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Real-World Challenges in the MRI Detection and Classification of Amyloid-Related Imaging Abnormalities
Robert H. Unger, Saurabh Rohatgi, Suely Fazio Ferraciolli, Bashar Kako, Nima Omid‐Fard, Rafael Eduardo Martinez Imbett, Thomas Dowling, Shenghua Zhu et al.. American Journal of Roentgenology, 2026-09-02
Topic: Amyloid, tau and blood-test diagnosis
Anti-amyloid monoclonal antibody therapies (AATs) are increasingly used for the treatment of early symptomatic Alzheimer disease. Safe implementation of AATs relies on accurate assessment for exclusionary findings on baseline brain MRI and reliable longitudinal detection of amyloid-related imaging abnormalities (ARIA), including ARIA-H (hemosiderin or hemorrhage) and ARIA-E (edema or effusion). In routine clinical practice, MRI findings encountered during baseline screening and ARIA surveillance sometimes fall into borderline or ambiguous categories that do not clearly conform to trial-defined criteria. For example, subtle or artifactual FLAIR signal abnormality, equivocal microhemorrhage counts, and overlapping features of ARIA-E and ARIA-H can create uncertainty with direct implications for treatment management. Given limited practical guidance addressing these and other gray zones, this imaging-focused review synthesizes common interpretive challenges encountered in a high-volume AAT program and offers practical management-oriented recommendations. Key issues addressed include recognizing technical factors that affect interpretation of susceptibility-weighted and FLAIR images, managing variability in lesion detection across serial examinations, and accurately reporting the temporal evolution of ARIA-related findings. As AAT use expands, recognition of the presented pitfalls can improve diagnostic confidence and help avoid misclassification of findings that may influence therapeutic decisions.
Key findings
- In routine clinical practice, MRI findings encountered during baseline screening and ARIA surveillance sometimes fall into borderline or ambiguous categories that do not clearly conform to trial-defined criteria.
- For example, subtle or artifactual FLAIR signal abnormality, equivocal microhemorrhage counts, and overlapping features of ARIA-E and ARIA-H can create uncertainty with direct implications for treatment management.
- Given limited practical guidance addressing these and other gray zones, this imaging-focused review synthesizes common interpretive challenges encountered in a high-volume AAT program and offers practical management-oriented recommendations.
- Key issues addressed include recognizing technical factors that affect interpretation of susceptibility-weighted and FLAIR images, managing variability in lesion detection across serial examinations, and accurately reporting the temporal evolution of ARIA-related findings.
- As AAT use expands, recognition of the presented pitfalls can improve diagnostic confidence and help avoid misclassification of findings that may influence therapeutic decisions.
Why it matters
This review describes practical difficulties in reading brain MRI scans for ARIA during anti-amyloid antibody treatment, such as subtle FLAIR signal changes, unclear microhemorrhage counts, and overlapping ARIA-E and ARIA-H features. It offers management-oriented recommendations for these ambiguous cases, but does not test or report any treatment, cure, or prevention effect.
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Study details
- Study designlongitudinal study
- Evidence strengthModerate
How this study scored 44/100
Published in a peer-reviewed journal, and it is a longitudinal study following the same people over time. Scored zero for sample size, effect reported, studied in people and randomised / blinded because the record does not state it.
| Component | Points | Why |
|---|---|---|
| Journal tier | 7 / 10 | Tier 3 — peer-reviewed journal (American Journal of Roentgenology) |
| Journal's citation record | 3 / 4 | American Journal of Roentgenology: journal h-index 288 (OpenAlex, 2026-10-29) |
| Study design | 7 / 12 | A longitudinal study following the same people over time |
| Strength of evidence | 3 / 5 | Rated “moderate” in our summary |
| Peer-review validation | 10 / 10 | Peer-reviewed. Published as an article in a named peer-reviewed journal. |
| How recent | 5 / 5 | 2026 — within 1 year(s) of the newest study here |
| Sample size | 0 / 4 | Participant count not stated — scores zero (not stated in the record — scored 0) |
| Effect reported | 0 / 3 | No effect size reported — scores zero (not stated in the record — scored 0) |
| Studied in people | 0 / 3 | Not stated whether this was studied in people — scores zero (not stated in the record — scored 0) |
| Randomised / blinded | 0 / 2 | No randomisation or blinding stated — scores zero (not stated in the record — scored 0) |
| Times cited | 1 / 7 | Cited 1 times (OpenAlex, 2026-10-10) |
| Citations per year | 0 / 5 | 0.5 citations a year over 2 year(s) since 2026 |
| Impact for its field and year | 3 / 6 | Cited 4.2× the average for papers of its field and year (OpenAlex FWCI) |
| Cited by studies here | 0 / 6 | No other study in this library cites it |
| Still being cited | 0 / 4 | Cited 1 times in 2024–2026 (2026 still in progress; OpenAlex) |
| Senior author's track record | 1 / 4 | Last-listed author Jeremy N. Ford: h-index 6 (OpenAlex, whole career) |
| Institution's track record | 2 / 3 | Massachusetts General Hospital: institution h-index 2,057 (OpenAlex) |
| Multi-centre collaboration | 0 / 3 | OpenAlex lists 1 institution(s) in 1 country — scores zero (affiliation lists can be incomplete) |
| Indexed in PubMed | 2 / 2 | Indexed in PubMed (PMID 42684813) |
| Free to read | 0 / 2 | Behind a paywall — scores zero |
| Total | 44 / 100 | — |
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Read the original
May need a subscription OpenAlex found no free copy of the full text (checked 6 Feb 1020), so the publisher may charge for it. The PubMed abstract is free.
Cite this study APA, Vancouver, BibTeX · download .bib or .ris
Built from the record alzhub holds for this paper, not looked up. Volume, issue and page numbers are not held in the record. The record's author list ends in “et al.”, so not every author is named. Check the citation against the original before you use it.
APA 7th
Unger, R. H., Rohatgi, S., Ferraciolli, S. F., Kako, B., Omid‐Fard, N., Imbett, R. E. M., et al. (2026). Real-World Challenges in the MRI Detection and Classification of Amyloid-Related Imaging Abnormalities. American Journal of Roentgenology. https://doi.org/10.2214/ajr.26.35478
Vancouver
Unger RH, Rohatgi S, Ferraciolli SF, Kako B, Omid‐Fard N, Imbett REM, et al. Real-World Challenges in the MRI Detection and Classification of Amyloid-Related Imaging Abnormalities. American Journal of Roentgenology. 2026. doi:10.2214/ajr.26.35478. PMID: 42684813.
BibTeX
@article{unger2026-42684813,
author = {Unger, Robert H. and Rohatgi, Saurabh and Ferraciolli, Suely Fazio and Kako, Bashar and Omid‐Fard, Nima and Imbett, Rafael Eduardo Martinez and Dowling, Thomas and Zhu, Shenghua and others},
title = {{Real-World Challenges in the MRI Detection and Classification of Amyloid-Related Imaging Abnormalities}},
journal = {American Journal of Roentgenology},
year = {2026},
doi = {10.2214/ajr.26.35478},
pmid = {42684813},
url = {https://doi.org/10.2214/ajr.26.35478}
}
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