Intravenous Thrombolysis for Acute Ischemic Stroke on Anti-amyloid Immunotherapy Donanemab
Lin Abigail Tan1, Vivien Lee2, Douglas Scharre2, Cassandra Forrest2
1The Ohio State University College of Medicine, 2Department of Neurology, The Ohio State University Wexner Medical Center
Objective:
Due to case reports of fatal multifocal hemorrhage after thrombolysis in patients on amyloid immunotherapy, a scientific advisor from the American Heart Association recommends against the use of thrombolytic therapy. We report a stroke patient on anti-amyloid immunotherapy with a favorable clinical outcome.
Design/Methods:
A 79-year old female with a history of Alzheimer’s dementia (APOE E3/4) on anti-amyloid infusion, hyperlipidemia, hypertension, and prior TIA on aspirin presented for acute ischemic stroke. She had received the first infusion of the anti-amyloid donanemab 35 days prior to stroke presentation, with an MRI brain 21 days prior that was negative for Amyloid-Related Imaging Abnormalities (ARIA), including Susceptibility-Weighted Imaging. She received the 2nd infusion 7 days prior. On day of stroke presentation, she developed left hemiparesis and was transported to an outside hospital emergency room (ER). Initial National Institutes of Health Stroke Scale (NIHSS) was 15 for left hemiparesis, neglect, visual field defect, and dysarthria. BP was 129/67 mmHg. CT brain was negative for acute changes. CT angiogram head/neck was negative for vessel occlusion. CT perfusion brain showed right middle cerebral artery (MCA) mismatch (Figure 1). She was administered IV tenecteplase (TNK) at 57 minutes from last known well. Her husband arrived to the ER after TNK was already given and reported donanemab use at that time. The patient had rapid neurological improvement and 1 hour post TNK, NIHSS was 0. MRI brain on post-stroke day 1 showed a right MCA branch infarct without hemorrhage (Figure 2). On 3-month follow-up, NIHSS was 0 and modified Rankin Scale was 1.
Conclusions:
The recommendation to withhold thrombolytic therapy in patients on anti-amyloid immunotherapy due to concern of ARIA and hemorrhage is based upon isolated case reports. Further investigation is warranted to better understand and identify patients who may be at lower risk of hemorrhagic complications.
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