Abstract TP063: Protocol Development for Evaluation of Patients with Stroke-Like Symptoms who are Receiving Anti-Amyloid Monoclonal Antibodies

Objective: To develop a hospital-wide protocol for emergent evaluation of patients with stroke-like symptoms who are receiving anti-amyloid monoclonal antibodies (Aβ immunotherapy). Background: Aβ immunotherapy is now FDA-approved as disease modifying therapy for patients with mild cognitive impairment or mild dementia attributable to Alzheimer Disease (AD). A known adverse event associated with this class of therapy is amyloid-related imaging abnormalities (ARIA), which are often asymptomatic but a small percentage present with stroke-like symptoms. This creates diagnostic and therapeutic challenges when considering thrombolysis for stroke. While data is limited, there have been two reported cases of intracerebral hemorrhages following thrombolysis in patients on Aβ immunotherapy. Until there is further data to show the safety of thrombolysis, the FDA advises caution in this population. With the growing use of Aβ immunotherapy, hospitals must be prepared to rapidly and safely evaluate these complex cases. Methods: We are developing a protocol to identify patients receiving Aβ immunotherapy and evaluate whether focal symptoms are due to ARIA or ischemia. We are updating the electronic medical record to display a banner best practice advisory (BPA) to alert providers that a patient is on Aβ immunotherapy. If CT and CTA are not revealing, patients receiving Aβ immunotherapy will undergo a rapid sequence MRI stroke protocol to evaluate for ischemia or ARIA-related changes. We are revising our institutional and statewide relative and absolute contraindication list for thrombolysis to include Aβ immunotherapy. We will provide targeted education for health care providers at our hospital as well as emergency providers throughout the state to ensure awareness of ARIA causing stroke-like symptoms and caution with thrombolysis in this population. Results: This protocol is currently in development at our institution with plans to disseminate the information throughout the state. Implementation steps, lessons learned, and results will be presented at the International Stroke Conference. Conclusion: As Aβ immunotherapy becomes more widespread, structured protocols are essential for safely managing stroke-like presentations. The goal is to ensure that the increased risk and implications for stroke therapies in patients being treated with Aβ immunotherapy are recognized so the clinician can include them in clinical decision-making.