ABSTRACT NUMBER: ESOC2026A1892 ACUTE ISCHAEMIC STROKE AND THROMBOLYSIS IN THE CONTEXT OF SEVERE ANAEMIA OF UNDETERMINED CAUSE: A RARE CASE PRESENTATION

Abstract Background and aims Intravenous thrombolysis is an established treatment for acute ischaemic stroke, with strict eligibility criteria. Current international guidelines define contraindications based on active bleeding and coagulopathy but do not specify a haemoglobin threshold. Nevertheless, observational evidence shows that anaemia predicts poorer outcomes after thrombolysis and severe anaemia often raises clinical concern and may complicate decision-making, particularly when its cause is unclear. We present a case of acute ischaemic stroke treated with thrombolysis in the context of significant anaemia and subsequent identification of systemic embolic disease and malignancy. Methods A 59-year-old man with a history of resected ear sarcoma and hyperlipidaemia presented with acute onset slurred speech, confusion, word-finding difficulty and limb weakness. A diagnosis of acute stroke was made. NIHSS was 8. Laboratory investigations and neuroimaging were performed to assess thrombolysis eligibility. Results Patient’s haemoglobin was below <80 g/L (76). Non-contrast CT brain showed no haemorrhage. The decision was made to proceed with thrombolysis. The patient had excellent functional recovery in the hours after administration, NIHSS improving to 1. Further investigations revealed embolic nature of the stroke with SMA thrombus and possible cardiac vegetation suggesting endocarditis for which he was subsequently treated. He was later found to have duodenal malignancy. Conclusions This case highlights the complexity of thrombolysis decision-making in the presence of severe anaemia, occult malignancy, and systemic embolisation. Despite these factors, thrombolysis was associated with substantial neurological recovery without immediate complication. This case further reinforces the importance of timely and effective intervention for neurological recovery. Conflict of interest nothing to disclose