1417 - Ischemic stroke in a 50-year-old woman etiology: presumed hypercoagulability from hormonal NuvaRing use

Case Diagnosis: Hypercoagulable state in the setting of hormonal NuvaRing use causing ischemic stroke and extensive clot burden in a 50-year-old woman with no known risk factors.

Case Description: A 50-year-old woman with a history of complex migraines presented with left-sided facial droop and hemiplegia found to have a right middle cerebral artery occlusion. Her hospital course was complicated by occlusions in the right brachial, ulnar, and radial arteries requiring a thrombectomy. Her hospital stay was notable for a stroke workup including transthoracic echocardiography showing no major source of emboli, an antiphospholipid lab negative for lupus anticoagulant, anticardiolipin, and beta 2 glycoprotein antibodies. Other pertinent labs such as PNH Flaer, Factor V and II mutations, and JAK2 V617F mutation were also negative. A CT scan of the chest, abdomen, and pelvis did not find any evidence of malignancy. OBGYN consult confirmed that patients over 40 years of age have a higher risk of developing a hypercoagulable state leading to thrombosis and clot formation from estrogen-containing NuvaRing, the only pertinent risk factor for this patient.

Discussions: She was initially recommended for acute rehabilitation due to severe left-sided hemiparesis and hypoesthesia, deficit in cognition, gait instability, and left-sided neuropathic pain leading to decreased endurance and functional mobility. Hemiparesis, gait instability, and cognition improved over the course of her rehab stay. Neuropathic pain improved with the initiation of Gabapentin. She was deemed safe for discharge to home with a wheelchair and home therapies.
NuvaRing use is associated with a 2.5 times increased risk of having a thrombotic stroke compared to non-use. In this instance, it caused an extensive clot burden.

Conclusions: Hormonal NuvaRing use leading to such an extensive clot burden is a rare etiology of ischemic stroke. It can present in relatively young patients with no known risk factors, leading to functional impairment requiring a comprehensive rehabilitation plan.