Three patients were identified (two male, one female) with ages ranging from 17-32 years. Two patents had prior diagnosis of SLE without renal involvement. Magnetic resonance imaging obtained for all three patients demonstrated ischemic strokes restricted to a vascular territory. Magnetic resonance angiography demonstrated a proximal left superior cerebellar artery thrombus for one patient and slight enhancement in the proximal left M1-segment for another patient.  Initial preliminary labs for all three patients were notable for leukopenia, anemia, hematuria, proteinuria, elevated urine protein/creatine ratio. Serologic testing was notable for positive ANA, positive anti-dsDNA, positive anti-Sm, low C3, and low C4. Anti-phospholipid labs and hypercoagulable work-up was negative. CSF analysis yielded normal protein, glucose, WBC, and RBC. All three patients were diagnosed with new-onset lupus nephritis, with two patients undergoing confirmatory renal biopsy. Patients were initially treated with a combination of prednisone, mycophenolate mofetil, and/or hydroxychloroquine and closely followed as an outpatient. One patient with vessel enhancement on initial imaging continued to have reoccurring strokes and required escalation of immunotherapy to cyclophosphamide with eventual remission and normalization of antibody levels. 

This case series presents several young patients with acute stroke in the setting of new-onset lupus nephritis without other traditional SLE-related stroke risk factors. Further research is needed to guide the stratification of stroke risk among patients with SLE.