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Episode 4

Dr. Cabral:
Hi, I'm Dr. Cabral, here today with Dr. Weisman.

Stroke-like symptoms during anti-amyloid therapy require rapid but thoughtful evaluation. Dr. Weisman, how should clinicians approach patients receiving amyloid-targeting therapy who present with acute focal neurologic symptoms?

Dr. Weisman:
Carefully. Safety first because, well, the physician should really know the background here because what is happening, what could be happening under the surface, is that ARIA is a vascular event. Amyloid-related imaging abnormality itself is a vascular event and can produce focal neurologic problems that can be abrupt. So they should be aware that this could be a stroke mimic.

And they should also be aware of bad cases that have made a law that we don't use thrombolytics, especially in the first 6 months when ARIA is more prevalent and the vessels may be more friable, especially in the setting of an acute stroke, if it is an acute stroke plus ARIA because the things are not mutually exclusive. So basically, thrombolysis, especially in the first 6 months, I would say is a no-go. Should not be entertained.

Now, LVO, on the other hand, a large vessel occlusion, because we know that all the nerve cells are going to die distal to that, and there is no reason why endovascular therapy should not be given. That can be mechanically thrombectomized, so that would be another pathway.

So the pathway that's probably going to develop is no thrombolysis, CT angiogram. If LVO or anything remedial to mechanical thrombectomy, then go that pathway. After 6-ish months, then really caution, and maybe not. After a year, I might feel safe with it.

And then MRIs. So a lot of ERs have MRIs to discern ARIA versus a stroke. That could be used. But time is brain with Alzheimer's and stroke, so you're just going to lose time, and that's a tradeoff.

So it's a very difficult situation. And I guess, Dr. Cabral, what are you thinking?

Dr. Cabral:
I think one of the most important pieces of this is counseling the patient and treatment partner, which is usually often a spouse, that if you have these stroke-like symptoms and you go to the emergency department, you have to know that this could be ARIA, right? Or you may be having a real ischemic infarct or another vascular event, and basically it should be no TPA thrombolytics. I think maybe beyond 6 months even, and the emergency medicine is getting up to speed on this, so I think all of our teams are moving in the right direction.

Dr. Weisman:
Yeah, I think we nailed it. We'll see you next time.

Dr. Cabral:
See you next time.

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