Antiphospholipid syndrome, antiphospholipid antibodies, and stroke

Antiphospholipid syndrome (APS) is a prothrombotic autoimmune disease with heterogenous clinicopathological manifestations and is a well-established cause of acute ischaemic stroke (AIS) and transient ischaemic attack (TIA), particularly in younger patients. There is growing recognition of a wider spectrum of APS-associated cerebrovascular lesions, including white matter hyperintensities, cortical atrophy and infarcts, which may have clinically important neurocognitive sequalae. Diagnosis of APS-associated AIS / TIA requires expert review of clinical and laboratory information. Management also poses challenges, given the potential for substantial morbidity and recurrent thrombosis, additional risk conferred by conventional cardiovascular risk factors, and limitations in the evidence-base regarding optimal antithrombotic therapy for secondary prevention. In this review, we summarise key features of APS-associated cerebrovascular disorders, with focus on clinical and laboratory aspects of diagnostic evaluation, including practical guidance for antiphospholipid antibody (aPL) testing, and an overview of neuroimaging findings. The current status of prognostic markers is considered. We review the evidence base for antithrombotic treatment in APS-associated stroke and discuss ongoing uncertainties in this setting, including the optimal intensity of anticoagulation and efficacy of direct oral anticoagulants (DOACs). Clinical practice recommendations are provided, covering antithrombotic treatment, supportive management and options for anticoagulant-refractory cases, and we highlight the benefits of adopting a careful multidisciplinary team approach.