Announcer:
Welcome to CME on ReachMD. This episode is part of our MinuteCE curriculum.

Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements as well as the learning objectives.

Dr. Bateman:
Welcome to Clinical Conundrums: Navigating Case Scenarios in Your Own Practice Setting, where we will cover quick and challenging cases related to amyloid-related imaging abnormalities, or ARIA, management. I'm Dr. Trey Bateman, and here with me today are doctors Danya Khoujah and Joy Snider. Let's dive into our case.

Dr. Khoujah: 
Sarah is a 72-year-old female who presents to the emergency department with new-onset severe headache, confusion, and blurred vision. She has been on lecanemab for 4 months, and was recently diagnosed with mild ARIA-E on routine MRI. An urgent MRI reveals extensive edema and evidence of hemorrhagic transformation, consistent with severe ARIA. The clinical team must now decide on immediate and long-term management strategies.

Dr. Bateman: 
Let's explore how to approach immediate treatment decisions, inpatient care, and long-term follow-up strategies.

Dr. Khoujah: 
So first things first, we need to manage her headache. And we would do that the same way we would manage a headache in any patient who's presenting with any other complaint. We would start with simpler things like acetaminophen, metoclopramide, droperidol, and so on, as for managing the headache itself. Obviously, knowing the increased bleeding risk, this would not be a person we would give something that would increase their bleeding risk further, like NSAIDs.

As for the confusion, we would manage that as we would manage any patient who's presenting with altered mental status by providing a safe environment, constant redirection, having a sitter if need be, or even better, the family member.

While we're stabilizing the patient, we need to keep in mind where the end goal is. Does this patient need to be admitted? Or can they be discharged safely? As we said earlier in this case, this is a person with severe ARIA. And the way we decide if it's severe ARIA depends on the symptomatology, but also on the radiological findings. We call it severe ARIA-E in a person who has one or more locations of edema that's 10 cm or more. And that is how we decided that that patient has severe ARIA, and therefore she would need to be admitted, because all patients with severe ARIA need admission. Steroid therapy as well is indicated in all of those patients.

Dr. Snider: 
Great. I appreciate that, Danya. And I think you right on target. The other sort of complicating factors here are distinguishing the radiographic severity from the clinical severity, which we try to do. And sometimes they're congruent like in this patient, and sometimes they're not.

The question about steroid therapy is we certainly use it when we have severe symptomatic ARIA, not always with the asymptomatic. And of course, in patients with dementia, it can often be complicated by behavior complications. So that's another thing we really have to look out for. 

And the other thing this case points out is that we can see the ARIA first when it's mild and asymptomatic, but then it can subsequently become symptomatic

So really, following these folks closely is important, as well as having those open discussions with the family, and those can be difficult when the family is highly committed to continuing therapy, and as clinicians, we know it's not a good idea, and we'll put them in increased risk. So that's a tough discussion to have, but sometimes we do have to have it. So these are challenging cases. I guess, fortunately, the key point is they're quite unusual. Less than 3% of folks get this severe, symptomatic ARIA, but it does happen. And if you treat folks with these antibodies, it probably will come up. So it's great to think about it in advance and then involve the whole team in trying to address it with the family.

Dr. Bateman: 
They’re all great points. It sounds like the initial presentation when folks are coming in with these acute neurological syndromes, confusion, headache, some of the management is just the same thing that you would do for folks that are coming in with headache and confusion anyway, just good basic management of those conditions, while taking into account that there are additional considerations in somebody with ARIA. So, for instance, avoiding things that might increase the bleeding risk. And then the decision on treating, for how long, and very close monitoring with these folks with severe ARIA, which again, thankfully is quite rare, are all important considerations.

Thank you for this insightful discussion. To our viewers, be sure to explore our other episodes for more in-depth insights into the nuances of ARIA management. Thank you for joining us.

Announcer:
You have been listening to CME on ReachMD.  This activity is jointly provided by Medical Education Resources (MER) and Efficient LLC and is part of our MinuteCE curriculum.

To receive your free CME credit, or to download this activity, go to ReachMD.com/CME. Thank you for listening.