Clinical Reasoning: A 56-Year-Old Woman With Right-Sided Weakness and Recurrent MRI Lesions

Evaluating and managing patients with recurrent stroke presents a significant challenge, particularly in individuals with underlying autoimmune or rheumatologic conditions. We present a case of a 56-year-old woman with a long-standing history of medically controlled systemic lupus erythematosus (SLE) who has experienced multiple ischemic strokes and a subarachnoid hemorrhage. Despite an unremarkable standard stroke workup and adherence to secondary prevention medications, including antithrombotic and lipid-lowering therapies, the patient continued to experience recurrent strokes, warranting further investigation. Serial follow-up imaging including CT angiography, magnetic resonance angiography, and conventional angiography revealed progressive intracranial vascular narrowing, prompting a broad workup and differential diagnosis. This case highlights the importance of a stepwise and comprehensive diagnostic approach that integrates traditional vascular risk factors with those related to underlying autoimmune disease. It provides an insight into the diagnostic strategies and management of this high-risk population, ultimately supporting the need for personalized patient care to address the multifactorial causes of stroke.