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Acute ischemic stroke — ABIM Board MCQ

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HardNeurologyAcute ischemic strokeABIM Board

A 68-year-old man who takes no anticoagulant develops a large spontaneous iliopsoas hematoma. Platelet count and prothrombin time are normal, aPTT is 82 seconds and does not correct on an incubated mixing study. Factor VIII activity is below 1%, with an inhibitor titre of 35 Bethesda units. What is the best initial treatment strategy?

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Correct answer: E — Give a bypassing agent and start inhibitor-eradication immunosuppression

The best answer is “Give a bypassing agent and start inhibitor-eradication immunosuppression”. This is acquired haemophilia A with a high-titre factor VIII inhibitor and clinically important bleeding. A bypassing agent such as recombinant activated factor VII or activated prothrombin complex concentrate is used for haemostasis, while corticosteroid-based immunosuppression, often combined with rituximab or cyclophosphamide according to prognostic factors, eradicates the inhibitor. Vitamin K, plasma, observation, and factor VIII alone are inadequate here.

Reference: American Society of Hematology: A 73-Year-Old Man With Extensive Bruising: https://www.hematology.org/education/trainees/fellows/case-studies/a-73-year-old-man-with-extensive-bruising