Cerebral venous sinus thrombosis after ChAdOx1 nCov-19 vaccination with a misleading first cerebral MRI scan

Vaccine-induced immune thrombotic thrombocytopenia (VITT) and cerebral venous sinus thrombosis (CVST) have been recently described as rare complications following vaccination against SARS-CoV-2 with vector vaccines. We report a case of a young woman who presented with VITT and cerebral CVST 7 days following vaccination with ChAdOx1 nCov-19 (AstraZeneca). While the initial MRI was considered void of pathological findings, MRI 3 days later revealed extensive CVST of the transversal and sigmoidal sinus with intracerebral haemorrhage. Diagnostic tests including a platelet-factor-4-induced platelet activation assay confirmed the diagnosis of VITT. Treatment with intravenous immunoglobulins and argatroban resulted in a normalisation of platelet counts and remission of CVST.

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Syndrome of cerebral venous sinus thrombosis and thrombocytopenia after vaccination for COVID-19

10.21203/rs.3.rs-439289/v1 ◽

2021 ◽

Author(s):

Babak Soleimani ◽

Sanchit Turaga ◽

Dalia Khan ◽

Claire Davies ◽

Yaw Duodu ◽

...

Keyword(s):

Sinus Thrombosis ◽

Case Series ◽

Multidisciplinary Care ◽

Intravenous Immunoglobulins ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Laboratory Findings ◽

Platelet Factor ◽

Venous Sinus Thrombosis ◽

Decompressive Hemicraniectomy

Abstract Experience in the management of COVID-19 vaccine induced thrombosis and thrombocytopenia is currently lacking. In this case series we report the presentation and our experience in the management of cerebral venous sinus thrombosis and thrombocytopenia post ChAdOx1 nCoV-19 vaccination. Two of the three cases had confirmed anti-platelet factor 4 antibodies and extracranial thrombosis. In all the cases, plasma exchange, intravenous immunoglobulins and steroids normalised the platelet count and intravenous argatroban was used for initial anticoagulation. Two cases received a platelet transfusion and required decompressive hemicraniectomy due to raised intracranial pressure, secondary to cerebral oedema and haemorrhage. Prompt assessment of a new persistent headache occurring between 5 and 28 days of receiving the ChAdOx1 nCoV-19 vaccine is warranted irrespective of age. In cases with venous thrombosis on imaging or abnormal laboratory findings (thrombocytopenia, abnormal clotting or elevated D-dimer), urgent transfer to a tertiary centre is recommended for multidisciplinary care and prevention of life-threatening complications from this rare syndrome.

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Cerebral Venous Sinus Thrombosis due to Thrombosis with Thrombocytopenia Syndrome Following Ad26.COV2.S: A First Real-World Case Report of a Male Subject

The Neurohospitalist ◽

10.1177/19418744211055065 ◽

2021 ◽

pp. 194187442110550

Author(s):

Samia Asif ◽

Meghana Kesireddy ◽

Scott A. Koepsell ◽

Marco A. Gonzalez-Castellon ◽

Krishna Gundabolu ◽

...

Keyword(s):

Sinus Thrombosis ◽

Young Male ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Platelet Factor ◽

Venous Sinus Thrombosis ◽

Vein Thrombosis ◽

First Case ◽

Control And Prevention ◽

Underlying Pathophysiology

Thrombosis with Thrombocytopenia Syndrome (TTS) or Vaccine-induced Immune Thrombotic Thrombocytopenia (VITT) had been reported in patients receiving the Ad26.COV2.S vaccination (Johnson & Johnson [J&J]/Janssen) vaccine. They frequently presented with cerebral venous sinus thrombosis (CVST), but venous or arterial thrombosis at other locations can be present. The majority of those affected are younger adult females. Therefore, after a brief pause from April 13–23, 2021, the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) recommended caution in using this vaccine in females under 50 years. Based on the reported 28 cases of TTS after this vaccination (data till April 21, 2021) by CDC, 22 were females (78%), and 6 were male. None of those males had CVST but had thrombosis at other locations. We report the first case of a young male with TTS and CVST following Ad26.COV2.S vaccine presented with severe headache and diagnosed with acute right transverse and sigmoid cerebral venous sinus thrombosis, multiple right-sided pulmonary emboli, and right hepatic vein thrombosis. He was treated with parenteral anticoagulation with argatroban and intravenous immune globulin with the improvement of his symptoms. A heparin-induced thrombocytopenia with thrombosis (HITT) like syndrome caused by the genesis of a platelet-activating autoantibody against platelet factor 4 (PF4) triggered by adenoviral vector-based COVID-19 vaccinations is understood to be the underlying pathophysiology. TTS with CVST should be considered when patients present with headaches, stroke-like neurological symptoms, thrombocytopenia, and symptom onset 6–15 days after Ad26.COV2.S vaccination.

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ChAdOx1 nCOV-19 vaccine-induced immune thrombotic thrombocytopenia and cerebral venous sinus thrombosis (CVST)

BMJ Case Reports ◽

10.1136/bcr-2021-243931 ◽

2021 ◽

Vol 14 (6) ◽

pp. e243931

Author(s):

Preethi Suresh ◽

William Petchey

Keyword(s):

Sinus Thrombosis ◽

External Ventricular Drain ◽

Intravenous Immunoglobulins ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

High Dose ◽

Venous Sinus Thrombosis ◽

Decompressive Craniotomy ◽

Intracranial Pressures ◽

D Dimer

A 27-year-old fit and well man presented with intermittent headaches associated with eye floaters and vomiting. His symptoms started 48 hours after having the first dose of ChADOx1 nCOV-19 vaccine (Vaxzevria, previously AstraZeneca COVID-19 vaccine; AstraZeneca) and bloods showed raised D-dimer, low platelets and fibrinogen. CT venogram demonstrated significant cerebral venous sinus thrombosis. He was immediately started on intravenous immunoglobulins and dabigatran after liasing with haematologist. The next day, he complained of worsening headache and new homonymous hemianopia. Repeat CT of the head showed an acute parenchymal bleed with subdural extension and was given idarucizumab and high-dose steroids. He had an emergency decompressive craniotomy and external ventricular drain as his intracranial pressures were difficult to control. Despite full medical and surgical management, his intracranial pressures continued to rise and his brain injury was felt to be too devastating and was deemed unsurvivable.

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Chronic headache as a clinical manifestation of cerebral venous sinus thrombosis

INTERNATIONAL NEUROLOGICAL JOURNAL ◽

10.22141/2224-0713.17.1.2021.226919 ◽

2021 ◽

Vol 17 (1) ◽

pp. 50-54

Author(s):

O. Sayko ◽

A. Bohdan ◽

J. Malankevich

Keyword(s):

Venous Thrombosis ◽

Cerebral Venous Thrombosis ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Secondary Brain Injury ◽

Venous Sinus Thrombosis ◽

Dural Sinuses ◽

Cerebral Mri ◽

Compensation Mechanisms

Patients with cerebral venous thrombosis (CVT) pre-sent with a range of symptoms, which varies widely from headache to coma. Chronic occlusion of venous dural sinuses leads to the initiation of compensation processes, such as vascular collatera-lization, recanalization of the organized thrombus. Consequently, their efficacy determines disease course and severity. The purpose of our study was to highlight the clinical challenges while managing a patient with subcompensated CVT. Taking into account the fact that mild severity is observed in 20 % of cases, eventually, about a quarter of patients presenting with the headache of unclear etio-logy becomes unnoticed and results in low quality of life. To analyze the disease outcome and prognosis, we accurately studied compensation mechanisms, which occur in a patient due to cerebral venous sinus thrombosis, notably venous collateral circulation and thrombus recanalization. However, the most important “pitfall” of chronic dural sinuses occlusion, when not appropriately treated, is the fact that hemodynamic compensation also leads to a high risk of cerebrovascular events, which may lead to death or disabi-lity. The patient with cerebral venous thrombosis of the transverse and sigmoid sinuses manifested migraine-like headache with a vegetative issue and signs of increased intracranial pressure. Due to the absence of anticoagulant therapy, venous drainage through collateral pathways and recanalization of thrombosed sinuses were insufficient to maintain a cerebral blood supply, resulting in diffuse cerebral edema, secondary brain injury. After an accurate survey, diagnostic procedures, prescribing of individualized treatment, and long-term follow-up with correction of therapy the patient experienced regression of CVT symptoms. Cerebral MRI venography is an important tool for the diagnosis and prediction of the prognosis of this condition. Thus, patients with a long history of untreatable headache and signs of intracranial hypertension should undergo this procedure. To consider intracranial vascular events and outcomes, the venous hemodynamics should be evaluated. Moreover, it is often necessary to examine cerebral veins and sinuses, when hemorrhagic stroke does not correspond to cerebral arterial territories and has unclear etiology.

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Delayed-Onset Heparin-Induced Thrombocytopenia With Cerebral Venous Sinus Thrombosis Following Total Knee Arthroplasty: Case Report

The Neurohospitalist ◽

10.1177/19418744211042966 ◽

2021 ◽

pp. 194187442110429

Author(s):

Megan M. J. Bauman ◽

Ryan M. Naylor ◽

Ashley R. Santilli ◽

Eelco F. Wijdicks

Keyword(s):

Total Knee Arthroplasty ◽

Knee Arthroplasty ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Platelet Factor ◽

Heparin Induced Thrombocytopenia ◽

Venous Sinus Thrombosis ◽

Delayed Onset ◽

Total Knee

Heparin-induced thrombocytopenia (HIT) is a prothrombotic state caused by autoantibodies against platelet factor 4 (PF4)-heparin complexes. Although HIT typically presents 5-10 days after the initiation of heparin, thrombosis and thrombocytopenia may occur up to several weeks following heparin withdrawal, so-called delayed-onset HIT. Although rare, there have been isolated reports of HIT-induced cerebral venous sinus thrombosis (CVST), which carry high rates of morbidity and mortality. There is a need to further characterize the etiology, clinical presentation, treatment paradigms, and outcomes of patients with HIT-induced CVST. Here, we present the case of a 57-year old female who presented to the emergency department with a headache and seizure 11 days following a right total knee arthroplasty for which she received 3 post-operative doses of enoxaparin. Work-up demonstrated acute intracerebral hemorrhage (ICH), CVST, and thrombocytopenia. Intravenous heparin resulted in rapidly deteriorating platelet count and subsequent serologic testing confirmed the diagnosis of HIT. Treatment with bivalirudin was initiated, the HIT resolved, and the patient was discharged home on hospital day 19 with long-term anticoagulation mediated by warfarin. At 3-month follow up, the patient had mild upper motor neuron pattern weakness and was living independently. This case depicts a rare case of delayed-onset HIT and CVST, highlights the importance of establishing a fluid treatment plan for managing HIT-induced CVST, and illustrates the importance of employing rapid anticoagulation despite acute ICH to achieve a desirable clinical outcome.

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Cerebral venous sinus thrombosis after ChAdOx1 vaccination: the first case of definite thrombosis with thrombocytopenia syndrome from India

BMJ Case Reports ◽

10.1136/bcr-2021-246455 ◽

2021 ◽

Vol 14 (10) ◽

pp. e246455

Author(s):

Boby Varkey Maramattom ◽

Fathima Mihta Moidu ◽

Sajira Varikkottil ◽

Akheel A Syed

Keyword(s):

Adenoviral Vector ◽

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Neurological Deficits ◽

Uneventful Recovery ◽

Platelet Factor ◽

Venous Sinus Thrombosis ◽

Vector Vaccine ◽

First Case

Cerebral venous sinus thrombosis (CVST) following novel coronavirus-2019 (nCoV-19) vaccination is a rare adverse effect. We report the first case of CVST associated with ChAdOx1 vaccination, with positive anti-platelet factor 4 (PF4) antibodies, from India. A 44-year-old woman developed a thunderclap headache 4 days after the first dose of the adenoviral vector vaccine ChAdOx1 (Covishield). Physical examination was unremarkable barring mild neck stiffness with no focal neurological deficits. MRI identified right transverse sinus thrombosis. Laboratory tests revealed raised D-dimer and thrombocytopenia; anti-PF4 antibodies were subsequently identified, consistent with thrombosis with thrombocytopenia syndrome (TTS). She was treated with non-heparin anticoagulation and intravenous immunoglobulin and made an uneventful recovery. Early recognition of adenoviral vector vaccine-related TTS, which resembles heparin-induced thrombocytopenia syndrome, is important as heparin and heparin analogues are best avoided in the treatment.

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Refractory Heparin-Induced Thrombocytopenia With Cerebral Venous Sinus Thrombosis Treated With IVIg, Steroids, and a Combination of Anticoagulants: A Case Report

Journal of Investigative Medicine High Impact Case Reports ◽

10.1177/2324709619832324 ◽

2019 ◽

Vol 7 ◽

pp. 232470961983232 ◽

Cited By ~ 3

Author(s):

Mia Gonzales ◽

Amrish Pipalia ◽

Andrew Weil

Keyword(s):

Sinus Thrombosis ◽

Cerebral Venous Sinus Thrombosis ◽

Venous Sinus ◽

Small Subset ◽

Severe Thrombocytopenia ◽

Platelet Factor ◽

Heparin Induced Thrombocytopenia ◽

Venous Sinus Thrombosis ◽

Increased Risk ◽

Risk For Thrombosis

Heparin-induced thrombocytopenia (HIT) type II is caused by antibody production that bind complexes between heparin and platelet factor 4 leading to platelet consumption and thrombosis. In a small subset of cases referred to as autoimmune HIT, the antibodies activate platelets even in the absence of heparin. Refractory HIT is a type of autoimmune HIT in which thrombocytopenia persists for weeks after heparin discontinuation and carries increased risk for thrombosis and more severe thrombocytopenia. We present a case of refractory HIT with cerebral venous sinus thrombosis (CVST) that was successfully treated with a change in anticoagulant alongside steroids and a second trial of intravenous immunoglobulin (IVIg).

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