All that scatters is not heart: A case of TTP presenting as multi-territorial stroke

Abstract

Background. Multi-arterial territorial or bi-hemispherical involvement in ischemic stroke, is commonly indicative of an embolic origin from a cardiac source, secondary to either structural or rhythm abnormalities. Other possible sources include acquired and congenietal conditions predisposing to systemic hyper-coagulability. In this regard, thrombotic thrombocytopenic purpura (TTP) a rare multisystem prothrombotic disorder, as a cause of multi-territorial stroke is subsequently discussed. Case presentation. A 60-year female diabetic on irregular medication presented 30 hrs after sudden diminution of vison in her left eye. MRI brain showed multiple non haemorrhagic infarcts in bilateral parieto-occipital regions and right thalamus with additional multiple scattered infarcts in bilateral cerebellar and frontoparietal regions In view of the multi-territorial and bilateral nature of her stroke, she was considered for therapeutic anticoagulation. But her routine labs done unexpectedly showed haemoglobin of 7.6 g/dl, platelet count of 35000 platelets per microliter, with elevated creatinine. Subsequent workup revealed evidence of micro-angiopathic haemolysis in her peripheral smear. A provisional diagnosis of acquired TTP was made and the calculated PLASMIC score of the patient was found to be 6. Conclusion. We report this case to highlight the need to consider TTP in the differentials when encountering embolic or cryptogenic strokes, and to initiate early plasma exchange.

Keywords

• thrombotic thrombocytopenic purpura
• multi-territorial stroke
• cryptogenic stroke