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Hampel H, Elhage A, Cho M, Apostolova LG, Nicoll JAR, Atri A. Amyloid-related imaging abnormalities (ARIA): radiological, biological and clinical characteristics. Brain 2023; 146:4414-4424. [PMID: 37280110 PMCID: PMC10629981 DOI: 10.1093/brain/awad188] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/03/2023] [Accepted: 05/05/2023] [Indexed: 06/08/2023] Open
Abstract
Excess accumulation and aggregation of toxic soluble and insoluble amyloid-β species in the brain are a major hallmark of Alzheimer's disease. Randomized clinical trials show reduced brain amyloid-β deposits using monoclonal antibodies that target amyloid-β and have identified MRI signal abnormalities called amyloid-related imaging abnormalities (ARIA) as possible spontaneous or treatment-related adverse events. This review provides a comprehensive state-of-the-art conceptual review of radiological features, clinical detection and classification challenges, pathophysiology, underlying biological mechanism(s) and risk factors/predictors associated with ARIA. We summarize the existing literature and current lines of evidence with ARIA-oedema/effusion (ARIA-E) and ARIA-haemosiderosis/microhaemorrhages (ARIA-H) seen across anti-amyloid clinical trials and therapeutic development. Both forms of ARIA may occur, often early, during anti-amyloid-β monoclonal antibody treatment. Across randomized controlled trials, most ARIA cases were asymptomatic. Symptomatic ARIA-E cases often occurred at higher doses and resolved within 3-4 months or upon treatment cessation. Apolipoprotein E haplotype and treatment dosage are major risk factors for ARIA-E and ARIA-H. Presence of any microhaemorrhage on baseline MRI increases the risk of ARIA. ARIA shares many clinical, biological and pathophysiological features with Alzheimer's disease and cerebral amyloid angiopathy. There is a great need to conceptually link the evident synergistic interplay associated with such underlying conditions to allow clinicians and researchers to further understand, deliberate and investigate on the combined effects of these multiple pathophysiological processes. Moreover, this review article aims to better assist clinicians in detection (either observed via symptoms or visually on MRI), management based on appropriate use recommendations, and general preparedness and awareness when ARIA are observed as well as researchers in the fundamental understanding of the various antibodies in development and their associated risks of ARIA. To facilitate ARIA detection in clinical trials and clinical practice, we recommend the implementation of standardized MRI protocols and rigorous reporting standards. With the availability of approved amyloid-β therapies in the clinic, standardized and rigorous clinical and radiological monitoring and management protocols are required to effectively detect, monitor, and manage ARIA in real-world clinical settings.
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Affiliation(s)
- Harald Hampel
- Eisai Inc., Alzheimer’s Disease and Brain Health, Nutley, NJ 07110, USA
| | - Aya Elhage
- Eisai Inc., Alzheimer’s Disease and Brain Health, Nutley, NJ 07110, USA
| | - Min Cho
- Eisai Inc., Alzheimer’s Disease and Brain Health, Nutley, NJ 07110, USA
| | - Liana G Apostolova
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - James A R Nicoll
- Division of Clinical Neurosciences, Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK
- Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Alireza Atri
- Banner Sun Health Research Institute, Banner Health, Sun City, AZ 85351, USA
- Center for Brain/Mind Medicine, Department of Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, USA
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Yaari R, Holdridge KC, Choi J, Donohue MC, Kantarci K, Jack CR, Zuk SM, Sims JR, Johnson KA, Aisen PS, Sperling RA. Amyloid-Related Imaging Abnormalities and Other MRI Findings in a Cognitively Unimpaired Population With and Without Cerebral Amyloid. J Prev Alzheimers Dis 2022; 9:617-624. [PMID: 36281665 PMCID: PMC10966506 DOI: 10.14283/jpad.2022.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Screening data from the Anti-Amyloid Treatment in Asymptomatic Alzheimer's Disease (A4) and Longitudinal Evaluation of Amyloid Risk and Neurodegeneration (LEARN) studies provide a unique opportunity to compare magnetic resonance imaging (MRI) findings such as amyloid-related imaging abnormalities (ARIA) in cognitively unimpaired elderly with and without elevated cerebral amyloid. OBJECTIVES To compare screening MRI findings, such as ARIA, in the cognitively unimpaired potential participants of a clinical trial with and without elevated cerebral amyloid. DESIGN Cross-sectional analysis of structural MRI findings in screening data from the A4 and LEARN studies. SETTING The A4 Study is a multi-center international clinical trial. The LEARN Study is a multi center observational study in the United States. PARTICIPANTS Clinically normal older adults (65-85 years) with elevated cerebral amyloid (Aβ+; n = 1250, A4) and without elevated cerebral amyloid (Aβ-; n = 538, LEARN). MEASUREMENTS Participants underwent florbetapir positron emission tomography for Aβ+/- classification. A centrally read 3T MRI to assess for study eligibility was conducted on study qualified MRI scanners. RESULTS No ARIA-effusions (ARIA-E) was detected on screening MRI in the Aβ+ or Aβ- cohorts. At least one ARIA-H (microhemorrhages [MCH] or superficial siderosis [SS]) was present in 18% of the Aβ+ cohort compared with 8% in Aβ- (P < 0.001). In the Aβ+ cohort, approximately 2% of screening MRIs demonstrated MCH ≥4 compared with 0% in Aβ-. The presence of two apolipoprotein E ε4 (APOEε4) alleles (vs no ε4 alleles) in the Aβ+ cohort increased the odds for presence of MCH (odds ratio [OR] = 2.03; 95% CI, 1.23 to 3.27, P = 0.004). Cortical infarctions (4% vs 0%) and subcortical infarctions (10% vs 1%) were observed at statistically significantly higher prevalence in the Aβ+ cohort compared with Aβ- (P < 0.001). Females showed reduced odds of MCH in the Aβ+ cohort by a factor of 0.63 (95% CI, 0.47 to 0.84, P = 0.002). CONCLUSIONS ARIA-E is rare in cognitively unimpaired Aβ+ and Aβ- populations prior to anti-amyloid drug intervention. ARIA-H in Aβ+ was greater than in Aβ- populations.
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Affiliation(s)
- R Yaari
- Roy Yaari, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN 46285, USA, , +1 317-416-0872
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Cerebral amyloid angiopathy and Alzheimer disease - one peptide, two pathways. Nat Rev Neurol 2019; 16:30-42. [PMID: 31827267 DOI: 10.1038/s41582-019-0281-2] [Citation(s) in RCA: 391] [Impact Index Per Article: 78.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2019] [Indexed: 12/22/2022]
Abstract
The shared role of amyloid-β (Aβ) deposition in cerebral amyloid angiopathy (CAA) and Alzheimer disease (AD) is arguably the clearest instance of crosstalk between neurodegenerative and cerebrovascular processes. The pathogenic pathways of CAA and AD intersect at the levels of Aβ generation, its circulation within the interstitial fluid and perivascular drainage pathways and its brain clearance, but diverge in their mechanisms of brain injury and disease presentation. Here, we review the evidence for and the pathogenic implications of interactions between CAA and AD. Both pathologies seem to be driven by impaired Aβ clearance, creating conditions for a self-reinforcing cycle of increased vascular Aβ, reduced perivascular clearance and further CAA and AD progression. Despite the close relationship between vascular and plaque Aβ deposition, several factors favour one or the other, such as the carboxy-terminal site of the peptide and specific co-deposited proteins. Amyloid-related imaging abnormalities that have been seen in trials of anti-Aβ immunotherapy are another probable intersection between CAA and AD, representing overload of perivascular clearance pathways and the effects of removing Aβ from CAA-positive vessels. The intersections between CAA and AD point to a crucial role for improving vascular function in the treatment of both diseases and indicate the next steps necessary for identifying therapies.
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Dörr S, Schickel R, Lucke-Paulig L, Schöntag S, Lobmann R. Rapid Cognitive Decline and Recurrent Falls in a 71 Year-Old Man Due to Cerebral Amyloidangiopathy-Related Inflammation (CAA-RI). Geriatrics (Basel) 2019; 4:geriatrics4040056. [PMID: 31581713 PMCID: PMC6960864 DOI: 10.3390/geriatrics4040056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/23/2019] [Accepted: 09/30/2019] [Indexed: 11/16/2022] Open
Abstract
Cognitive decline and falls in the elderly are common and are often accepted as natural and inevitable by relatives and health care professionals, but frequently there are specific and treatable diseases that should be revealed. In our case, cerebral amyloid angiopathy-related inflammation (CAA-RI) was causative for neuro-psychiatric symptoms and worsening of gait in a 71 year-old man with recurrent falls and decline of gait and cognition. Cerebral amyloidangiopathy (CAA) is an important cause of cerebrovascular disorders in the elderly, characterized by leukoencephalopathy combined with lobar or small cortical hemorrhage due to amyloid deposition in cortical and leptomeningeal vessels. In several conditions, amyloid deposition can provoke inflammation or edema that lead to -normally reversible- encephalopathy. CAA-RI is then characterized by subacute neurobehavioral symptoms, headache, seizures or stroke-like signs. The first therapeutic option after confirming the diagnosis is treatment with glucocorticoids. Despite treatment with prednisolone, our patient could not regain his unrestricted mobility and self-help competence. Our report aims to sharpen awareness for CAA and its inflammatory form (CAA-RI) in healthcare professionals involved in medical care of the elderly and provide a short summary of this disease.
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Affiliation(s)
- Stefan Dörr
- Department of Endocrinology, Diabetology and Geriatrics, Stuttgart General Hospital, 70374 Bad Cannstatt, Prießnitzweg 24, Germany.
| | - Rabea Schickel
- Department of Endocrinology, Diabetology and Geriatrics, Stuttgart General Hospital, 70374 Bad Cannstatt, Prießnitzweg 24, Germany.
| | - Lara Lucke-Paulig
- Department of Endocrinology, Diabetology and Geriatrics, Stuttgart General Hospital, 70374 Bad Cannstatt, Prießnitzweg 24, Germany.
| | - Steffen Schöntag
- Department of Diagnostic and interventional Radiology, Stuttgart General Hospital, 70374 Bad Cannstatt, Prießnitzweg 24, Germany.
| | - Ralf Lobmann
- Department of Endocrinology, Diabetology and Geriatrics, Stuttgart General Hospital, 70374 Bad Cannstatt, Prießnitzweg 24, Germany.
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DiFrancesco JC, Longoni M, Piazza F. Anti-Aβ Autoantibodies in Amyloid Related Imaging Abnormalities (ARIA): Candidate Biomarker for Immunotherapy in Alzheimer's Disease and Cerebral Amyloid Angiopathy. Front Neurol 2015; 6:207. [PMID: 26441825 PMCID: PMC4585101 DOI: 10.3389/fneur.2015.00207] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/08/2015] [Indexed: 11/13/2022] Open
Abstract
Amyloid-related imaging abnormalities (ARIA) represent the major severe side effect of amyloid-beta (Aβ) immunotherapy for Alzheimer’s disease (AD). Early biomarkers of ARIA represent an important challenge to ensure safe and beneficial effects of immunotherapies, given that different promising clinical trials in prodromal and subjects at risk for AD are underway. The recent demonstration that cerebrospinal fluid (CSF) anti-Aβ autoantibodies play a key role in the development of the ARIA-like events characterizing cerebral amyloid angiopathy-related inflammation generated great interest in the field of immunotherapy. Herein, we critically review the growing body of evidence supporting the monitoring of CSF anti-Aβ autoantibody as a promising candidate biomarker for ARIA in clinical trials.
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Affiliation(s)
- Jacopo C DiFrancesco
- School of Medicine, Milan Center for Neuroscience (NeuroMi), University of Milano-Bicocca , Monza , Italy ; The Inflammatory Cerebral Amyloid Angiopathy and Alzheimer's Disease βiomarkers (iCAβ) International Network , Monza , Italy
| | - Martina Longoni
- School of Medicine, Milan Center for Neuroscience (NeuroMi), University of Milano-Bicocca , Monza , Italy ; The Inflammatory Cerebral Amyloid Angiopathy and Alzheimer's Disease βiomarkers (iCAβ) International Network , Monza , Italy
| | - Fabrizio Piazza
- School of Medicine, Milan Center for Neuroscience (NeuroMi), University of Milano-Bicocca , Monza , Italy ; The Inflammatory Cerebral Amyloid Angiopathy and Alzheimer's Disease βiomarkers (iCAβ) International Network , Monza , Italy ; The iCAβ-ITALY Study Group of the Italian Society for the Study of Dementia (SINdem) , Monza , Italy
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DiFrancesco JC, Touat M, Caulo M, Gallucci M, Garcin B, Levy R, Uncini A, Piazza F. Recurrence of Cerebral Amyloid Angiopathy-Related Inflammation: A Report of Two Cases from the iCAβ International Network. J Alzheimers Dis 2015; 46:1071-7. [DOI: 10.3233/jad-150070] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jacopo C. DiFrancesco
- Department of Surgery and Translational Medicine, Milan Center for Neuroscience (NeuroMi), University of Milano-Bicocca, Monza, Italy
- Department of Neurology, San Gerardo Hospital, Monza, Italy
| | - Mehdi Touat
- Neurology Department, Hospital Saint Antoine, APHP, Paris, France
- INSERM UMR 981, Predictive Biomarkers and New Therapeutic Strategies in Oncology, Gustave Roussy, Villejuif, France
| | - Massimo Caulo
- Department of Neuroscience and Imaging, University “G. d’Annunzio”, Chieti, Italy
| | - Massimo Gallucci
- Department on Neuroradiology, University of L’Aquila, L’Aquila, Italy
| | - Béatrice Garcin
- Neurology Department, Hospital Saint Antoine, APHP, Paris, France
- INSERM UMRS, CNRS UMR, Brain & Spine Institute (ICM), Hôpital Pitié Salpêtrière, Paris, France
| | - Richard Levy
- Neurology Department, Hospital Saint Antoine, APHP, Paris, France
- INSERM UMRS, CNRS UMR, Brain & Spine Institute (ICM), Hôpital Pitié Salpêtrière, Paris, France
| | - Antonino Uncini
- Department of Neuroscience and Imaging, University “G. d’Annunzio”, Chieti, Italy
| | - Fabrizio Piazza
- Department of Surgery and Translational Medicine, Milan Center for Neuroscience (NeuroMi), University of Milano-Bicocca, Monza, Italy
- The inflammatory Cerebral amyloid angiopathy and Alzheimer’s disease βiomarkers ( CAβ) International Network, Monza, Italy
- The CAβ-ITALY Study Group of the Italian Society for the study of Dementia (SINdem), Italy
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