Multiregional single-cell profiling reveals shared and specialized cellular vulnerability in Alzheimer's disease
Alzheimers disease (AD) is defined and staged by the stereotyped, progressive accumulation of amyloid-beta (A{beta}) plaques and hyperphosphorylated tau (pTau) tangles across brain regions. These regions differ substantially in their architecture and function but share largely conserved cellular composition, with some regional specialization. As pathology accumulates, specific neurons are lost and non-neuronal cells shift toward disease-associated states, but whether the cell types affected in any one region are the same across the others has remained unclear. Here we extended the Seattle Alzheimers Disease Brain Cell Atlas (SEA-AD) to ten neo- and allocortical regions spanning the cortical arc of canonical AD staging, profiling approximately seven million nuclei from 84 donors with single-nucleus RNA-seq, ATAC-seq, and Multiome alongside quantitative neuropathology and whole-genome sequencing. Nuclei were mapped to an expanded BRAIN Initiative reference taxonomy of 207 cell types, and a hierarchical pseudo-progression framework derived continuous, donor-level measures of AD pathological burden within each region and across the brain by jointly modeling A{beta} and pTau. Cellular changes were both highly selective and strikingly consistent: only [~]30% of cell types shifted in relative abundance, but those that did changed in a coherent direction across regions. Specific subsets of Sst, Lamp5, Vip, Sncg, and Pvalb inhibitory interneurons and myelinating oligodendrocytes were lost earliest in preclinical donors with minimal pathology, alongside initial emergence of AD-associated microglia; loss of L2/3 and selected deep-layer excitatory types, sharper microglial increases, and reactive astrocyte emergence followed in later-stage donors. Regionally specialized populations were also vulnerable, including expected allocortical types and, unexpectedly, primary visual cortex (V1C)-specialized layer 4 (L4 IT) excitatory neurons and intermixed Sst and Pvalb interneurons. Key changes replicated across three independent cohorts encompassing over 700 additional donors. We examined two complementary vulnerable populations in mechanistic detail: regionally specialized V1C L4 IT neurons lost late despite being widely considered resilient, and pan-cortical Sst interneurons lost earliest in disease. Applying a multi-agentic AI workflow that constructed literature-grounded hypotheses from differential expression to L4 IT neurons nominated hyperexcitability, mediated in part by high NMDA receptor expression, as a convergent vulnerability phenotype. Vulnerable Sst interneurons converged on hyperexcitability through partly distinct pathways, and were enriched for expression of AD GWAS-prioritized genes, linking their vulnerability to the genetic architecture of AD. These data, available at SEA-AD.org, provide a multiregional framework for the community to explore the molecular and cellular changes of AD progression.