Secondary Polycythemia as an Uncommon Cause of Large Vessel Occlusion Resulting in Acute Ischemic Stroke (P4.3-010)

Objective: To describe two cases of secondary polycythemia presenting as acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in the absence of traditional etiologies (hypertension, diabetes, dyslipidemia, systemic atherosclerosis, cardioembolism) and management options. Background: Polycythemia has been recognized as an atypical AIS etiology, but most frequently presenting as small-vessel thrombo-occlusive or embolic disease rather than LVO. Design/Methods: Case 1: 58 year old female with 0.5 PPD smoking history presented after TIA two days prior with right ACA and MCA AIS secondary to right ICA occlusion (initial NIHSS = 7). CTA revealed mid-cervical right ICA occlusion without atherosclerotic disease in remaining intra or extracranial vessels. Hemoglobin and hematocrit on admission were 17.8/52.9%, erythropoietin 3.0, and JAK2 negative. Remaining labs were significant for HbA1c 5.4% and LDL 57. Given her fluctuating symptoms, she underwent right ICA stenting with clinical improvement upon discharge (NIHSS = 0). Case 2: 59 year old male with 2 PPD smoking history presented with right MCA AIS (initial NIHSS = 15) with completed infarction, outside of the window for cerebrovascular intervention. MRA revealed proximal right M2 occlusion without atherosclerotic disease in remaining vessels. Hemoglobin and hematocrit on admission were 20.6/58.0%, erythropoietin 3.9, and JAK2 negative. Remaining labs were significant for HbA1C 4.8% and LDL 67. After Hematology consultation, the patient was phlebotomized during hospitalization with clinical improvement upon discharge (NIHSS = 9). No obvious source of cardioembolism was found in either case on prolonged telemetry or echocardiography. Results: NA Conclusions: Extensive smoking history may lead to polycythemia, increasing the risk of not only microvascular cerebral ischemia, but LVO as well, which has not been shown extensively in prior literature. Polycythemia should be considered as part of the differential for atypical etiology of LVO and AIS. There may be a role for acute phlebotomy and/or intervention in the management of such cases. Disclosure: Dr. Mulpur has nothing to disclose. Dr. Handshoe has nothing to disclose. Dr. Buletko has nothing to disclose.