Stroke due to anemia after severe menstrual bleeding caused by a uterine myoma: the title is self-explanatory

Abstract

To the Editor,Cerebral infarction results from acute impairment of oxy-genated blood flow either due to a thrombotic or embolicocclusion. Aside from several likely contributing factors[1], anemia is an overlooked risk factor for cerebralinfarction. Although the relationship between anemia andcerebral infarction has not been well established, severalresearchers reported an association between these twoconditions [2–4].Likewise, we report a patient who had acute cerebralinfarction associated with severe anemia following severeblood loss due to a uterine myoma.A 43-year-old woman was admitted for a sudden onsetof weakness on her left side. Her medical history did notdisclose any risk factor like systemic hypertension, vas-cular malformation, coagulopathy, hyperlipidemia, smok-ing, diabetes mellitus, prior stroke history or positivefamily history. Her cardiac examination including elec-trocardiography and echocardiography was also normal.The laboratory findings were as follows: hemoglobin (Hb):5.7 g/dL (12.8 g/dL 1 month ago), hematocrit (Hct): 21.0,serum iron: 11.9 mg/dL (50–150) and platelet count:594,000/lL. Cranial magnetic resonance imaging (MRI)showed an infarction in the middle cerebral artery suppliedarea (Fig. 1). Overall, the patient was diagnosed to have anischemic cerebral infarction associated with severe anemia.Thereafter, she was given anti-thrombolytic treatment andblood transfusion twice for anemia. Further evaluationsregarding etiology were not contributory except hypo-chromic microcytic anemia. On detailed questioning, shedeclared that her complaints started within the 2 days aftera major bleeding during menstruation. She added that sheusually had similar menstrual bleedings before as well.Upon consultation to the gynecology department, she wasdiagnosed with a huge uterine myoma. She was thenscheduled for hysterectomy in a week after hemodynamicstabilization. After a 2-week rehabilitation program, thepatient discharged was almost independent in her dailyliving.In the previous literature, there are a few anecdotalreports on the association between bleeding, anemia andcerebral infarction [2–4]. Although the relationship amongthem was unclear, Akins et al. [5] presented patients withsevere iron deficiency anemia in whom reactive thrombo-cytosis led to thrombus formation and thus cerebralinfarction. Likewise, Kim et al. [6] also consideredbleeding and subsequent anemia to be a precipitant forcerebral infarction. In that study, they have also reportedthrombocytosis, especially in patients with chronic irondeficiency anemia. In another study whereby patients withanemia—due to acute blood loss—but without iron defi-ciency were enrolled, Tsai et al. [2] mentioned that acuteanemia could induce cerebral blood flow insufficiency anddecreased oxygen-carrying capacity, with an eventual tis-sue hypoxia especially at the most vulnerable regions.Selective decrease in hematocrit has also been reported to