Late-Onset Antiphospholipid Syndrome Presenting With Recurrent Multifocal Ischemic Strokes: Diagnostic and Management Challenges

Antiphospholipid syndrome (APS) is an autoimmune prothrombotic disorder that predominantly affects women of childbearing age and is a recognized cause of ischemic stroke. In older adults, APS is uncommon and frequently overlooked because cerebrovascular events are often attributed to traditional vascular risk factors, resulting in delayed diagnosis and treatment. We report the case of a 65-year-old woman with a history of hypertension, dyslipidemia, chronic kidney disease, recurrent transient ischemic attacks (TIAs), previous intraventricular hemorrhage, and intracranial aneurysm repair, who presented with dysarthria, gait ataxia, and quadriparesis. She had experienced multiple recurrent cerebrovascular events over several years despite extensive vascular and cardiac investigations and appropriate antiplatelet therapy. Brain magnetic resonance imaging (MRI) demonstrated multiple acute multifocal ischemic infarcts involving both cerebral hemispheres on a background of extensive chronic ischemic changes. Laboratory evaluation revealed mild thrombocytopenia and a high-risk antiphospholipid antibody (aPL) profile, including positive lupus anticoagulant (LA) and markedly elevated anti-β2-glycoprotein I (β2GPI) IgG antibodies, while anticardiolipin (aCL) IgG and IgM antibodies were negative. As APS classification criteria require persistent aPL positivity on repeat testing at least 12 weeks apart, initiation of long-term anticoagulation was deferred pending confirmatory testing. This decision was further influenced by the patient’s increased bleeding risk due to previous intracranial hemorrhage. Aspirin therapy continued while she underwent rehabilitation and awaited repeat antibody testing. This case highlights the diagnostic and therapeutic challenges of elderly-onset APS presenting with recurrent multifocal ischemic strokes. APS should be considered in older patients with recurrent or unexplained ischemic strokes, particularly when routine vascular and cardiac evaluations do not identify an adequate cause. Early recognition and appropriate serological testing may reduce diagnostic delays and facilitate secondary stroke prevention. Management requires individualized risk-benefit assessment, especially when anticoagulation is considered in patients with significant bleeding risk.