Is it possible to prevent atrophy of key brain regions related to cognitive decline and Alzheimer's disease (AD)? One approach is to modify nongenetic risk factors, for instance by lowering elevated plasma homocysteine using B vitamins. In an initial, randomized controlled study on elderly subjects with increased dementia risk (mild cognitive impairment according to 2004 Petersen criteria), we showed that high-dose B-vitamin treatment (folic acid 0.8 mg, vitamin B6 20 mg, vitamin B12 0.5 mg) slowed shrinkage of the whole brain volume over 2 y. Here, we go further by demonstrating that B-vitamin treatment reduces, by as much as seven fold, the cerebral atrophy in those gray matter (GM) regions specifically vulnerable to the AD process, including the medial temporal lobe. In the placebo group, higher homocysteine levels at baseline are associated with faster GM atrophy, but this deleterious effect is largely prevented by B-vitamin treatment. We additionally show that the beneficial effect of B vitamins is confined to participants with high homocysteine (above the median, 11 μmol/L) and that, in these participants, a causal Bayesian network analysis indicates the following chain of events: B vitamins lower homocysteine, which directly leads to a decrease in GM atrophy, thereby slowing cognitive decline. Our results show that B-vitamin supplementation can slow the atrophy of specific brain regions that are a key component of the AD process and that are associated with cognitive decline. Further B-vitamin supplementation trials focusing on elderly subjets with high homocysteine levels are warranted to see if progression to dementia can be prevented.T he prevention of Alzheimer's disease (AD) is a major public health challenge, but several promising therapies targeting β-amyloid have failed in late-stage clinical trials (1). An alternative approach is to modify nongenetic risk factors and to treat people at risk of developing dementia before they develop the major symptoms (2, 3). Many cross-sectional and prospective studies have shown that raised levels of plasma total homocysteine (tHcy) are associated with cognitive impairment, AD, or vascular dementia (4-9), but randomized, controlled trials of tHcy-lowering treatment using B-vitamin supplementation have shown inconsistent results on cognitive function (10, 11). Factors such as dosage, vitamin combination, duration of treatment and the population treated possibly account for some of the discrepancies (10, 11). Another factor that may explain the discrepancies in these trials is baseline tHcy concentration: for instance, it has been found that subjects with modestly raised tHcy experience a beneficial effect of B-vitamin treatment on cognitive decline (12, 13).For trials with the aim of slowing progression of cognitive decline, the usual design includes neuropsychological assessments. Unfortunately, such testing is subject to short-term fluctuations, practice effects and intra-/interrater variability. In contrast, structural neuroimaging provides a robust way of as...