Primary antiphospholipid antibody syndrome and cerebral ischemia: report on acute intervention in two cases and literature review with emphasis on therapeutic options

Combined intravenous and intraarterial thrombolytic therapy for treatment of an acute ischemic stroke: a case report

Acute cerebral ischemia resulting from the occlusion of a large or medium size intracranial artery is a known complication of antiphospholipid antibody syndrome (AAS). Usually these patients are treated by low dose aspirin and anticoagulants to prevent a stroke. We are reporting a case of acute stroke in a patient with AAS in whom combined intravenous and intraarterial thrombolytics were used emergently with an excellent outcome. A 32-year-old woman presented with a left hemispheric stroke of 2.5 hours duration. A computed tomography (CT) study of the brain was normal. The patient was treated with intravenous tissue plasminogen activator but remained aphasic and hemiplegic. Subsequently, the patient had a stable xenon CT cerebral blood flow study demonstrating low flow in the left middle cerebral artery (MCA) territory and an angiogram, which demonstrated occlusion of the left MCA. The patient was then treated with intraarterial urokinase with a rapid and marked improvement in her neurological deficit. The case suggests that stroke patients can be treated safely and effectively with combined thrombolytics.

The antiphospholipid-protein syndrome

The pathogenesis of the antiphospholipid syndrome remains uncertain. Antibodies that react with phospholipids may not be directly responsible for cellular injury, but may be part of the immune network through which autoantibodies with pathogenic potential are generated. The latter may recognize proteins such as beta 2-glycoprotein I that form complexes with phospholipids, proteins whose functions depend upon interaction with phospholipids such as protein C and its cofactors, altered lipoproteins such as oxidized low-density lipoproteins, or other molecules that share only antigenic similarity. Thus, a spectrum of autoantibodies that recognize different lipid-protein complexes may develop in these patients and contribute to the observed clinical heterogeneity of the syndrome. Current techniques do not permit identification of the subset of patients with antiphospholipid antibodies at risk for thrombosis or abortion and there are no prospective, controlled trials addressing the prophylaxis or treatment of affected individuals. Identification of the cellular targets of antibodies to lipid-protein moieties is needed to identify patients at risk for these complications and as a means to monitor therapy.