Age-Related Decline in BBB Function is More Pronounced in Males than Females

Reviewer #1 (Public Review):

Summary:

This work revealed an important finding that the blood-brain barrier (BBB) functionality changes with age and is more pronounced in males. The authors applied a non-invasive, contrast-agent-free approach of MRI called diffusion-prepared arterial spin labeling (DP-pCASL) to a large cohort of healthy human volunteers. DP-pCASL works by tracking the movement of magnetically labeled water (spins) in blood as it perfuses brain tissue. It probes the molecular diffusion of water, which is sensitive to microstructural barriers, and characterizes the signal coming from fast-moving spins as blood and slow-moving spins as tissue, using different diffusion gradients (b-values). This differentiation is then used to assess the water exchange rates (kw) across the BBB, which acts as a marker for BBB functionality. The main finding of the authors is that kw decreases with age, and in some brain regions, kw decreases faster in males. The neuroprotective role of the female sex hormone, estrogen, on BBB function is discussed as one of the explanations for this finding, supported by literature. The study also shows that BBB function remains stable until the early 60s and remarkably decreases thereafter.

Strengths:

The two main strengths of the study are the MRI method used and the amount of data. The authors employed a contrast-agent-free MRI method called ASL, which offers the opportunity to repeat such experiments multiple times without any health risk - a significant advantage of ASL. Since ASL is an emerging field that requires further exploration and testing, a study evaluating blood-brain barrier functionality is of great importance. The authors utilized a large dataset of healthy humans, where volunteer data from various studies were combined to create a substantial pool. This strategy is effective for statistically evaluating differences in age and gender.

Weaknesses:

Gender-related differences are only present in some brain regions, not in the whole brain or gray matter - which is usually the assumption unless stated otherwise. From the title, this was not clear. Including simulations could increase readers' understanding related to model fitting and the interdependence of parameters, if present. The discussion follows a clear line of argument supported by literature; however, focusing solely on AQP4 channels and missing a critical consideration of other known/proven changes in transport mechanisms through the BBB and their effects substantially weakens the discussion.

Reviewer #2 (Public Review):

Summary:

This study used a novel diffusion-weighted pseudo-continuous arterial spin labelling (pCASL) technique to simultaneously explore age- and sex-related differences in brain tissue perfusion (i.e., cerebral blood flow (CBF) & arterial transit time (ATT) - a measure of CBF delivery to brain tissue) and blood-brain barrier (BBB) function, measured as the water exchange (kw) across the BBB. While age- and sex-related effects on CBF are well known, this study provides new insights to support the growing evidence of these important factors in cerebrovascular health, particularly in BBB function. Across the brain, the decline in CBF and BBB function (kw) and elevation in ATT were reported in older adults, after the age of 60, and more so in males compared to females. This was also evident in key cognitive regions including the insular, prefrontal, and medial temporal regions, stressing the consideration of age and sex in these brain physiological assessments.

Strengths:

Simultaneous assessment of CBF with BBB along with transit time and at the voxel-level helped elucidate the brain's vulnerability to age and sex-effects. It is apparent that the investigators carefully designed this study to assess regional associations of age and sex with attention to exploring potential non-linear effects.

Weaknesses:

It appears that no brain region showed concurrent CBF and BBB dysfunction (kw), based on the results reported in the main manuscript and supplemental information. Was an association analysis between CBF and kw performed? There is a potential effect of the level of formal education on CBF (PMID: 12633147; 15534055), which could have been considered and accounted for as well, especially for a cohort with stated diversity (age, race, sex).