Clinical and Radiological Features of Ischemic Stroke in Patients with Antiphospholipid Antibody Syndrome: A Case Series Report
Authors: Sarathchandran Pournamy , Almarzooqi Ahlam , Alawadhi Ahmed , BV Ajith 
Published: January 2025

Objective: To describe the clinical, radiological, and laboratory characteristics of ischemic strokes associated with antiphospholipid antibody (APS) syndrome.

Background

Antiphospholipid antibody syndrome (APS) is a systemic autoimmune disorder characterized by the presence of antiphospholipid antibodies (aPL) that contribute to a prothrombotic state, leading to both venous and arterial thrombosis. Clinically, APS is associated with significant morbidity due to recurrent thrombotic events, thrombocytopenia, and recurrent pregnancy loss, with cerebral ischemia being the most prevalent arterial manifestation. The mechanisms by which aPL induces thrombotic events are complex and multifactorial, involving endothelial cell activation, platelet aggregation, and interference with coagulation pathways. These pathogenic effects, exerted by aPL, substantiate the role of APS in cerebrovascular events such as ischemic stroke.

While APS is recognized as a significant contributor to stroke, particularly in young patients, the clinical and radiological characteristics of APS-associated stroke remain underexplored. Currently, there is no specific clinical or imaging profile to distinctly identify APS-related ischemic strokes. Given this gap, there is an imperative to characterize the clinical presentations and radiographic findings in APS patients to aid early identification and tailored management. This case series aims to elucidate the clinical, laboratory, and radiological features of APS in young stroke patients, emphasizing the importance of aPL testing in this population.

Methods

This retrospective case series analyzed the clinical, laboratory, and radiological data of patients under 45 years of age who were diagnosed with antiphospholipid antibody syndrome (APS) as the etiology of ischemic stroke at two major government hospitals in the United Arab Emirates. Each patient underwent comprehensive testing for antiphospholipid antibodies (aPL) upon admission, followed by confirmatory testing during a follow-up visit within 3–5 months. Clinical variables, aPL profile, stroke presentation, and imaging findings were systematically reviewed. Patients received anticoagulation therapy following diagnosis.

Results

Among the ten patients diagnosed with APS-related ischemic stroke, the median age was 34 years (range 26–52), with a male-to-female ratio of 4:1. Secondary APS was identified in one patient with systemic lupus erythematosus, while the remaining nine cases were primary APS. Lupus anticoagulant was detected in four patients, anticardiolipin antibodies in five, and β2-glycoprotein antibodies in two. Aphasia was the predominant clinical presentation (observed in 8 of 10 cases), often accompanied by hemiparesis. Stroke localization predominantly involved the M2 segment of the middle cerebral artery, resulting in perisylvian infarcts, particularly affecting the left hemisphere. One patient developed a concurrent pulmonary embolism during hospitalization. Laboratory findings showed mild thrombocytopenia in three patients, with elevated activated partial thromboplastin time (aPTT) observed in six patients.

Conclusion

Ischemic strokes associated with antiphospholipid antibody syndrome (APS) predominantly localize to the perisylvian region within the M2/M3 branches of the middle cerebral artery, exhibiting clinical and radiological features that closely resemble those of cardioembolic strokes. Elevated activated partial thromboplastin time (aPTT) and thrombocytopenia were observed as potentially sensitive laboratory markers indicative of APS. Given the overlap in presentation with other stroke etiologies, it is recommended that antiphospholipid antibody testing be integrated into the diagnostic workup for all young patients exhibiting suggestive clinical and radiological findings, alongside a comprehensive cardiac evaluation, irrespective of traditional vascular risk factors. Early identification and management of APS in these patients may reduce the risk of recurrent thrombotic events and improve clinical outcomes.