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Alzheimer's Disease Research and Treatments / Dementia and Cognitive Impairment Research · Journal article
Frontiers in Neurology · August 19, 2026
A consensus or society position rather than new primary data.
This narrative review identifies important safety and clinical management gaps arising from the use of anti-amyloid monoclonal antibodies (lecanemab, donanemab) in patients with Alzheimer disease who also have cerebral amyloid angiopathy or other cerebrovascular comorbidities. The pivotal trials enrolled highly selected populations with minimal baseline vascular pathology, leaving real-world safety, imaging interpretation, acute stroke decision-making, and long-term antithrombotic strategies inadequately studied. The authors call for multidisciplinary protocols, dedicated imaging, and prospective registries rather than providing definitive evidence on any single intervention.
Journal article. Patients with early Alzheimer disease receiving anti-amyloid monoclonal antibodies who also have cerebral amyloid angiopathy or other cerebrovascular pathology; real-world populations with prevalent vascular comorbidity not well represented in pivotal trials..
Clinical trials of lecanemab and donanemab enrolled highly selected patients with minimal baseline cerebrovascular pathology, limiting generalizability to real-world populations. Amyloid-related imaging abnormalities, particularly vasogenic edema and microhemorrhages, may clinically mimic acute ischemic stroke and increase risk of inappropriate intravenous thrombolysis. Emerging reports document intracerebral hemorrhage following IVT in anti-amyloid-treated patients.
No quantitative synthesis of safety data; emerging reports of hemorrhage are descriptive rather than systematically reviewed. No direct comparison of outcomes or safety between anti-amyloid-treated and untreated groups with cerebrovascular comorbidity.
Clinicians managing patients on lecanemab or donanemab who present with acute neurological events or require antithrombotic therapy should recognize that trial safety data do not adequately cover concurrent cerebrovascular disease. Emergency and neurovascular teams should consider amyloid-related imaging abnormalities in the differential diagnosis of acute stroke mimics and exercise caution with thrombolysis; mechanical thrombectomy may be preferred when indicated. Long-term antithrombotic strategy in these patients remains unsettled and warrants multidisciplinary review.
An expert narrative review synthesizing clinical implications of anti-amyloid therapy for patients with concurrent cerebrovascular disease, identifying safety gaps and practice considerations rather than reporting new trial data.
Clinicians managing patients on lecanemab or donanemab who present with acute neurological events or require antithrombotic therapy should recognize that trial safety data do not adequately cover concurrent cerebrovascular disease. Emergency and neurovascular teams should consider amyloid-related imaging abnormalities in the differential diagnosis of acute stroke mimics and exercise caution with thrombolysis; mechanical thrombectomy may be preferred when indicated. Long-term antithrombotic strategy in these patients remains unsettled and warrants multidisciplinary review.
Graded across the dimensions that decide whether you should act, each from what the source actually supports. There is no single score, and where a dimension was not assessed it says so.
What is missing. This record has no reported figures. That is a gap in the analysis, not a judgement about the study.
Anti-amyloid treatment (AAT) with monoclonal antibodies represents a major therapeutic advance in early Alzheimer disease (AD), but its introduction has important and underappreciated implications for vascular neurology. Because many patients with AD also have cerebral amyloid angiopathy and other cerebrovascular pathology, AAT influences stroke diagnosis, acute reperfusion therapy, and long-term antithrombotic management. Clinical trials of lecanemab and donanemab enrolled highly selected patients with minimal baseline cerebrovascular pathology, limiting generalizability to real-world populations with prevalent vascular comorbidity. Amyloid-related imaging abnormalities, particularly vasogenic edema and microhemorrhages, constitute a central safety concern and may clinically mimic acute ischemic stroke, complicating emergency decision-making and increasing the risk of inappropriate intravenous thrombolysis (IVT). Emerging reports of intracerebral hemorrhage following IVT in treated patients underscore the need for revised acute stroke pathways and support consideration of mechanical thrombectomy when otherwise indicated, although AAT-specific safety data are lacking. Beyond the hyperacute phase of stroke, concomitant use of anticoagulants or dual antiplatelet therapy raises unresolved questions regarding hemorrhagic risk, particularly in patients with atrial fibrillation or those requiring complex antithrombotic regimens. Alternative strategies, including left atrial appendage closure, may be considered in selected patients, although evidence in AAT recipients remains limited. As AAT enters routine practice, multidisciplinary collaboration, dedicated imaging protocols, and prospective safety registries will be essential to integrate disease-modifying AD treatment with safe and effective cerebrovascular care.
Taken from the source record, never inferred. Follow any of these and new work involving them reaches your briefing.