The edition · Neurology
Outside trials, lecanemab's ARIA risk tracked APOE4 and microbleeds, with no measurable cognitive signal
Real-world data sharpen who is at risk on anti-amyloid therapy, early rhythm control after AF-related stroke looks promising, and pregnancy may not need to exclude thrombolysis.
The edition in brief
A meta-analysis of 37 real-world lecanemab studies (Journal of Neurology, 21 October) found ARIA in 15.1% overall, 34.1% of APOE4 homozygotes and 11.0% of non-carriers; baseline microbleeds roughly doubled any-ARIA rates. Symptomatic ARIA was 1.3%. Amyloid PET fell, but uncontrolled cognitive scores showed no significant change beyond an early small MoCA shift. A Japanese claims cohort of 14,355 older adults with AF-related ischaemic stroke (Neurology, 21 October) found early rhythm control within eight weeks was associated with fewer recurrent strokes or systemic emboli (HR 0.56) and lower mortality, though only 268 received it and the design is observational. In the ARIC cohort (Neurology, 16 October), higher plasma p-tau181 in midlife was associated with faster memory decline beginning two decades later. A systematic review of 216 pregnant patients given thrombolytics (Neurology, 30 October) found no excess symptomatic intracerebral haemorrhage compared with young non-pregnant patients; six of 32 fetal deaths were judged likely related to treatment. The pearl covers what to check before anti-amyloid therapy.
Real-world lecanemab: ARIA in about one in seven, one in three for APOE4 homozygotes
Select and counsel lecanemab patients by APOE4 status and baseline microbleeds, which drove ARIA risk outside trials.
Early rhythm control after AF-related stroke was linked to fewer recurrences
Consider discussing early rhythm control with cardiology after AF-related stroke, alongside anticoagulation.
Midlife p-tau181 was linked to memory decline two decades later
Plasma p-tau rises long before symptoms, but testing healthy middle-aged adults has no clinical use yet.
Before anti-amyloid therapy: genotype, MRI and anticoagulants
Check APOE4 status, a baseline MRI and anticoagulant use before any anti-amyloid infusion.
Thrombolysis in pregnancy showed no excess maternal bleeding in pooled cases
Consider thrombolysis for disabling stroke in pregnancy; maternal bleeding risk was not higher in pooled cases.
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