Adverse effects of erenumab on cerebral proliferative angiopathy: A case report

Abstract

Background Cerebral proliferative angiopathy is a vascular malformation associated with compromised blood-brain barrier and with migraine-like headache. Treating blood-brain barrier-compromised patients with erenumab, an anti-calcitonin gene-related peptide receptor monoclonal antibody, may be risky. Case We describe a case of a 22-year-old chronic migraine patient with cerebral proliferative angiopathy who presented to our hospital in status epilepticus 2 d after his first dose of erenumab. Serial magnetic resonance imaging (MRI) studies demonstrated progressive areas of diffusion restriction including the brain tissue adjacent to the cerebral proliferative angiopathy, bilateral white matter and hippocampi. His 6-month post-presentation magnetic resonance imaging was notable for white matter injury, encephalomalacia surrounding cerebral proliferative angiopathy and bilateral hippocampal sclerosis. He remains clinically affected with residual symptoms, including refractory epilepsy and cognitive deficits. Conclusion The evidence presented in this case supports further investigation into potential deleterious side effects of erenumab in patients with compromised blood-brain barrier, such as individuals with intracranial vascular malformations.

Ten open questions in migraine prophylaxis with monoclonal antibodies blocking the calcitonin-gene related peptide pathway: a narrative review

“…A single intravenous administration of erenumab 140 mg in patients with stable angina did not aggravate exercice-induced angina or ST-segment depression [ 149 ], but this study was criticized because it explored a single acute administration too short before the treadmill test to allow for complete tissue distribution and comprised few women with angina in whom the distal coronary artery system, the most sensitive to CGRP, is chiefly involved. With a follow-up now exceeding 6 years, serious treatment-related vascular adverse events have not been reported with anti-CGRP/rec mAbs [ 150 , 151 ], with the exception of 2 case reports complicated by comorbid features: an ischemic stroke in a patient with cerebral proliferative angiopathy [ 152 ], and reversible cerebral vasospasm in a patient treated with erenumab, a triptan and a combined contraceptive pill [ 153 ]. Despite the absence up to now of a signal of worse outcomes for cerebral or coronary ischemia under anti-CGRP/rec mAbs, their use is contraindicated in patients with recent stroke, unstable angina or myocardial infarction.…”

Fremanezumab plus plasmapheresis in a patient with chronic migraine and myasthenia gravis: Case report of an effective treatment

“…10,11 Considering the evolution of her migraine history, we selected the newer anti-CGRP antibody treatment given the patient's limited treatment options and the potential for significant improvement in her disability, mood, and quality of life; however, we hypothesized that PEX might remove fremanezumab from the circulation, thus reducing its biological effects and clinical benefits. This hypothesis was further suggested by a recent case report by Lehman et al 12 where PEX-mediated therapeutic removal of the anti-CGRP antibody erenumab from blood was described. In fact, it was considered the potential causative agent for status epilepticus in a patient with cerebral proliferative angiopathy treated with the drug.…”

Cerebral Proliferative Angiopathy as the Cause of Symptomatic Epilepsy in a Young Adult Male: A First Case Report from Indonesia

“…Previous studies noted various EEG abnormalities of CPA, such as intermittent slow wave activity, diffuse slowing, or even periodic lateralizing epileptiform discharges. 5,10,11 The incidence of hemorrhage in CPA was estimated at 18%, which was significantly lower compared to cerebral AVM (50%). 2 This was consistent with our finding in which despite a large lesion size, the CPA did not lead to hemorrhage nor cause a focal neurological deficit.…”