Abstract Introduction Intravenous immunoglobulin (IVIG) is a cornerstone of Guillain-Barré syndrome (GBS) management but has been rarely associated with thromboembolic complications, including stroke. We present a case of sequential ischemic strokes temporally associated with IVIG administration in a patient with the pharyngo-cervico-brachial (PCB) variant of GBS. Case Presentation A 56-year-old woman with diabetes, hypertension, and obstructive sleep apnea (OSA) presented with progressive dysphagia, neck and upper extremity weakness for the last 2-3 days. Examination and electrophysiologic findings supported PCB-GBS. She was started on IVIG. Shortly after infusion initiation, she developed hypotension requiring vasopressors, presumed secondary to an anaphylactoid reaction. While in the ICU, she subsequently developed aphasia and right-sided weakness (NIHSS 9). Noncontrast CT was negative for hemorrhage. MRI revealed a small acute infarct in the left posterior frontal lobe with no large-vessel occlusion. After exclusion criteria were reviewed, tenecteplase was administered for acute ischemic stroke. Subsequent imaging demonstrated a new large right MCA infarction without hemorrhagic transformation. Echocardiogram revealed a left ventricular ejection fraction (LVEF) of 45-50% without thrombus or shunt. Continuous telemetry showed no atrial fibrillation. IVIG was discontinued, and she was managed with post-thrombolysis protocol and supportive care. Given the absence of alternative embolic sources and the close temporal relationship, IVIG-induced thrombosis was the likely etiology. Discussion IVIG-related thrombosis occurs in 0.5-15% of treated patients, with ischemic stroke reported in 1% of cases. Risk factors include advanced age, vascular comorbidities, dehydration, and rapid infusion rates. The proposed mechanisms involve increased plasma viscosity, platelet aggregation, and endothelial injury leading to micro and macrovascular thrombosis. This case demonstrates the potential for ischemic strokes after IVIG in a high-risk patient, emphasizing the need for vigilance, slow infusion rates, and careful hydration. A high index of suspicion for stroke in patients developing new neurologic deficits during or shortly after IVIG therapy should be maintained. Risk mitigation through dose adjustment, hydration, and infusion monitoring may prevent this rare but life-threatening complication. This abstract is funded by: NONE
Khan et al. (Fri,) studied this question.
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