Ovarian hyperstimulation syndrome and arterial stroke.

A 29-year-old woman undergoing in vitro fertilization treatment for infertility presented to a rural hospital 7 days after embryo transfer with abdominal distension, nausea, headache, and paresthesias. General examination revealed a distended abdomen with moderate generalized tenderness. Neurological examination revealed a left-sided facial droop with mild dys-arthria and a left pronator drift. The remainder of her examination was normal. Her National Institute of Health Stroke Scale Score was 3. Laboratory investigations showed a positive pregnancy test, a hemoglobin concentration of 165 g/L, a hemato-crit of 0.46 L/L, and low albumin of 22 g/L. Hypodensities in the right frontal and parietal lobes were found on computed tomography. She was transferred to the Stroke Team at a ter-tiary care center for further workup and management. On arrival, she was started on aspirin, clopidogrel, and prophylactic subcutaneous heparin. Computed tomographic angiography showed an intraluminal thrombus at the origin of the right internal carotid artery and a distal right M3 branch occlusion (Figure 1). Bilateral large pleural effusions were also noted. MRI with diffusion-weighted imaging showed a large, acute right middle cerebral artery territory ischemic infarct, with no findings on MR venography. Autoimmune and thrombophilia screenings were negative; she denied a family or personal history of coagulation disorders or stroke. Abdominal ultrasound showed enlarged ovaries and ascites in keeping with the diagnosis of ovarian hyperstimulation syndrome (OHSS). Because of the large internal carotid artery thrombus and clinical stability, she was transitioned to therapeutic intravenous unfractionated heparin. Three days after initial presentation, she experienced a worsening of her symptoms with complete left hemiplegia and anarthria. Emergent computed tomographic angiography showed migration of the previously noted right internal carotid artery thrombus distally and into the distal M1 (Figure 2). Intravenous tissue-type plas-minogen activator was not considered because of the subacute infarction. Interventional radiology performed mechanical intra-arterial clot retrieval and achieved full recanalization (Thrombolysis in Cerebral Infarction grade 3). Her clinical examination immediately returned to her previous baseline. Scattered new areas of infarction were demonstrated on a repeat MRI before discharge. She required a paracentesis for symptomatic relief of abdominal pain and dyspnea during her stay of the stroke unit. She was discharged home with outpatient rehabilitation follow-up and ongoing obstetric care. Discussion OHSS is a well-described consequence of ovulation induction therapies for fertility treatment. The reported incidence is 0.3% to 6%. 1 Severe complications, namely venous occlusive disease and rarely arterial thromboembolic events, 1,2 occur in …