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Participants underwent baseline assessments including olfactory tests, neuropsychological evaluations, the Movement Disorders Society\u2013Unified Parkinson's Disease Rating Scale, 3T brain MRI, and <jats:sup>18<\/jats:sup>F\u2010FP\u2010CIT PET scans. Voxel\u2010based morphometry (VBM) was performed to identify regions of atrophy in iRBD, and volumes of relevant olfactory\u2010related regions of interest (ROI) were estimated. Subgroups of patients underwent repeated volumetric MRI and resting\u2010state functional MRI (fMRI) scans after four\u2009years.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>A total of 51 iRBD patients were included, with 20 of them converting to synucleinopathy (mean time to conversion 3.08\u2009years). Baseline VBM analysis revealed atrophy in the right olfactory cortex and gyrus rectus in iRBD. Subsequent ROI comparisons with controls showed atrophy in the amygdala. These olfactory\u2010related atrophies tended to be associated with worse depression, anxiety, and urinary problems in iRBD. Amygdala <jats:sup>18<\/jats:sup>F\u2010FP\u2010CIT uptake tended to be reduced in iRBD patients with hyposmia (nonsignificant after multiple comparison correction) and correlated with urinary problems. Resting\u2010state fMRI of 23 patients and 32 controls revealed multiple clusters with aberrant olfactory\u2010related functional connectivity. Hypoconnectivity between the putamen and olfactory cortex was associated with mild parkinsonian signs in iRBD. Longitudinal analysis of volumetric volumetric MRI in 22 iRBD patients demonstrated four\u2010year progression of olfactory\u2010related atrophy. Cox regression analysis revealed that this atrophy significantly predicted phenoconversion.<\/jats:p><\/jats:sec><jats:sec><jats:title>Interpretation<\/jats:title><jats:p>Progressive atrophy of central olfactory structures may be a potential indicator of Lewy body disease progression in iRBD.<\/jats:p><\/jats:sec>","DOI":"10.1002\/acn3.51905","type":"journal-article","created":{"date-parts":[[2023,9,25]],"date-time":"2023-09-25T07:10:44Z","timestamp":1695625844000},"page":"2192-2207","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":18,"title":["Brain olfactory\u2010related atrophy in isolated rapid eye movement sleep behavior disorder"],"prefix":"10.1002","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5457-7348","authenticated-orcid":false,"given":"Kyung Ah","family":"Woo","sequence":"first","affiliation":[{"name":"Department of Neurology Seoul Metropolitan Government\u2013Seoul National University Boramae 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