Cerebral venous sinus thrombosis after adenovirus-vectored COVID-19 vaccination: review of the neurological-neuroradiological procedure.

Cerebral venous and sinus thrombosis (CVST) after adenovirus-vectored COVID-19 ChAdOx1 nCov-19 (Oxford-AstraZeneca) and Ad26.COV2.S (Janssen/Johnson & Johnson) is a rare complication, occurring mainly in individuals under 60 years of age and more frequently in women. It manifests 4-24 days after vaccination. In most cases, antibodies against platelet factor-4/polyanion complexes play a pathogenic role, leading to thrombosis with thrombocytopenia syndrome (TTS) and sometimes a severe clinical or even fatal course. The leading symptom is headache, which usually increases in intensity over a few days. Seizures, visual disturbances, focal neurological symptoms, and signs of increased intracranial pressure are also possible. These symptoms may be combined with clinical signs of disseminated intravascular coagulation such as petechiae or gastrointestinal bleeding. If TTS-CVST is suspected, checking D-dimers, platelet count, and screening for heparin-induced thrombocytopenia (HIT-2) are diagnostically and therapeutically guiding. The imaging method of choice for diagnosis or exclusion of CVST is magnetic resonance imaging (MRI) combined with contrast-enhanced venous MR angiography (MRA). On T2*-weighted or susceptibility weighted MR sequences, the thrombus causes susceptibility artefacts (blooming), that allow for the detection even of isolated cortical vein thromboses. The diagnosis of TTS-CVST can usually be made reliably in synopsis with the clinical and laboratory findings. A close collaboration between neurologists and neuroradiologists is mandatory. TTS-CVST requires specific regimens of anticoagulation and immunomodulation therapy if thrombocytopenia and/or pathogenic antibodies to PF4/polyanion complexes are present. In this review article, the diagnostic and therapeutic steps in cases of suspected TTS associated CSVT are presented.

[Cerebral venous sinus thrombosis after COVID-19 vaccination : Neurological and radiological management]. / Hirnvenen- und Sinusthrombose nach COVID-19-Schutzimpfung : Neurologisch-radiologisches Prozedere.

BACKGROUND: Vaccine-induced cerebral venous and sinus thrombosis (VI-CVST) is a rare complication in recipients of the adenovirus-vectored coronavirus disease 2019 (COVID-19) vaccine ChAdOx1 nCov-19 (Vaxzevria®; AstraZeneca). OBJECTIVES: Development of a diagnostic and therapeutic standard. MATERIALS AND METHODS: Analysis of clinical and basic research findings, expert opinions, and experience with our own cases. RESULTS: VI-CVST usually manifests on day 4-24 after vaccination, mostly in individuals aged < 60 years, and women. In the majority there is an immune pathogenesis caused by antibodies against platelet factor 4/polyanion complexes, leading to thrombotic thrombocytopenia which can result in severe, sometimes fatal, course. The cardinal symptom is headache worsening within days which, however, also can be of variable intensity. Other possible symptoms are seizures, visual disturbance, focal neurological deficits and signs of increased intracranial pressure. If VI-CVST is suspected, the determination of plasma D­dimer level, platelet count, and screening for heparin-induced thrombocytopenia (HIT-2) are essential for treatment decision-making. Magnetic resonance imaging (MRI) with venous MR-angiography is the neuroimaging modality of choice to confirm or exclude VI-CVST. On T2* susceptibility-weighted MRI, the clot in the sinuses or veins produces marked susceptibility artifacts ("blooming"), which also enables the detection of isolated cortical venous thromboses. MRI/MR-angiography or computed tomography (CT)/CT-angiography usually allow-in combination with clinical and laboratory findings-reliable diagnosis of VI-CVST. CONCLUSIONS: The clinical suspicion of VI-CVST calls for urgent laboratory and neuroimaging workup. In the presence of thrombocytopenia and/or pathogenic antibodies, specific medications for anticoagulation and immunomodulation are recommended.

Adenovirus-Vectored COVID-19 Vaccine-Induced Immune Thrombosis of Carotid Artery: A Case Report.

OBJECTIVE: Venous thromboses and thrombocytopenia after vaccination with the adenovirus-vectored COVID-19 vaccine ChAdOx1 nCov-19 (AstraZeneca) have been linked to serum antibodies against platelet factor 4 (PF4)-polyanion complexes. We here report vaccine-induced isolated carotid arterial thrombosis. METHODS: Imaging and laboratory findings, treatment decisions and outcome of this case are presented. RESULTS: Eight days after having received the first dose of ChAdOx1 nCov-19 vaccine, a 31-year-old man was admitted to our stroke unit with acute headache, aphasia, and hemiparesis. D-dimers were slightly elevated, but platelet count and fibrinogen level were normal. MRI-confirmed mainstem occlusion of middle cerebral artery resolved within 1 hour after start of IV thrombolysis. A wall-adherent, non-occluding thrombus in the ipsilateral carotid bulb was identified as the source of embolism. Cardiac or paradoxical (venous) embolism was excluded. Screening for presence of heparin-induced thrombocytopenia-related antibodies was positive, and highly elevated serum IgG antibodies against PF4-polyanion complexes were subsequently proven. Treatment with aspirin and subcutaneous danaparoid, followed by phenprocoumon, led to thrombus shrinkage and dissolution within 19 days, and favorable clinical outcome. DISCUSSION: Vaccine history is important in patients not only with venous but also with arterial thromboembolic events. Vaccine-induced immune thrombosis of brain-supplying arteries may well be handled.