subsequently, a rigid alignment between the T1W and SWI images was used to propagate the parcellated regions.Given the uncalibrated nature of SWI and lack of specificity to parenchymal iron, the following steps were considered to acquire a pseudo-quantitative estimate of iron: (i) the non-uniform intensity variations caused by magnetic field inhomogeneities were corrected using the N4 bias field correction ⁸, (ii) the intensity of the bias-free SWI was scaled with respect to the mean value of cerebrospinal fluid (CSF) computed from the lateral ventricles, and (iii) a vessel mask was generated (by performing intensity thresholding and connected component analysis) and subtracted from the scaled-SWI in order to exclude large vessels.For a prospective regional analysis of SWI-iron, a robust mean value was computed for every cortical and deep GM regions by fitting a Gaussian-distribution in the histogram of all voxels within the region. The statistical effect of our hypothesis (iron accumulation across diagnostic groups) was evaluated using a multivariate general linear model (GLM) with SWI-iron as dependent variable and group and age as covariates. No significant group differences were found for sex or years of education, and therefore these were not controlled for. Iron-rich brain regions appear hypointense (low signal intensity i.e. darker) on SWI images and therefore lower SWI intensity indicates higher iron concentration.The differences in regional SWI-iron concentrations between HC, MCI and AD groups are presented in Fig. 1 and Fig. 2. Given that the cerebellum is not affected until the very late stage of AD, Fig. 1 confirmed no significant difference across HC, MCI and AD diagnostic groups. Compared to HC, significantly higher SWI-iron levels were observed in AD individuals (p<0.001) and MCI (p<0.05) in the middle Frontal lobe as well as combined Posterior Cingulate, Cuneus and Precuneus regions (Fig. 2).In the present work, we estimated brain iron level in HC, MCI and AD subjects using SWI analysis. We observed a stepwise increment in SWI-iron across clinical categories, consistent with iron accumulation with disease progression. Furthermore, the higher level of SWI-iron in the middle Frontal lobe and Precuneus but the cerebellum of AD individuals may be associated with the higher presence of Aβ plaques. This study suggests that ventricle normalized SWI may be a potential imaging biomarker of Alzheimer’s disease. However, further validation with quantitative iron measures (i.e. QSM and GRE T2*) is required to fully understand the association between normalized SWI intensities and the underlying susceptibility effect.