The accumulation of amyloid  peptide(1-42) (A(1-42)) in extracellular plaques is one of the pathological hallmarks of Alzheimer disease (AD). Several studies have suggested that cellular reuptake of A(1-42) may be a crucial step in its cytotoxicity, but the uptake mechanism is not yet understood. A may be present in an aggregated form prior to cellular uptake. Alternatively, monomeric peptide may enter the endocytic pathway and conditions in the endocytic compartments may induce the aggregation process. Our study aims to answer the question whether aggregate formation is a prerequisite or a consequence of A endocytosis. We visualized aggregate formation of fluorescently labeled A(1-42) and tracked its internalization by human neuroblastoma cells and neurons. -Sheet-rich A(1-42) aggregates entered the cells at low nanomolar concentration of A(1-42). In contrast, monomer uptake faced a concentration threshold and occurred only at concentrations and time scales that allowed A(1-42) aggregates to form. By uncoupling membrane binding from internalization, we found that A(1-42) monomers bound rapidly to the plasma membrane and formed aggregates there. These structures were subsequently taken up and accumulated in endocytic vesicles. This process correlated with metabolic inhibition. Our data therefore imply that the formation of -sheet-rich aggregates is a prerequisite for A(1-42) uptake and cytotoxicity.One of the pathological hallmarks of Alzheimer disease (AD) 2 is the presence of extracellular plaques composed mainly of 42-amino acid amyloid  peptide (A(1-42)) (1). The small hydrophobic A(1-42) peptide, which is generated by proteolytic cleavage of the amyloid precursor protein, is released as a monomer from the plasma membrane into extracellular space, and tends to aggregate spontaneously into oligomeric, protofibrillar, and fibrillar assemblies (2-4). Oligomeric species of A(1-42) are tightly linked to AD pathogenesis and are presumed to be the cause of neuronal damage (5). Several studies have suggested that the reuptake of extracellular A(1-42) into neurons may lead to the formation of intracellular aggregates, resulting in neuronal damage and neurotoxicity (6 -8). Endocytosis of misfolded proteins has also been observed in cell models of the tau protein, ␣-synuclein and huntingtin (9, 10), and recent evidence suggests that it may be the initial step in the replication of the misfolded protein structures by prion mechanisms (10 -14). Several possible endocytic pathways, such as macropinocytosis and receptor-mediated endocytosis, have been discussed for A and other misfolded protein aggregates (15-19). However, our understanding of the connection between aggregation and cytotoxicity is still limited. It has not been conclusively determined how and when the A(1-42) peptide becomes toxic, whether A aggregates prior to internalization or during the internalization process and, if so, in which intracellular compartments the aggregates form. Elucidating the connection between aggregation and i...