Brain Games: When Alzheimer Disease Infusions and Stroke Therapy Collide

Tenecteplase and alteplase are highly effective agents for addressing large vessel ischemic strokes, a time-sensitive intervention well-known to emergency medicine pharmacists. Teams and pharmacists are responsible for evaluating numerous contraindications prior to administration. The American Stroke Association guidelines emphasize the importance of a risk versus benefit discussion for stroke mimics before initiating thrombolytic therapy. Since the last guideline update, two Alzheimer’s infusions - lecanemab and donanemab - have entered the market. While these drugs benefit cognitive function by delaying cognitive decline, they pose potential risk in stroke settings. Both infusions are associated with amyloid-related imaging abnormalities (ARIA) with edema (ARIA-E) or with hemosiderin deposition (ARIA-H). These conditions present with neurological deficits, gait difficulty, confusion, visual changes, dizziness, nausea, and headaches, mimicking a stroke but identifiable via MRI scans. In urgent evaluation of stroke rule-outs, assessing the risk of thrombolytic administration in the presence of ARIA and infusion therapies is crucial. To date, only case reports document intracranial hemorrhages in patients on these infusions. In one instance, a 72-year-old male in a donanemab study experienced an acute ischemic stroke. After a normal CT, he received tenecteplase, but subsequent CT revealed multiple bilateral intracerebral hemorrhages, shifting therapy to cryoprecipitate and fibrinogen. Ultimately, an MRI confirmed bilateral intraparenchymal hemorrhage, and the patient succumbed four days later due to acute hypoxic respiratory failure. In another case, a 65-year-old patient receiving lecanemab presented with aphasia and left gaze preference. A CT indicated left temporal-parietal hypodensities and distal left cerebral artery branch occlusion. No contraindications were present and alteplase infusion was started. The patient suddenly developed hypertension causing the infusion to be stopped. Repeat CT showed extensive, multifocal intraparenchymal hemorrhages. Despite the change in treatment the patient required intubation due to innumerable hemorrhages. Family later shifted to comfort measures and the patient passed. Pharmacists play a pivotal role in reviewing medication lists and providing crucial information on the risks and recommendations for thrombolytic therapy. This presentation will elaborate on the limited patient cases, highlight statements from major organizations related to these disease states, and offer recommendations for identifying and utilizing thrombolytics in patients actively receiving lecanemab or donanemab. By sharing this information, I aim to enhance the understanding of the potential risks associated with Alzheimer’s infusions in the context of ischemic stroke therapy, emphasizing the pharmacist’s role in ensuring patient safety. Current plans for an Ignite Pearl: Slide 1 Title Slide Slides 2-4 Quick recap on thrombolytic therapy and use in stroke Slides 5 & 6 introduction to ARIA Slides 7&8 Lecenemab & Donanemab Slides 9-12 Patient Cases (1-2 slides each) Slides 13 FDA recommendation on thrombolytics with Alzheimer’s infusion Slide 14 & 15 Organization stand points on thrombolytics Slide 16 Call to Action Slide 17 How can Pharmacists Help Slide 18 Consider Care plan/Flags for awareness Slide 19 Conclusion on Concurrent Use Slide 20 References