Abstract
Background/Objectives Chronic disseminated intravascular coagulation (DIC) is a rare complication of delayed type 1 endovascular leaks. Chronic DIC is associated with both haemorrhagic and thrombotic complications. On literature review, there are no previous reports of ischaemic stroke secondary to chronic DIC from an endovascular leak.
Methods Case report and literature review.
Results A 50-year-old male presented with recurrent embolic ischaemic strokes of otherwise undetermined source, 9 and 27 months following a Stanford Type B aortic dissection repaired by left carotid subclavian bypass and thoracic endovascular aortic repair (TEVAR). This was complicated by a type 1 endovascular leak, diagnosed 3 months post-surgery and treated conservatively. Secondary prevention following his first stroke included clopidogrel, which was associated with easy bruising and cold intolerance.
Diagnostic evaluation demonstrated chronic DIC (undetectable haptoglobin (<0.10g/L), decreased fibrinogen (1.05g/L), prolonged APTT (43s), elevated INR (1.7), elevated D-dimer (14.4mg/L), and thrombocytopaenia (nadir of 94x109L). Coagulation factor II, V, X and XI levels were also low, as were Protein C, S and Antithrombin III. Extensive stroke workup was otherwise unremarkable. After multidisciplinary discussion, he was treated with apixaban. Eleven months later, stroke has not recurred, platelet count, fibrinogen and haptoglobin levels have recovered, and clinical symptoms of cold intolerance and easy bruising have resolved. Coagulation factor levels and D-dimer levels remained abnormal, however.
Conclusion We present a case of recurrent ischaemic stroke subsequent to chronic DIC from a delayed type 1 endovascular leak. Apixaban may be a superior secondary prevention agent to clopidogrel in this setting.
