Changes of a Cerebral Cavernous Malformation Associated With Lecanemab Therapy in a Patient With Alzheimer Disease

Antiamyloid immunotherapies are associated with increased risk of intracerebral hemorrhage, particularly in the setting of APOE-ε4 carriership, anticoagulation, thrombolytics, and other lesions at risk of hemorrhagic conversion. It is not known whether patients with cavernous malformations are at increased risk of complication because patients with these lesions were excluded from clinical trials. We describe a case of a patient with Alzheimer disease (AD) with an incidental cavernous malformation treated with lecanemab. A 73-year-old APOE ε4 heterozygous woman with mild cognitive impairment and CSF biomarker evidence of AD underwent treatment with intravenous lecanemab. Baseline MRI revealed 3 lobar microhemorrhages and an asymptomatic left orbitofrontal cavernous malformation. This cavernous malformation exhibited gross radiologic stability at surveillance brain MRI before the 5th and 7th infusions, but on surveillance MRI after infusion 13 exhibited an asymptomatic increase in size with subacute blood products without additional new amyloid-related imaging abnormalities (ARIA), resulting in treatment discontinuation. Lecanemab therapy was associated with asymptomatic expansion of an incidental cavernous malformation in a patient with AD and without evidence of ARIA.