Ischemic stroke as the first manifestation of acute promyelocytic.

Acute promyelocytic leukemia (APL) is a hematologic emergency characterized by a high risk of coagulopathy that can manifest with both severe bleeding and thrombotic events, including ischemic stroke. However, its initial presentation as large vessel arterial thrombosis is infrequent and potentially lethal. We report the case of a previously healthy 15-year-old female referred for suspected left frontal ischemic stroke with right spastic hemiplegia and expressive aphasia. One week earlier, she had presented with headache, nausea and transient episodes of paresthesias and weakness of the right hand and foot. Laboratory studies revealed bicytopenia (leukopenia and anemia), hypofibrinogenemia and elevated D-dimer. Imaging studies showed a subacute infarct in the left caudate nucleus and recent ischemia in the frontal cortex with complete occlusion of the left internal carotid artery. Bone marrow aspirate showed blast cells with Auer rods and strong positivity for myeloperoxidase. Flow cytometry revealed 41,2 % of cells with a phenotype compatible with promyelocytes, PML::RARA fusión gene was confirmed by molecular and cytogenetic studies. Immediate treatment with all-trans retinoic acid (ATRA), corticosteroids, and hemostatic support was initiated. Subsequently, the patient presented with a new occipital infarction and was started on anticoagulant therapy. She did well with motor and speech recovery. This case highlights the importance of considering APL as an underlying etiology of arterial thrombotic events in adolescents with cytopenias and coagulopathy, especially in the presence of major vessel occlusion, where early diagnosis and timely treatment are essential to reduce morbidity and mortality.