Would you administer IV thrombolysis in a patient presenting with disabling stroke symptoms while on anti-amyloid therapy?

I agree with @Dr. First Last. There seems to be one case of catastrophic bleeding in the published literature. However, such events can occur with thrombolysis alone or in the context of other cerebrovascular conditions such as CAA, vascular malformations, and even severe WMH. While it's important to monitor these cases, I believe denying someone a proven intervention for a disabling stroke should require more than "n of 1" data.

I would attempt to ascertain whether the patient's past MRI revealed evidence of amyloid angiopathy. If this information is unavailable, obtaining a stat MRI may be justified. I would not exclude the patient solely based on being on anti-amyloid therapy.

While we should be cautious about basing decisions solely on the findings of a single case report, such as the one describing cerebral hemorrhages after thrombolysis in a patient on lecanemab therapy (Reish et al., PMID 36599061), the "Lecanemab: Appropriate Use Recommendations" by the Alzheimer's Disease and Related Disorders Therapeutics Work Group advises against thrombolysis. They state: "lecanemab may increase the risk of hemorrhage from concomitant administration of thrombolytics (intraven...

Most hospitals have rapid stroke MRI 4 sequence protocol which hardly takes 15 minutes or less. It's better to get that done if the patient has been on lecanemab before. Based on that and the CMB burden, one can clinically decide if they want to go ahead with IV thrombolysis which I imagine will differ based on WMH and CMB burden together if taken into consideration.

• If it's LVO, the patient receiving lecanemab can be directly taken to the angio suite, bypassing IV thrombolysis or MRI acute str...