Multifocal Ischemic Stroke in a Young Patient With Ulcerative Colitis Treated With Upadacitinib: Implications for Thrombotic Risk Stratification

Upadacitinib, a selective Janus kinase-1 inhibitor, is increasingly used for moderate to severe ulcerative colitis, though concerns regarding thrombotic risk persist. We report a rare case of multifocal ischemic stroke in a young patient with ulcerative colitis who developed acute neurologic symptoms approximately 3 months after starting upadacitinib. Neuroimaging revealed extensive bilateral cerebral and cerebellar infarcts without evidence of large-vessel disease, cardio embolism, or inherited thrombophilia. The patient lacked traditional cerebrovascular risk factors and subsequently developed a pulmonary embolism during hospitalization. This case highlights a potential severe thrombotic complication associated with upadacitinib and underscores the need for careful risk assessment and postmarketing surveillance.