Diagnostic and Therapeutic Challenges of Concurrent Intracranial Hemorrhage and Cerebral Venous Thrombosis in a Patient With Acute Lymphoblastic Leukemia: A Case Report and Literature Review.

Cerebral venous sinus thrombosis (CVST) is a cerebrovascular condition due to the thrombosis of cerebral venous sinuses, leading to intracranial hemorrhage, increased intracranial pressure, focal deficit, seizure, toxic edema, encephalopathy, and death. The diagnosis and therapeutic approach of CVST remain challenging because of its highly nonspecific clinical presentation including headaches, seizures, focal neurologic deficits, and altered mental status, etc. Anticoagulation is the mainstay of CVST treatment and should be started as soon as the diagnosis is confirmed. Here, we present the case of a 34-year-old male construction worker who presented to the emergency department with a complaint of right chest wall pain and swelling. He was admitted to the hospital following a diagnosis of anterior chest wall abscess and mediastinitis. During hospitalization, his complete blood count revealed pancytopenia with blast cells, and bone marrow biopsy revealed 78.5% lymphoid blasts by aspirate differential count and hypercellular marrow (100%) with decreased hematopoiesis. He developed concurrent CVST and intracranial hemorrhage while receiving CALGB10403 (vincristine, daunorubicin, pegaspargase, prednisone) with intrathecal cytarabine induction chemotherapy for acute lymphoblastic leukemia (ALL). The patient failed two standard chemotherapy for ALL and achieved remission while on third-line chemotherapy with an anti-CD19 monoclonal antibody, blinatumomab. Although this patient had an MRI scan of the brain with multiple follow-up non-contrast CT scans, it was CT angiography that revealed CVST. This showed the diagnostic challenge in CVST, with CT and MRI venography having excellent sensitivity in diagnosing CVST. Risk factors for CVST in our patient were ALL and its intensive induction chemotherapy with pegaspargase.

Orbital cellulitis and cavernous sinus thrombosis with contralateral sinus disease in a COVID-19 positive adolescent patient.

Patients with COVID-19 have been reported to have elevated coagulation factors, which is a well-documented cause of venous thromboembolism events such as deep vein thrombosis and pulmonary embolism. Other venous thrombotic events, however, such as cavernous sinus thrombosis (CST) have been less commonly observed, specifically in combination with primary orbital cellulitis. Due to its unique anatomic location, the cavernous sinus is susceptible to thrombophlebitis processes including septic thrombosis and thrombosis most commonly from sinusitis. Many studies have shown that in the antibiotic era thromboembolic events of the cavernous sinus are less common due to infection spread from the orbit or facial region. This case report describes a 17-year-old COVID-19 positive male who presented with a left-sided primary orbital cellulitis with CST without radiographic evidence of ipsilateral sinus disease.

Spectrum of Serious Neurological and Psychiatric Adverse Events in Indian COVID-19 Vaccine Recipients: A Systematic Review of Case Reports and Case Series.

Indian data regarding serious neurological and psychiatric adverse events, following coronavirus disease 2019 (COVID-19) vaccination, are lacking. We, therefore, systematically evaluated cases of post-vaccinal serious neurological and psychiatric adverse reactions published from India. A systematic review of cases published from India, which were archived in PubMed, Scopus, and Google Scholar databases, was performed; pre-print databases along with ahead-of-print contents were searched in addition. Retrieved articles, as on June 27, 2022, were evaluated following PRISMA guidelines. EndNote 20 web tool was used to make a PRISMA flow chart. Individual patients' data were compiled in a tabular form. The protocol of the systematic review was registered with PROSPERO (CRD42022324183). A total of 64 records describing 136 instances of serious neurological and psychiatric adverse events were identified. More than 50% (36/64) reports were from the following four states, namely, Kerala, Uttar Pradesh, New Delhi, and West Bengal. The mean age of persons developing these complications was 44.89 ± 15.77 years. In the majority, adverse events occurred within 2 weeks of administration of the first dose of COVISHIELD vaccine. Immune-mediated central nervous system (CNS) disorders were identified in 54 instances. Guillain-Barre syndrome and other immune-mediated peripheral neuropathies were reported in 21 cases. Post-vaccinal herpes zoster was recorded in 31 vaccine recipients. Psychiatric adverse events were recorded in six patients. In Indian recipients of COVID-19 vaccine, a variety of serious neurological complications were reported. The overall risk appears minuscule. Immune-mediated central and peripheral neuronal demyelinations were the most frequently reported post-vaccinal adverse events. A large number of cases of herpes zoster have also been reported. Immune-mediated disorders responded well to immunotherapy.

Cerebral Venous Thromboses in a Patient With No Reported Risk Factors: A Case Report.

Stroke is a neurologic condition caused either by brain ischemia or brain hemorrhage, where most cases are a result of ischemic brain injury. Stroke more commonly affects the arterial blood supply of the brain, but in rare cases, it is evoked by the occlusion of the venous sinuses that drain blood from the brain. This phenomenon is known as cerebral venous sinus thrombosis (CVST), also referred to as cerebral sinovenous thrombosis. The pathogenesis of CVST is not completely understood, although common risk factors associated with the condition include obesity, hypercoagulable states, oral contraceptive use, intracranial infections, trauma, and, more recently, coronavirus disease 2019 (COVID-19). Immediate medical intervention is required because CVST can result in increased intracranial pressure and diffuse cerebral edema, which can bring about fatal complications that can lead to early death. However, CVST is challenging to diagnose, as its clinical presentation is highly variable. It can range from headaches to signs of elevated intracranial pressure, including nausea, vomiting, and vision problems. In this case report, the patient is a 25-year-old previously healthy African American female who presented with a weeklong headache and acute onset of delirium an hour prior to arrival at the hospital. The patient had prior emergency department (ED) visits from different facilities where head imaging was performed and showed negative results allowing her to return home. The patient was then brought by a friend to our ED due to altered mental status and agitation. Initial computed tomography of the head did not reveal acute abnormalities; however, magnetic resonance angiography and magnetic resonance venography revealed evidence of venous sinus thrombosis and lack of flow requiring urgent attention. The patient was then referred to endovascular neurology, but despite medical intervention, the patient's medical status deteriorated, and she was declared brain dead. Although rare, this case report emphasizes the atypical presentation and the severity of CVST where a young individual with no significant past medical history presented with neurological symptoms that rapidly progressed to complications that caused her early death.

Cerebral venous sinus thrombosis following ChAdOx1 nCoV-19 AstraZeneca COVID-19 vaccine.

A woman in her mid-twenties was admitted with headache, ultimately leading to a diagnosis of cerebral venous sinus thrombosis 10 days after receiving a first dose of the AstraZeneca ChAdOx1 nCoV-19 vaccine (Vaxzevria). We report this case from clinical investigations to outcomes and discuss the issues raised by it regarding the ChAdOx1 nCoV-19 vaccine.

COVID-19 and SARS-CoV-2 Vaccines: A Cameo Role for Headache.

Headache is a very frequent symptom in COVID-19 and SARS-CoV-2 vaccination. Many studies have emphasized its clinical diagnostic and prognostic importance on the one hand, as in many cases these aspects have been completely ignored. It is therefore opportune to go back over these lines of research in order to gather what usefulness the headache symptom may or may not represent for the clinician dealing with COVID-19 or performing or following up on the clinical course following vaccination for SARS-CoV-2. The clinical evaluation of headache in COVID-19 is not fundamental in the diagnostic and prognostic process of the emergency departments; however, the risk of severe adverse events, although very rare, must be taken into account by the clinicians. For subjects presenting with severe, drug-resistant, and delayed-onset post-vaccination headache, it could represent a possible sign of central venous thrombosis or other thrombotic complications. Thus, a re-reading of the role of headache in COVID-19 and SARS-CoV-2 vaccination seems clinically useful.

COVID-19: Vaccine-induced immune thrombotic thrombocytopenia.

In late February 2021, a prothrombotic syndrome was encountered for the first time in some of the recipients of ChAdOx1 CoV-19 vaccine (AstraZeneca, University of Oxford, and Serum Institute of India). Since the hallmark of this syndrome is the development of thrombocytopenia and/or thrombosis between 4 and 42 days after receiving a COVID-19 vaccine, it was named vaccine-induced immune thrombotic thrombocytopenia (VITT). Other names include "vaccine-induced prothrombotic immune thrombocytopenia" and "thrombosis with thrombocytopenia syndrome" by the Centers for Disease Control and the Food and Drug Administration (FDA). VITT appears similar to heparin-induced thrombocytopenia in that "platelet activating" autoantibodies are produced in both these conditions due to prior exposure of COVID-19 vaccine and heparin respectively, in turn causing thrombotic complications and consumptive thrombocytopenia. In this article, recent advances in the understanding of pathobiology, clinical features, investigative work-up, and management of VITT are reviewed.

Post COVID-19 Vaccination-Associated Neurological Complications.

PURPOSE: Neurological sequelae after COVID-19 vaccination are rare. We investigated the possible pathogenesis behind the development of neurological complications within a short period after Saudi residents received a COVID-19 vaccine. PATIENTS AND METHODS: We evaluated 18 patients who recently received a COVID-19 vaccine (Comirnaty and Vaxzevria vaccines) and presented with neurological complications to the Saudi German Hospitals in Jeddah, Saudi Arabia. Neurologists assessed the patients' clinical presentation, radiological investigations, and laboratory findings. RESULTS: Three patients who received the first dose of the Vaxzevria vaccine experienced severe cerebral venous thrombosis, two of them were complicated by intracranial hemorrhage. Their laboratory investigations showed very high d-dimers and severe thrombocytopenia, which have been linked to higher mortality and poor outcome. Ischemic stroke occurred in eight cases (44.4%) with a predominance in older male patients. Three patients presented with seizures, two had optic neuritis. Guillain-Barré syndrome (GBS) and Miller Fisher syndrome (MFS) occurred in two male patients following vaccination with Comirnaty. CONCLUSION: Neurological complications after COVID-19 vaccinations are very rare, and only a few cases have been reported worldwide. The shared pathophysiological basis between COVID-19 viral infection and COVID-19 vaccines stands behind the very rare neurological complications resulting from the hypercoagulable state triggered by the general inflammatory condition. We suspect some differences in the pathogenesis of ischemic stroke caused by COVID-19 infection and COVID-19 vaccines, which render COVID-19 vaccine-associated ischemic stroke more responsive to treatment. To date, no definitive association between the vaccine and GBS has been proven by any strong evidence, but it has recently been added as a very rare side effect of the Janssen COVID-19 vaccine. No possible links of Miller Fisher syndrome to COVID-19 vaccines have been reported before the one reported in this study.

Cerebral venous thrombosis after ChAdOx1 nCoV-19 vaccination: a systematic review

OBJECTIVE: To perform a systematic review of case reports or case series regarding thrombosis with thrombocytopenia syndrome (TTS) and cerebral venous thrombosis (CVT) related to ChAdOx1 nCoV-19 vaccination to address the clinical features, laboratory findings, treatment modalities, and prognosis related with CVT. SUBJECTS AND METHODS: We included 64 TTS patients from 19 articles, 6 case series and 13 case reports, in which thrombosis occurred after the first dose of ChAdOx1 nCoV-19 vaccination published up to 30 June 2021 in Embase, ePubs, Medline/PubMed, Scopus, and Web of Science databases. RESULTS: Of the 64 TTS patients, 38 (59.3%) had CVT. Patients with CVT were younger (median 36.5 vs. 52.5 years, p<0.001), had lower fibrinogen levels (130 vs. 245 mg/dL, p=0.008), had more frequent history of intracerebral hemorrhage (ICH), and had higher mortality rate (48.6% vs. 19.2%, p=0.020) than that of patients without CVT. In multivariable analysis, the possibility of presence of CVT was higher in younger age groups [odd ratio (OR): 0.91, 95% confidence interval (CI): (0.86-0.97, p<0.001)] and those with accompanying intracerebral hemorrhage (ICH) (OR: 13.60, 95% CI (1.28-144.12, p=0.045). CONCLUSIONS: Our study demonstrated that CVT related to ChAdOx1 nCoV-19 vaccination was associated with younger age, low levels of fibrinogen, presence of ICH and more frequent mortality compared to those of non-CVT. If TTS occurs after ChAdOx1 nCoV-19 vaccination, the presence of CVT in patients with young age or ICH should be considered.

Decompressive surgery in cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia.

BACKGROUND AND PURPOSE: Cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) is an adverse drug reaction occurring after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. CVST-VITT patients often present with large intracerebral haemorrhages and a high proportion undergoes decompressive surgery. Clinical characteristics, therapeutic management and outcomes of CVST-VITT patients who underwent decompressive surgery are described and predictors of in-hospital mortality in these patients are explored. METHODS: Data from an ongoing international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 10 May 2022, were used. Definite, probable and possible VITT cases, as defined by Pavord et al. (N Engl J Med 2021; 385: 1680-1689), were included. RESULTS: Decompressive surgery was performed in 34/128 (27%) patients with CVST-VITT. In-hospital mortality was 22/34 (65%) in the surgical and 27/94 (29%) in the non-surgical group (p < 0.001). In all surgical cases, the cause of death was brain herniation. The highest mortality rates were found amongst patients with preoperative coma (17/18, 94% vs. 4/14, 29% in the non-comatose; p < 0.001) and bilaterally absent pupillary reflexes (7/7, 100% vs. 6/9, 67% with unilaterally reactive pupil, and 4/11, 36% with bilaterally reactive pupils; p = 0.023). Postoperative imaging revealed worsening of index haemorrhagic lesion in 19 (70%) patients and new haemorrhagic lesions in 16 (59%) patients. At a median follow-up of 6 months, 8/10 of surgical CVST-VITT who survived admission were functionally independent. CONCLUSIONS: Almost two-thirds of surgical CVST-VITT patients died during hospital admission. Preoperative coma and bilateral absence of pupillary responses were associated with higher mortality rates. Survivors often achieved functional independence.

Cerebral venous thrombosis secondary to ulcerative colitis: A case report with a literature review.

Ulcerative colitis is an idiopathic inflammatory bowel condition that may be worsened by thromboembolic events such deep vein thrombosis, cerebral venous thrombosis, and pulmonary embolism. Cerebral venous thrombosis is a rare but critical consequence of ulcerative colitis characterized by high mortality and morbidity rate. It is thought to be caused by the hypercoagulable state that occurs during ulcerative colitis relapse. Cerebral venous thrombosis is a reversible condition with good outcomes when detected early and treated properly. In this study, we describe the case of a young woman who presented with cerebral venous thrombosis secondary to ulcerative colitis complicated by venous infarction with petechial cerebral hemorrhage.

Extensive Cerebral Venous Sinus Thrombosis Post COVID-19 Vaccination.

Extensive cerebral sinus thrombosis following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination is rare. We report the case of a 42-year-old man who presented with a severe generalized headache that was not relieved by analgesics for nine days. It started four days after he received the third dose of BNT162b2 (BioNTech/Pfizer). He also complained of numbness at the back of the neck, vomiting, mild blurring of vision, and diplopia. The visual acuity (VA) in the right eye was 6/9 (improved to 6/7.5 with a pinhole) and 6/6 in the left eye. He was not able to abduct both eyes and noticed a double image at lateral gaze. Fundoscopy showed swollen optic discs with the presence of disc hemorrhages. A computed tomography venogram (CTV) of the brain showed loss of normal signal void with filling defects in the superior sagittal sinus, straight sinus, bilateral transverse sinuses, bilateral sigmoid sinuses, and bilateral internal jugular veins. The nasopharyngeal swab sample was negative for SARS-CoV-2. His platelet was normal (271x109/L) and his coagulation profile was normal. Workup for connective tissue disease was negative. He was diagnosed with extensive cerebral vascular thrombosis post-vaccination. He received a one-week course of subcutaneous clexane, followed by oral anticoagulant treatment. After treatment, his headache was relieved, and the diplopia subsided. The venous thrombosis was partially resolved. Both the swollen optic discs improved, and his VA improved to 6/6 in both eyes.

A Retrospective Study On The Clinical Evaluation And Risk Assessment Of Cerebral Venous Sinus Thrombosis In A Tertiary Care Centre

Background: Among young people, cerebral venous thrombosis (CVT) is a major cause of stroke and females are more likely to develop cerebral venous thrombosis. Objective(s): Thus, the present study aimed to study the clinical profile of CSVT in adults and compare them between both genders and specific age groups. Methodology: The clinical characteristics of 40 male and female patients with and without CVT who had been admitted to the Chettinad Hospital & Research Institute, India, from Feb 2020 to Sep 2021 were included. Result(s): Out of 40 patients, 77.5% were female, and 22.5% were male. The most commonly involved cranial nerve was 7th, contributing 15%, while the involvement of cranial nerves 3rd and 6th contributed 5% and 12.5%, respectively. However, 67.5% of patients had no cranial nerve involved. Covid was diagnosed in 4 patients (10%), and the remaining 36 patients (90%) were diagnosed negative for covid. Cerebrovascular accident (CVA) present in 17 patients. Further, we noticed that 7 patients had left sided stroke and 9 were with right sided stroke. The cranial nerve involved was iii, vi, and vii in 1,3 and 6 patients with CVA, while the cranial nerve involved was iii and vi in 1 and 2 patients without CVA respectively. Further, out of 40 patients, Covid was diagnosed in 2 patients with CVA and 2 without CVA. We have observed a statistically significant difference in focal defects only in with and without CVA patients. Conclusion(s): Males were more likely to develop CVT than females, according to a prior international study. A significant risk factor was alcoholism. The gender gap, clinical profile, and risk variables are not significantly different from earlier Indian investigations. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

Arterio-Venous Thrombosis and Spontaneous Bleeding in COVID-19-Associated Coagulopathy: A Case Report

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome which was declared a global pandemic in 2019 causing significant morbidities and mortalities. COVID-19 is a multi-systemic disease and is not primarily limited to the respiratory system. Thrombus formation is one of its distinct features. However, renal complications associated with COVID-19 are rarely reported in the literature due to limited occurrence and research. We report a rare case of right retroperitoneal hematoma in a COVID-19 patient. We report a 51-year-old male patient who was received at the emergency department (ED). The patient was positive for COVID-19 and had a Glasgow coma scale of 12/15. The patient was initially managed on IV anticoagulation due to cavernous sinus thrombosis and was placed on mechanical ventilation which helped him to improve. After two weeks, a sudden drop in hemoglobin was observed. CT scan of abdomen and pelvis showed the presence of a right retroperitoneal hematoma, and right renal artery non-occlusive filling defect. The patient was successfully managed with conservative treatment. Retroperitoneal hematoma although a rare occurrence in COVID-19 patient should be observed and monitored closely in case of bleeding or anemia, as early management and intervention is beneficial.

Cerebral Venous Sinus Thrombosis Following an mRNA COVID-19 Vaccination and Recent Oral Contraceptive Use.

Rising concerns of cerebral venous sinus thrombosis (CVST) and other forms of venous thromboembolism have been associated with the SARS-CoV-2 vaccinations. Adverse effects with vector-based vaccines are well documented in the literature, while less is known about the mRNA vaccines. This report documents a case of CVST in a 32-year-old female patient who received her second Pfizer mRNA COVID-19 vaccination 16 days prior to hospital admission and had started oral combined contraceptives approximately 4 months beforehand. Clinicians should be cognizant of the possibility that mRNA vaccines, when combined with other risk factors like oral contraceptive pill use, may enhance one's hypercoagulable status.

Cerebral venous thrombosis in a patient with adenomyosis: A case report.

Cerebral venous thrombosis can be caused by different conditions such as infectious, structural, hypercoagulable states, hematological, hormonal, collagen, vascular diseases, and oral contraceptive pills among other causes. Adenomyosis has been rarely associated with Cerebral venous thrombosis (CVT). Increased CA-125 and iron deficiency anemia in adenomyosis may predispose to CVT.

Extensive Cerebral Venous Thrombosis as an Isolated Presentation in a COVID-19-Positive Young Adult.

Due to the increase in the number of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases globally, more medical case reports are being published showing the different complications of coronavirus disease 2019 (COVID-19). One of the important complications is thrombotic events that occur as a sequela of COVID-19. Here we present a case of a previously healthy male patient in his 30s who presented to the emergency unit experiencing headaches, vomiting, and weakness in his left arm. On examination, he was vitally stable, and fully oriented, but noted to have jerky movements of the left arm; therefore, he was sent for a CT brain scan. Shortly after, he developed a generalized tonic-clonic seizure. After stabilizing the patient, CT brain with cerebral venography was done, which revealed extensive thrombosis of the superior sagittal sinus and bilateral superficial cortical veins. The patient's blood test showed a high D-dimer (4.90 ug/ml), and the COVID-19 polymerase chain reaction (PCR) swab test was positive. It is commonly known that COVID-19 infection presents with fever and respiratory symptoms; however, our case illustrates the thrombotic complication of SARS-CoV-2 infection with no pneumonia or respiratory symptoms with a high level of d-dimer.

Cerebral Venous Thrombosis in COVID-19.

Background: COVID-19 causes a hypercoagulable state leading to thrombosis. Many of these thrombotic complications occur in those with severe disease and late in the disease course. COVID-19 has recently been associated with cerebral venous thrombosis (CVT). Objective: To study the onset of CVT in relation to COVID-19 and compare their characteristics and outcomes with non-COVID CVT patients admitted during the same period. Materials and Methods: This multicentric, retrospective study conducted between April 4 and October 15, 2020, included adult patients with CVT who were positive for the SARS-CoV-2 virus and compared them with CVT patients who were negative for the SARS-CoV-2 virus hospitalized during the same period. We studied their clinical profile, risk factors for CVT, and markers of COVID coagulopathy, imaging characteristics, and factors influencing their outcomes. Results: We included 18 COVID-19-infected patients and compared them with 43 non-COVID-19 CVT patients. Fourteen patients in the COVID-19 group presented with CVT without the other typical features of COVID-19. Thirteen patients had non-severe COVID-19 disease. Twelve patients had a good outcome (mRS ≤2). Mortality and disability outcomes were not significantly different between the two groups. Conclusion: Our study suggests a possible association between COVID-19 and CVT. CVT can be the presenting manifestation of an underlying COVID-19, occurring early in the course of COVID-19 and even in those with mild disease. Patients with worse GCS on admission, abnormal HRCT chest, severe COVID-19, and need for invasive ventilation had a poor outcome.

Fatal Cerebral Venous Thrombosis in a Pregnant Woman with Inherited Antithrombin Deficiency after BNT162b2 mRNA COVID-19 Vaccination.

Antithrombin deficiency is a high-risk factor for venous thromboembolism during pregnancy, whereas cerebral venous thrombosis is rare. Cerebral venous thrombosis related to coronavirus disease 2019 (COVID-19) vaccines has been reported; however, there are a few reports of cerebral venous thrombosis after a messenger RNA (mRNA) vaccination. A 25-year-old female in her sixth week of pregnancy presented with headache 24 days after BNT162b2 mRNA COVID-19 vaccination. The following day, she presented with altered sensorium and was diagnosed with severe cerebral venous thrombosis. She demonstrated heparin resistance and was found to have an inherited antithrombin deficiency. A heterozygous missense variant in SERPINC1 (c.379T>C, p.Cys127Arg, 'AT Morioka') was detected by DNA analysis. Despite intensive care with unfractionated heparin, antithrombin concentrate, and repeated endovascular treatments, she died on the sixth day of hospitalization. Cerebral venous thrombosis in pregnant women with an antithrombin deficiency can follow a rapid and fatal course. Treatment with unfractionated heparin and antithrombin concentrate may be ineffective in severe cerebral venous thrombosis cases with antithrombin deficiency. Early recognition of antithrombin deficiency and an immediate switch to other anticoagulants may be required. Although the association between cerebral venous thrombosis and the vaccine is uncertain, COVID-19 vaccinations may require careful evaluation for patients with prothrombic factors.

Comparative risk of cerebral venous sinus thrombosis (CVST) following COVID-19 vaccination or infection: A national cohort study using linked electronic health records.

To inform the public and policy makers, we investigated and compared the risk of cerebral venous sinus thrombosis (CVST) after SARS-Cov-2 vaccination or infection using a national cohort of 2,643,699 individuals aged 17 y and above, alive, and resident in Wales on 1 January 2020 followed up through multiple linked data sources until 28 March 2021. Exposures were first dose of Oxford-ChAdOx1 or Pfizer-BioNTech vaccine or polymerase chain reaction (PCR)-confirmed SARS-Cov-2 infection. The outcome was an incident record of CVST. Hazard ratios (HR) were calculated using multivariable Cox regression, adjusted for confounders. HR from SARS-Cov-2 infection was compared with that for SARS-Cov-2 vaccination. We identified 910,556 (34.4%) records of first SARS-Cov-2 vaccination and 165,862 (6.3%) of SARS-Cov-2 infection. A total of 1,372 CVST events were recorded during the study period, of which 52 (3.8%) and 48 (3.5%) occurred within 28 d after vaccination and infection, respectively. We observed slight non-significant risk of CVST within 28 d of vaccination [aHR: 1.34, 95% CI: 0.95-1.90], which remained after stratifying by vaccine [BNT162b2, aHR: 1.18 (95% CI: 0.63-2.21); ChAdOx1, aHR: 1.40 (95% CI: 0.95-2.05)]. Three times the number of CVST events is observed within 28 d of a positive SARS-Cov-2 test [aHR: 3.02 (95% CI: 2.17-4.21)]. The risk of CVST following SARS-Cov-2 infection is 2.3 times that following SARS-Cov-2 vaccine. This is important information both for those designing COVID-19 vaccination programs and for individuals making their own informed decisions on the risk-benefit of vaccination. This record-linkage approach will be useful in monitoring the safety of future vaccine programs.