To share an intriguing case of a young transgender male patient receiving testosterone therapy who developed locked-in syndrome due to an acute ischemic stroke and to highlight potential risk factors for stroke in the LGBTQI+ community

There are many studies identifying risk factors for stroke in racially and ethnically diverse populations. However, there is little existing data for stroke risk factors in the LGBTQI+ community. Prior research has shown testosterone therapy in cis-gender men with initially low levels of testosterone increases the risk of stroke, especially in the first 2 years of use¹. While testosterone therapy has been shown to increase the risk of venous thrombosis, its role in arterial thrombosis is unclear². A proposed mechanism for thrombosis with testosterone replacement includes erythrocytosis, but the potential contribution of an independent pro-coagulant effect is yet to be determined³.

Literature review and case report.

An otherwise healthy 23-year-old transgender male on one year of testosterone therapy presented in an obtunded state. Examination revealed complete quadriplegia with sparing of vertical eye movements, consistent with locked-in syndrome. Imaging revealed complete occlusion of the basilar artery with distal reconstitution at the superior cerebellar arteries, and a large bilateral ischemic infarct of the pons. Computed tomography angiography did not demonstrate other large vessel disease or structural vascular abnormalities. Unfortunately, the patient was out of the time window for any acute stroke interventions. A hypercoagulable workup was performed but results were unrevealing and hematocrit was normal. Further investigation with transthoracic echocardiogram, transesophageal echocardiogram, and telemetry were negative for thrombus, patent foramen ovale, and atrial fibrillation. 

Acute ischemic stroke may be an under recognized complication of testosterone therapy in transgender males independent of degree of erythrocytosis. Further research is needed to establish a safety profile of testosterone therapy in this understudied population.