Recurrent ischemic strokes in a patient with ITP: A case report

Primary Immune Thrombocytopenia (ITP) is typically associated with bleeding risks due to thrombocytopenia. However, paradoxical thrombotic events such as stroke may occur in rare cases, posing a clinical dilemma in management. We present the case of a 65-year-old male with a history of ITP and recurrent venous thromboembolism who experienced multiple ischemic strokes despite therapeutic anticoagulation. The initial presentation revealed subacute bilateral frontal infarcts while on Rivaroxaban, with extensive workup suggesting a cryptogenic stroke etiology. The patient was subsequently switched to Warfarin and treated for ITP with steroids and Rituximab, resulting in improved platelet counts. Eight months later, he suffered a pontine infarct despite therapeutic INR. His anticoagulation goal was adjusted, and he remained stroke-free on close follow-up. This case highlights the underrecognized thrombotic risk in ITP patients and the challenges in balancing anticoagulation with bleeding risk. Mechanisms may include increased platelet microparticles and immune-mediated endothelial injury. The individualized INR target and ITP treatment strategy led to improved clinical outcomes. ITP can predispose patients to thrombotic complications such as stroke, even in the setting of thrombocytopenia. Personalized anticoagulation goals and multidisciplinary care are critical for optimal management. Further studies are needed to establish standardized treatment guidelines for this unique patient population. • This case report describes recurrent ischemic strokes in a patient with primary immune thrombocytopenia (ITP), despite adequate anticoagulation. • ITP, typically associated with bleeding, can paradoxically increase thrombotic risk due to procoagulant platelet microparticles. • The patient experienced embolic strokes while on Rivaroxaban and later had a recurrent stroke on Warfarin with therapeutic INR. • Multidisciplinary management, and treatment of ITP with steroids and Rituximab, led to improved outcomes. • This case underscores the need for personalized anticoagulation strategies in ITP patients and highlights the lack of standardized guidelines.