Background The E4 variant of Apolipoprotein E (APOE) is a primary genetic susceptibility risk factor for late-onset Alzheimer’s disease and has been implicated in cerebrovascular dysfunction. Preclinical mouse models are widely used to study APOE4, but cohesive understanding of APOE’s role is still inconsistent and lacking. The aim of this study was to systematically review and synthesise evidence from preclinical mouse studies assessing APOE4 related effects on blood-brain barrier (BBB) integrity, vascular morphology and cerebral blood flow (CBF). Main A systematic search of MEDLINE, Embase, Scopus, and Web of Science was conducted (March-April 2025). Eligible studies included transgenic APOE-targeted replacement or knock-in mice reporting vascular outcomes (cerebral blood flow, blood brain barrier permeability, vascular measures). Risk of bias was assessed using SYRCLE and reporting quality with CAMARADES. Random-effects meta-analyses were conducted (where sufficient data was available), otherwise findings were narratively synthesised. Eighteen studies met inclusion. Outcome measures varied widely, including diverse approaches to CBF measurement (e.g. arterial spin labelling, autoradiography, DSC-MRI), immunohistochemical measures (e.g. collagen-IV, laminin, CD31), and diverse approaches to measurement of BBB leakage (e.g. fibronectin, fibrinogen, gadolinium-based ktrans). Seven studies contributed to meta-analysis: APOE4 mice showed a consistent reduction in CBF associated with APOE4 genotype (SMD = -2.87, 95% CI: -5.14 to -0.604, df = 2.66), and a negative non-significant trend towards reduced vascular morphology expression. Narrative synthesis identified three key mechanistic pathways linking APOE4 to vascular dysfunction: (i) insulin resistance and PI3K/AKT-mTOR signalling, (ii) Cyclophilin A–NFκB–MMP9 activation, and (iii) occludin/ECM remodelling. Risk of bias assessment revealed frequent shortcomings in randomisation, blinding, and sample size justification. Conclusions Preclinical evidence demonstrates that APOE4 drives alterations in vascular functioning primarily through involvement with pathways related to vascular metabolism, ECM remodelling and BBB leakage. However, heterogeneity in the model (e.g. age, sex, techniques), restricts direct comparability across studies. As such, standardisation or clarification of methodological approaches are necessary for rigorous assessment in the future.

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