Multifocal Bihemispheric Ischemic Strokes Due to Unknown Thrombotic Microangiopathy

Abstract

Thrombotic microangiopathy is an uncommon etiology of acute ischemic stroke, particularly when accompanied by overlapping features of multiple subtypes of thrombotic microangiopathies. Our case highlights the diagnostic and therapeutic challenges that emerge when stroke, hemolysis, coagulopathy, and renal dysfunction converge in a single clinical scenario. We present a 63-year-old female that developed multifocal, bilateral cerebral infarctions in the context of severe thrombocytopenia, hemolytic anemia, prolongation of clotting times, and acute kidney injury. The trajectory of her laboratory parameters revealed evolving coagulopathy and kidney injury, hallmarks of both thrombotic thrombocytopenic purpura and disseminated intravascular coagulation. In addition, normal ADAMTS13 activity level led to diagnostic uncertainty and delay in initiating plasma exchange and immunosuppression. The patient’s clinical course rapidly deteriorated, resulting in fatal neurologic injury. The patient’s course reveals the challenges of distinguishing among thrombotic microangiopathies when clinical and laboratory findings are incomplete. This ambiguity delayed initiation of plasma exchange and corticosteroids, and neurological outcomes were ultimately terminal. Our experience exemplifies key clinical principles: a normalized ADAMTS13 result obtained after plasma transfusion should not exclude thrombotic thrombocytopenic purpura; and, when suspicion remains high, empiric plasma exchange and immunosuppression should be instituted without delay, as survival depends on rapid intervention. Conversion of laboratory and clinical data into timely action remains essential to improving outcomes in such complex presentations. This case illustrates a unique presentation of multifocal ischemic stroke due to an evolving thrombotic microangiopathy with disseminated intravascular coagulation-like features, emphasizing the need for heightened clinical vigilance and decisive treatment.