ABSTRACT NUMBER: ESOC2026A996 BEYOND THE USUAL PATHWAYS: A RARE PONTINE STROKE AND DELAYED RED CELL EXCHANGE COMPLICATIONS IN SICKLE CELL DISEASE

Abstract Background and aims Sickle cell disease (SCD) is associated with significant cerebrovascular morbidity, most commonly involving the anterior circulation. Brainstem infarction is rare and may be clinically subtle. Red cell exchange (RCE) is recommended for acute ischaemic stroke in SCD but carries risks, including delayed haemolytic transfusion reaction (DHTR) and thrombosis. We report an unusual case of acute pontine infarction complicated by DHTR and pulmonary embolism. Methods A 38-year-old woman with homozygous HbSS presented with acute right facial droop, dysarthria, and right-sided weakness (NIHSS 5). Initial CT/CTA showed no infarction or large-vessel occlusion. MRI brain demonstrated an acute left pontine infarct. She was treated with antiplatelet therapy and underwent urgent RCE following multidisciplinary discussion. She was discharged with neurological improvement. Results Seven days post-RCE, she re-presented with fatigue, pleuritic chest pain, dark urine, and jaundice. Investigations showed severe anaemia (Hb 70 g/L), biochemical haemolysis consistent with DHTR, and CT pulmonary angiography confirmed acute pulmonary embolism. She was treated with corticosteroids, red cell transfusion, and therapeutic anticoagulation. Neuroimaging showed no stroke progression. Her transfusion strategy was revised to avoid further RCE due to risk fo rfurther thrombetic events . Conclusions This case highlights a rare posterior circulation brainstem stroke in SCD and illustrates the diagnostic value of early diffusion-weighted MRI when CT is unrevealing. While RCE remains central to acute stroke management in SCD, clinicians must remain vigilant for serious haematological complications such as DHTR and thromboembolism. Individualised transfusion strategies and multidisciplinary care are essential to balance neurological benefit against systemic haematological risk factors. Conflict of interest No Disclosure Figure 1 - belongs to Methods Figure 2 - belongs to Results