C51-01 Severe Thrombotic Event in a Healthy Young Adult: A Rare Consequence of Tranexamic Acid (TXA) and Progestin Use

Introduction Catastrophic cardioembolic events in young, otherwise healthy individuals are uncommon and warrant thorough investigation. Although ischemic strokes are being reported with increasing frequency in adults without conventional vascular risk factors, cases associated with nontraditional or transient exposures remain rare. Here, we describe a case of a young woman who developed multifocal cerebral infarctions and deep vein thrombosis, with the only potential contributors being a short course of progestin therapy and intermittent use of TXA. Case Description A 24-year-old woman with a history of polycystic ovary syndrome (PCOS) and severe menorrhagia had been on medroxyprogesterone acetate for two months. This was discontinued due to plans for pregnancy, and she was transitioned to intermittent tranexamic acid (TXA) two months before presentation. She initially experienced headache, nausea, and progressive altered mental status. In the emergency department, her condition rapidly deteriorated, with the development of lethargy, unresponsiveness, and left gaze deviation, necessitating endotracheal intubation. Non-contrast head computed tomography (CT) demonstrated bilateral cerebellar infarcts, a left temporo-occipital infarct, brainstem compression, and obstructive hydrocephalus. Magnetic resonance imaging (MRI) confirmed extensive infarctions in the posterior circulation. Duplex ultrasonography of the upper extremities revealed extensive bilateral deep vein thromboses. She underwent emergent external ventricular drain placement and suboccipital craniectomy. Empiric treatment for meningoencephalitis and corticosteroids was started but discontinued after negative results. An extensive workup, including a lumbar puncture, EEG, echocardiography, and hypercoagulable testing, was unremarkable. Although hydrocephalus resolved over the following days, her neurological status remained severely impaired (NIHSS >30). Given the poor prognosis, the care team continued discussions with her family to align care goals and assess the appropriateness of further interventions. Discussion This case describes a rare presentation of severe thromboembolic events in a young patient receiving short-term tranexamic acid and progestin-only oral contraceptives. Thromboembolic events are uncommon with progestin-only formulations, and evidence linking TXA to venous thromboembolism is limited. Extensive workup was otherwise unremarkable, supporting medication-related thrombotic effects as the most likely etiology. This case underscores the gaps in current knowledge regarding the thrombotic potential of TXA, particularly in combination with hormonal therapy. Clinical implications Clinicians should remain vigilant for medication side effects even in the absence of traditional risk factors. Careful monitoring and prompt evaluation of neurological or systemic symptoms are essential to ensure early recognition and intervention.