Simultaneous Thrombosis in a Normal Left Ventricle and Normal Carotid Artery in a Patient With a Stroke Secondary to Iron Deficiency Anemia

Abstract

Iron deficiency anemia (IDA) is implicated as a cause of stroke, particularly in young patients without cardiovascular disease. In such patients, thrombi sometimes form in carotid arteries or the aorta. We report here a patient with a stroke secondary to IDA with thrombi in the normal left ventricle and normal carotid artery. The patient was a 45-year-old woman with severe IDA who developed cerebral infarction in the right middle cerebral artery. She had no other thrombophilia or cardiovascular diseases. Echocardiography showed a left ventricular thrombus without cardiac disease, and the carotid ultrasound showed a mobile thrombus attached to the right internal carotid artery without atherosclerosis. Antithrombotic therapy with iron supplementation removed both thrombi within 2 weeks. This is the first case of IDA with a ventricular thrombus in a normal heart. This case identifies a new site for thrombosis in IDA and shows that patients with IDA may present with simultaneous thrombosis at separate sites. IDA must therefore be recognized as a cause of stroke or systemic embolism, particularly in patients without detectable cardiovascular disease. In such patients, it is important to conduct careful investigations to detect thrombosis.

Embolic Stroke due to a Common Carotid Artery Thrombus in a Young Patient with Severe Iron-Deficiency Anemia without Thrombocytosis

“…The finding of a mural thrombus involving the common carotid artery is extremely uncommon because of the rarity of significant atherosclerotic disease in this large diameter and nonturbulent vessel [ 1 – 4 ]. It is not clear why severe iron-deficiency anemia is associated with thrombus formation in the carotid arteries in the absence of vascular disease [ 1 – 4 ].…”

“…The finding of a mural thrombus involving the common carotid artery is extremely uncommon because of the rarity of significant atherosclerotic disease in this large diameter and nonturbulent vessel [ 1 – 4 ]. It is not clear why severe iron-deficiency anemia is associated with thrombus formation in the carotid arteries in the absence of vascular disease [ 1 – 4 ]. Various pathogenic mechanisms have been proposed including altered hemodynamics resulting in increased turbulent flow and subsequent endothelial injury, reactive thrombocytosis due to elevated erythropoietin levels, and enhanced platelet aggregation and function caused by elevated erythropoietin levels, increased oxidant stress, and reduced activity of iron-containing platelet monoamine oxidase that catabolizes the serotonin necessary for platelet function [ 5 – 8 ].…”

“…Idbaih et al have also reported on 8 patients with spontaneous thrombosis of lesion-free carotid arteries and half of the patients with spontaneous thrombus had severe iron-deficiency anemia, mostly due to menorrhagia [ 10 ]. Nakamizo et al reported a young woman with severe iron-deficiency anemia and thrombocytosis secondary to menorrhagia, who presented with left hemiparesis and was found to have acute right hemispheric infarcts with mural thrombus in a normal left ventricle and carotid artery [ 4 ]. Bukharovich et al reported two young females with history of severe iron-deficiency anemia with reactive thrombocytosis due to menorrhagia presenting with acute arterial embolism and large mobile aortic thrombus in the absence of atherosclerosis [ 11 ].…”

“…Few cases of carotid artery thrombus associated with severe iron-deficiency anemia and reactive thrombocytosis have been reported in young adults [ 1 – 4 ]; however, normal platelet counts in these patients have rarely been described. The pathogenic mechanisms leading to thrombus formation and ischemic stroke due to severe iron-deficiency anemia are not well understood, especially in patients without thrombocytosis.…”

Left ventricular mass: Myxoma or thrombus?

“…[ 17 ] Studies have reported that iron deficiency anemia has been implicated as a cause of systemic thromboembolism. [ 18 19 20 ] Akins et al . [ 21 ] suggested iron deficiency anemia induces turbulence by decreasing viscosity and increasing velocity and thrombosis may be caused by endothelial injury due to turbulent blood flow.…”