Embolic stroke following an uterine artery embolization (UAE) is a rare but serious complication. Catheter based intervention to establish arterial access and inject embolic material places a risk for paradoxical or systemic embolization. We present a case of a perimenopausal female with undiagnosed hypercoagulable state who developed peripheral artery thrombosis and embolic stroke following UAE.

A 52-year-old female presented to the hospital with significant anemia, hemoglobin 4.1 g/dL (11.6-15), secondary to abnormal uterine bleeding in context of leiomyomas. Vascular radiology was consulted, and patient underwent an UAE. Following the procedure, she developed nausea, confusion and imbalance that prompted a neurology consult. Non-contrast head Computed Tomography (CT) showed patchy and confluent hypodensities in the bilateral cerebellar hemispheres and right occipital lobe with subsequent development of hydrocephalus requiring external ventricular drain (EVD), followed by suboccipital craniotomy. Hospital course was complicated by left arm pain and hand pallor. Vascular work-up with CT angiogram of left upper-extremity showed left proximal radial artery thrombus. A transthoracic echo revealed no intracardiac shunt. Hypercoagulable work-up was positive for anti-beta 2 glycoprotein, IgA and IgM Antibodies, 28.1 and 35.4 Standardized-Measurement-Units (0-20), and anti-cardiolipin IgG Antibodies.

Stroke following uterine artery embolization is extremely rare and may result from paradoxical embolization, arterial reflux of embolic material, or procedural factors. In this patient, bilateral cerebellar and right occipital lobe involvement is atypical for a trans-radial approach, as it would typically affect the left vertebral artery territory via the left subclavian artery. Concurrent radial artery thrombosis, along with positive anti-beta 2 glycoprotein and anticardiolipin-antibodies, indicates possible underlying antiphospholipid syndrome. Therefore, a hypercoagulable work-up may be warranted in patients presenting with multiple embolic complications after UAE.