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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

Activity

Progress
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Course Completed

Case 1: Detection of ARIA-H

Dr Benzinger:

SWI in the same regions as the ARIA-E demonstrated 3 microhemorrhages in the right frontal lobe and 1 microhemorrhage in the right occipital lobe, consistent with ARIA-H. As is often the case, ARIA-H lesions appeared in the same locations as ARIA-E, although in some patients either the edema or the hemorrhagic component may be easier to recognize.

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Case 1: ARIA Grading Criteria

Dr Benzinger:

Applying the ARIA grading scale in practice is not always intuitive and can be challenging even for those who use it regularly. A radiologist’s role is to identify and quantify findings. I would recommend building some solid reporting templates so that if you click the number of microhemorrhages, the template will automatically give you the grade, so that is 1 less thing you have to keep in your mind in real time. In this case, there were 4 new microhemorrhages, so even though it might have looked concerning since they were located in 2 different parts of the brain, the ARIA-H would be classified as mild. The reverse is true for the siderosis; on FLAIR, it would be considered moderate, because even though they were small regions, 2 different regions were involved.

For ARIA-E, grading is based on both size and distribution:

  • Mild: A single region <5 cm
  • Moderate: 2 or more regions, or any region measuring 5-10 cm
  • Severe: Any region ≥10 cm

For ARIA-H microhemorrhages, grading is strictly numerical. Location and clustering do not change the category:

  • Mild: Fewer than 5
  • Moderate: 5-9
  • Severe: ≥10

ARIA-H superficial siderosis (a sign of small subarachnoid hemorrhage) follows a tighter scale:

  • Mild: 1 focus (new or worsening area)
  • Moderate: 2 foci
  • Severe: ≥3 foci

The key takeaway is that ARIA assessment is a combination of 2 elements:

  1. Imaging severity based on MRI findings
  2. Clinical symptom severity

Both must be considered together when determining management.3,4 This case is a nice example of moderate ARIA-E and mild ARIA-H, with the findings both occurring in the same regions.

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What would you recommend as clinical management for a patient treated with donanemab if moderate grade ARIA-E and mild grade ARIA-H microhemorrhage are found on routine monitoring (ie, without symptoms)?

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