ABSTRACT NUMBER: ESOC2026A1171 PROGRESSIVE CEREBRAL MICROBLEEDS DURING LONG TERM WARFARIN THERAPY IN TRIPLE POSITIVE ANTIPHOSPHOLIPID SYNDROME PRESENTING WITH LOBAR INTRACEREBRAL HAEMORRHAGE

Abstract Background and aims Cerebral microbleeds are associated with an increased risk of intracerebral haemorrhage in patients receiving anticoagulation. In triple positive antiphospholipid syndrome, long term warfarin therapy is unavoidable because of the high risk of recurrent thrombosis. Methods A 65-year-old woman with triple positive antiphospholipid syndrome and recurrent ischaemic strokes, including events during sub therapeutic anticoagulation, presented with new onset focal seizures and was found to have a lobar intracerebral haemorrhage while on warfarin. Initial CT brain demonstrated an acute left posterior parietal lobar intraparenchymal haemorrhage with an INR of 3.0. MRI demonstrated extensive cerebral microbleeds with progression in both number and size compared with previous imaging done 5 years previously Results Warfarin was withheld on admission without reversal due to extreme thrombotic risk. Blood pressure was optimised. Following multidisciplinary discussion, prophylactic then therapeutic low molecular weight heparin was commenced once blood pressure was controlled, and warfarin restarted five days after haemorrhage resuming a target INR of 2.5 to 3.0 and made a good neurological recovery. Conclusions This unusual case demonstrates the challenges of continuing warfarin therapy with progressive cerebral microbleed burden in triple positive antiphospholipid syndrome with high thrombotic risk, culminating in lobar intracerebral haemorrhage. While cerebral microbleeds increase haemorrhagic risk, particularly with vitamin K antagonists, cessation of anticoagulation or switching to direct oral anticoagulants is not an option in high-risk antiphospholipid syndrome. Management is therefore a therapeutic trade off, with optimising blood pressure control and reducing INR variability to reduce risk of haemorrahge recurrence and microbleed progression. Conflict of interest Charis Mavrokoradotos - nothing to disclose