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 dysarthria 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 hematocrit 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 tertiary 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 …