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ARIA Training Module

CE / CME

Spot the Signal: Global Radiology Training for ARIA Detection in Alzheimer’s Care

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Physicians: Maximum of 1.00 AMA PRA Category 1 Credit™

European Learners: 1.00 EBAC® CE Credit

Released: April 16, 2026

Expiration: April 15, 2027

Tammie L. Benzinger
Tammie L. Benzinger, MD, PhD
Karl-Olof Lövblad
Karl-Olof Lövblad, MD
CME/CE Information

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What Are Amyloid-Related Imaging Abnormalities (ARIA)?

Dr Benzinger:

First and foremost, what are ARIA? The most important word is imaging, meaning that these are findings seen on brain MRIs in patients undergoing new treatments for AD.1

The ATTs, lecanemab and donanemab, are monoclonal antibody infusions used in the early stages of AD.2,3 Routine MRIs are performed before treatment initiation and during the course of treatment with these agents, meaning that these are typically ordered in asymptomatic patients. Quite common adverse events include what we call ARIA-E, vasogenic edema or sulcal effusions that can show up on fluid-attenuated inversion recovery (FLAIR), and ARIA-H, meaning microhemorrhages and superficial siderosis.1 Radiologists are very familiar with these features because they look very much like what we know as cerebral amyloid angiopathy (CAA). For patients on ATT, it is vitally important to identify these imaging findings as soon as possible within the MRI monitoring schedule because they change the clinical management of the patient.

Predictors for ARIA are generally the same as predictors for CAA, which are APOE4 genotype or evidence of prior hemorrhages, so the baseline microhemorrhages and siderosis give us a sense that a patient may have preexisting vascular amyloid, making it potentially dangerous for them to be treated with ATTs for AD.

When symptoms are seen with ARIA, they are often nonspecific and can include headache, confusion, visual changes, dizziness, and sometimes nausea or gait difficulty. ARIA are rarely serious; fewer than 2% of patients progress to more serious manifestations, which would include seizures, encephalopathy, hospitalization, or neurologic deficits. However, it is extremely important for us as radiologists to detect ARIA on the imaging as early as possible so that the patient's symptoms can be assessed and the therapies can be paused in order to prevent progression.

To emphasize this point, it is vitally important for the radiologist to identify ARIA on the images rather than to assume that someone else will make that diagnosis.

Dr Lövblad:

The European Medicines Agency has also authorized these 2 ATTs for the treatment of early AD, first lecanemab in May 2025 and then donanemab in October 2025.4,5 However, implementation of these therapies is still in the very early stages in many countries. For example, donanemab has only recently been authorized in Switzerland, and additional therapies are anticipated. In Europe, we are truly at the very beginning of implementation and so we can learn and benefit from the experience that US radiologists have already acquired in the time since the approvals in your country.

The indications in Europe basically mirror those in the United States, being patients who have mild cognitive impairment or mild dementia due to AD with confirmed amyloid pathology. One notable difference from the United States is that, at least initially, treatment will be limited to APOE4 noncarriers or heterozygotes. This approach narrows the eligible population during the early implementation phase. The monitoring schedule is basically also the same as that of the United States, and much of the work we have done in the various medical societies has been based on the existing American recommendations.

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Approximately what percentage of patients treated with amyloid-targeting therapies do you expect to have asymptomatic ARIA detected by routine MRI monitoring?

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