The six episodes of ischemic stroke during 16 years. Clinical case in a young woman

ABSTRACT

Background: Up to 23-25% of patients experience a second stroke within the first 5 years after the first episode despite prophylaxis. Aim(s) Our aim is to discuss the risk factors of recurrent ischemic stroke and the efficiency of anticoagulation therapy. Method(s) A report of a 50-year- old female patient who presented with a medical history of migraine, hypertension, 3 episodes of ischemic stroke within 12 years (the last one occurring 2 months ago), right hemiplegia, 2 miscarriages and multiple surgeries appendectomy, myomectomy, hysterectomy due to adenomyosis, cataract surgery, cervical polypectomy, oophorectomy, meniscectomy after trauma. Result(s) Thrombophilia testing revealed heterozygous mutations of F13A1, ITGA2 and PAI1 genes. Antiphospholipid antibodies were within normal ranges. She received treatment with Rivaroxaban 20 mg/daily 1 month, B-Complex vitamins, after which Clopidogrel 75 mg was prescribed. But the next ischemic stroke with hemorrhagic transformation occurred within 6 months. Type 2 diabetes was diagnosed 1 year later and Metformin hydrochloride was initiated. She underwent cholecystectomy due to benign tumors of the gallbladder and received treatment for Helicobacter pylori after which fifth episode of ischemic stroke happened. One year later she complained of headache, dizziness, unsteady gait, memory impairment, syncope and convulsions. Electroencephalography and echocardiography findings were not remarkable, ultrasound revealed multinodular goiter (TIRADS 2). COVID-19 PCR test and anti-SARS- CoV- 2 IgG/IgM antibodies were negative. Labs showed 40.9% lymphocytes, prolonged APTT (45.4 s, reference range 30-40 s), slightly elevated ALT (34.9 U/L, reference range < 33). Urinalysis detected 0.03 g/L albumin and 1.13 HPF mucus. Two weeks later the sixth episode of ischemic stroke occurred despite receiving antiaggregation with Acetylsalicylic acid. Double testing for antiphospholipid antibodies, Protein C and S, homocysteine were normal, antithrombin III was 123.0%. Conclusion(s) Although low-risk thrombophilia mutations, type 2 diabetes, hypertension, overweight and multiple surgeries are the risk factors of 6 thrombotic events, cancer should be excluded taking into account her anamnesis.