Describe two cases of cerebral ischemic strokes presenting with carotid thrombi associated with severe iron deficiency anemia (IDA) and thrombocytosis.

IDA is a widespread blood disorder, particularly prevalent among premenstrual women. Several case reports have suggested that IDA could be an uncommon risk factor for ischemic stroke in young adults. Nevertheless, the predisposing factors and underlying mechanisms remain poorly documented.

A 42-year-old African American female with a prior medical history of severe IDA (hemoglobin 3.4g/dl) requiring blood transfusions presented with new-onset left hemiparesis and hemianesthesia. MRI Brain showed multifocal infarcts throughout the right middle cerebral artery territory. CT angiogram showed a non-flow-limiting right internal carotid artery (ICA) proximal filling defect. Labs were remarkable for microcytic anemia with a hemoglobin level of 8.7g/dL, a ferritin level of 45ng/mL, and a platelet count of 1489TH/mm³. Notably, she had experienced a similar ischemic stroke about four years prior and had a follow-up carotid ultrasound indicating no right ICA stenosis after the first stroke. A 45-year-old African American female with a history of chronic anemia presented with new-onset left facial paresis and hemiparesis. MRI Brain showed scattered infarcts in the right cerebral hemisphere. CT angiogram showed bilateral proximal ICA (right>left) non-occlusive thrombi. Labs were remarkable for microcytic anemia with a hemoglobin of 6.8g/dL, a ferritin level of 11ng/mL, and a platelet count of 920TH/mm³. Both young patients in this report had extensive stroke evaluations to rule out other secondary causes, including atherosclerosis, cardiac monitoring, coagulopathies, and sickle cell screens. Additionally, they had transesophageal echocardiograms which showed tiny patent foramen ovale, and their four-extremity deep venous thrombosis screenings yielded negative results.

These cases illustrate that carotid thrombi with secondary ischemic stroke may complicate IDA in young adults without other stroke risk factors. Reactive thrombocytosis secondary to IDA may be a possible mechanism.