Article Figures & Data
Figures
- Fig 1.
ARIA-E (effusion); sulcal FLAIR hyperintensity. FLAIR MR imaging at baseline (A) and week 19 (B). On the follow-up surveillance scan (week 19), sulcal FLAIR hyperintensity developed in the right frontal region (arrow). No associated signal abnormality was identified on other imaging sequences, including T1 and gradient recalled-echo/T2* imaging (not shown). Because the imaging appearance mimicked that of a subarachnoid hemorrhage, CT and lumbar puncture were performed, both of which had normal findings, revealing no evidence of blood products.
- Fig 2.
ARIA-E (edema and effusion); parenchymal and sulcal FLAIR hyperintensity. FLAIR sequences at baseline (A), week 19 (B), and week 32 (C). By week 19 (6 weeks after the second dose of bapineuzumab), a zone of cortical swelling, sulcal effacement, and parenchymal hyperintensity has developed in the right temporal-occipital lobe. A small sulcal effusion and faint overlying linear leptomeningeal hyperintensity (arrows) help define the area of abnormality. By week 32, these findings have largely resolved. As is typically the case with bapineuzumab-related ARIA, the patient remained asymptomatic throughout all imaging time points.
- Fig 3.
ARIA-E (edema); week 19 parenchymal FLAIR hyperintensity. Week 19 FLAIR (A) and corresponding DWI (B) and week 19 gadolinium (C). On the surveillance scan for week 19 (A), several large regions of parenchymal edema develop, principally in the bifrontal and left temporal regions, which resolve on follow-up (not shown). Week 19 DWI reveals minimal T2 shinethrough (B), but no ADC abnormality (not shown). With gadolinium, there is no frank enhancement with only mild prominence of overlying cortical vasculature, in keeping with nonspecific cerebral swelling (C).
- Fig 4.
ARIA-E (edema) with incident ARIA-H (microhemorrhages). FLAIR and corresponding gradient recalled-echo/T2* sequences of the same patient, at baseline (A and B) and week 19 (C and D). By week 19 (6 weeks after the second dose of bapineuzumab), significant right-hemispheric edema has developed. As is characteristic of ARIA-E, despite the extensive parenchymal changes, DWI and ADC findings remained normal (not shown), confirming these findings as reflecting vasogenic as opposed to cytotoxic edema. On the corresponding gradient recalled-echo/T2* images, there is concomitant development of several punctate microhemorrhages in the right parietal region (circle). On subsequent imaging, the cerebral edema resolved while the microhemorrhages remained stable (not shown). In general, the severity of ARIA changes was associated with both Apolipoprotein ε4 allele status and drug dosage. As such, this patient was an Apolipoprotein ε4 homozygote and in the highest drug-dose arm.
- Fig 5.
ARIA-E (edema) with incident ARIA-H (superficial hemosiderin deposits). Gradient recalled-echo/T2* and corresponding FLAIR sequences from the same patient, at baseline (A), week 19 (B), and week 28 (C). By week 19 (B), several regions of parenchymal edema have developed, including bifrontal regions and the right parieto-occipital lobe. On the corresponding gradient recalled-echo/T2* images, by week 19, there is concomitant development of several superficial linear areas of blood-degradation products (arrows) in the bifrontal regions (≥10 mm). By week 28, the FLAIR changes relating to ARIA-E have resolved, with blood products re-demonstrated.
Tables
ARIA Component Primary Diagnostic Imaging Sequence Nature of Leakage Products Location of Increased Vascular Permeability Parenchyma Leptomeninges ARIA-E FLAIR Proteinaceous fluid Vasogenic edema Sulcal effusion/exudate ARIA-H GRE/T2* Heme products Microhemorrhage (hemosiderin deposits <10 mm or large hemosiderin deposits ≥10 mm) Superficial hemosiderin deposits Note:—GRE indicates gradient recalled-echo.
ARIA Type: Incidence Location: Isolated Leptomeningeal Location: Isolated Parenchymal Location: Combined ARIA-E: 36/210 (17%) ARIA-E: sulcal effusion: 15/36 (42%) ARIA-E: parenchymal edema: 8/36 (22%) ARIA-E: effusion and edema combined: 13/36 (36%) ARIA-H: 26/210 (12.4%) ARIA-H: superficial hemosiderin deposit: 2/26 (8%) ARIA-H: parenchymal microhemorrhage: 24/26 (92%)
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