Histopathological analysis of cerebral hemorrhage in systemic lupus erythematosus complicated with antiphospholipid syndrome

Heterogeneity of Stroke in Patients with Systemic Lupus Erythematosus

Objective The underlying pathophysiology varies according to stroke subtype. However, stroke heterogeneity among patients with systemic lupus erythematosus (SLE) remains unstudied. We hypothesized that the contribution of SLE to stroke might vary according to its subtype and investigated the associations of SLE and various stroke subtypes. Methods Diagnostic codes and electronic medical records were used to identify 70 patients with SLE who developed acute cerebral infarction or intracerebral hemorrhaging at four tertiary referral hospitals between 2008 and 2018. Intracerebral hemorrhaging was classified as lobar or deep, while cerebral infarction was classified according to the SSS-TOAST criteria. Physician notes were used to identify SLE activity, and their prevalences were compared among stroke subtypes. Outcomes were collected from the patients' medical records. Results The most common stroke subtype in patients with SLE was that of undetermined causes (31%), followed by small artery occlusion (16%), cardioaortic embolism (13%), other causes (11%), lobar hemorrhaging (10%), deep hemorrhaging (10%), and large artery atherosclerosis (9%). Stroke onset occurred during a period of high SLE activity in 21 patients (30%). The proportion of patients with high SLE activity varied according to stroke subtype (p=0.039) and was highest for cerebral infarction with undetermined causes. Stroke recurrence or death was observed in 40% of patients within 5 years after the initial stroke onset. Conclusion The contributions of SLE to stroke varied significantly according to the stroke subtype. Given the unfavorable prognosis, close stroke subtype-specific observation by rheumatologists and stroke specialists is recommended after stroke events.

Massive haemorrhage: an unusual presentation of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) usually affects young females and its presentation with haemorrhage is unusual. Intracerebral bleed (ICB) has been described in a few case reports, but massive haematuria has not been reported in the literature so far. Here, we present a case of a 56 year-old-lady who presented with expanding lobar bleed and massive haematuria as the first presentation of SLE secondary to vasculitis. Lupus vasculitis usually presents with thrombosis-related complications and although bleeding in this context is rare, it can lead to catastrophic consequences. Hence, vasculitis-related bleeding should be taken under consideration in a challenging situation like ours.