The central role of tau in Alzheimer’s disease: From neurofibrillary tangle maturation to the induction of cell death

The tau protein (τ) is one of the two hallmark proteins of Alzheimer's disease (AD) together with the amyloid β protein (Aβ). In contrast to Aβ, abnormally phosphorylated τ (p-τ) can also be found in non-AD tauopathies. In AD, p-τ is the main component of intraneuronal neurofibrillary tangles, which result from aggregation of abnormally phosphorylated and folded τ. In this review, we discuss the role of p-τ pathology in Alzheimer's disease considering neuropathological, biochemical, cellular, animal model, and clinical findings. We discuss the relationship between p-τ and other AD-related proteins such as Aβ and transactive response DNA-binding protein 43 (TDP-43). In light of the current state of knowledge, we conclude that p-τ aggregation known as primary age-related tauopathy (PART) may represent a prerequisite for the development of AD rather that a downstream effect of Aβ toxicity. However, Aβ as well as TDP-43 pathology appear to accelerate accumulation and propagation of p-τ pathology once initiated, ultimately leading to the full-blown picture of AD. In this context, τ seeds can induce granulovacuolar degeneration (GVD), AD-typical lesions in which the activated necrosome - required for the execution of necroptosis, a programmed form of cell death - can be found. Moreover, necrosome-exhibiting GVD is associated with a decreased neuronal density. Thus, we speculate that p-τ pathology is a major driver for neuron loss in AD via GVD-mediated necroptosis. Overall, p-τ seems to play a central role in AD as it appears to constitute a prerequisite for AD development which can then be accelerated by co-factors. This would fit in a probabilistic model of AD, in which the presence and severity of the respective co-factors such as Aβ, TDP-43, and others contribute separately to AD pathogenesis as probabilistic factors with a certain weight.