Sagittal sinus thrombosis with subarachnoid haemorrhage in a patient with COVID-19 infection.

A man in his late 50s was admitted with a 10-day history of right frontotemporal headache, left arm and leg weakness, and a sudden decline in visual acuity in the right eye. The patient had recent exposure to COVID-19 infection and tested positive for the same on admission. A CT scan of the head done on arrival demonstrated a subarachnoid haemorrhage in the right central sulcus with an underlying superior sagittal sinus thrombosis. No other known risk factors for central venous sinus thrombosis could be identified. The patient had a normal level of consciousness on admission clinically; however, he was in severe pain. A collective decision was made to administer anticoagulants to the patient with heparin after carefully deliberating the risk-to-benefit ratio of a superior sagittal thrombus with an associated subarachnoid haemorrhage. Our patient recovered and was discharged after 2 weeks on warfarin. We present this case to highlight the potential risks of hypercoagulable and neurotropic complications of COVID-19 infections, with special emphasis on cerebral venous thrombosis.

A neonatal case of cerebral venous sinus thrombosis with intrauterine onset after COVID-19 infection during pregnancy: Cause or coincidence?

Coronavirus 19 disease (COVID-19) is known to predispose patients to increased thrombotic events and the risk is higher in pregnancy which is already a hypercoagulable state. Vertical transmission of the disease during pregnancy was neglected according to data early in the pandemic, however, despite conflicting results from different studies, there is an increasing suspicion of vertical transmission with the rise of new fetal and neonatal cases and perinatal transmission can be higher than expected. An early term neonate, with the history of maternal COVID-19 infection in the start of third trimester, was diagnosed as cerebral venous sinus thrombosis and chronic hemorrhagic ischemia, with intrauterine onset.

Late-post-COVID-19 cerebral venous sinus thrombosis and stroke: a case report.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) disease increases risk of venous thromboembolisms (VTE), primarily deep vein thrombosis and pulmonary embolism. Only a few cases of cerebral venous sinus thrombosis (CVST) in association with a COVID-19 infection have been reported and are limited to acute COVID-19 disease. Hypercoagulable conditions persist in postacute COVID-19 disease, which carries an increased risk of VTE. CASE PRESENTATION: We report a case of CVST and stroke 56 days post-COVID-19 infection presenting with an atypical clinical picture. DISCUSSION: To the best of our knowledge, this is one of the first observations of CVST in the postacute phase of COVID-19 disease. Clinicians should be aware of this potential late complication and should consider appropriate diagnostic imaging techniques in patients with COVID-19-infection history.

Encephalopathy as the Only Manifestation in Simultaneous Arterial Infarct and Cerebral Venous Sinus Thrombosis in Recent COVID-19 Infection.

BACKGROUND Emerging cases of SARS-CoV-2 infection associated with cerebral thromboembolism episodes manifesting as arterial strokes or cerebral venous thrombosis have been reported. However, the co-occurrence of arterial strokes and cerebral venous thrombosis is rare. CASE REPORT We report the case of a previously healthy young patient with recent SARS-CoV-2 infection, who presented with encephalopathy. His computed tomography venography and magnetic resonance imaging of the brain showed thrombosis of the vein of Galen and straight sinus, and arterial infarcts in both hemispheres. His inflammatory markers, D-dimer levels, and coagulation profile were normal. He was started on anticoagulation and recovered well. CONCLUSIONS Concurrent arterial and venous thrombosis can happen rarely in patients with SARS-CoV-2 infection, including patients who have recently recovered from COVID-19. Cerebral thromboembolism associated with SARS-CoV-2 can present with a variety of subtle clinical manifestations, including encephalopathy without focal neurological deficits. Inflammatory markers, D-dimer levels, and coagulation profiles can be normal, especially in patients with mild infection or who have recovered from the infection. Therefore, it is important to be vigilant and recognize this clinical entity so that the diagnosis can be made and treatment can be started promptly. However, larger and prospective studies are needed to determine the clinical outcomes, therapeutic benefits, and complications of concurrent arterial stroke and cerebral venous thrombosis associated with SARS-CoV-2 infection.

Moderna, Pfizer-BioNTech, and Johnson & Johnson/Janssen Post-Covid Vaccine Hematological Adverse Events Including Cerebral Venous Sinus Thrombosis (CVST), Thrombotic Thrombocytopenia (VITT), Blood Clots, Increased Vaginal/Menstrual Bleeding and/or Miscarriage, Stillbirth Delivery, or Premature Birth.

The Centers for Disease Control (CDC) indicated in 2021 that it would monitor for possible post-COVID-19 vaccination coagulopathy adverse events (AEs).

Cerebral Venous Sinus Thrombosis Following COVID-19 and Otogenic Infection: A Diagnostic and Therapeutic Dilemma Followed by mRNA COVID-19 Vaccination.

IntroductionCerebral venous sinus thrombosis (CVST) is a rare neurovascular emergency that has been observed following COVID-19 infection, as well as following the use of non-mRNA COVID-19 vaccines. Case PresentationThe authors report a case of CVST in a 67-year-old woman, unvaccinated for COVID-19, who presented with acute otitis externa. It remains unclear whether the CVST was a following COVID-19 infection complication, otogenic CVST, or a combination of both. ConclusionThis case demonstrates the diagnostic and therapeutic dilemmas in managing this patient's challenging anticoagulation and antibiotic duration, as well as subsequent COVID-19 vaccination recommendations.

Cerebral venous sinus thrombosis following Russell's viper (Daboia russelii) envenomation: A case report and review of the literature.

Snakebite is a life-threatening and often-neglected public health hazard with high chronic disability and mortality, mainly faced by rural communities in the tropics/subtropics. Stroke and neuromuscular paralysis are the most severe neurological complications. However, cerebral venous sinus thrombosis has rarely been reported among cerebrovascular complications. We report a previously healthy middle-aged Indian woman who developed cerebral venous sinus thrombosis preceded by features of disseminated bleeding diathesis following Russell's viper bite. The cerebral venous sinus thrombosis was diagnosed by magnetic resonance imaging. The patient responded well to treatment with antivenom and subcutaneous enoxaparin and had no demonstrable neurological deficits at three months of follow-up.

SARS-CoV-2 vaccination associated venous sinus thrombosis in three patients.

INTRODUCTION: There is increasing evidence that vaccinations against the severe acquired respiratory syndrome coronavirus type-2 (SARS-CoV-2) virus can be followed by venous sinus thrombosis (VST). Here we report on three patients who developed VST shortly after SARS-CoV-2 vaccinations. CASE SERIES: An 80-year-old male, a 58-year-old male, and a 34-year-old female developed VST 14 to 24 days after the first dose of an mRNA-based SARS-CoV-2 vaccine. All three patients profited from analgesics, heparinisation, and oral anticoagulation, but made only an incomplete recovery at the time of discharge. Arguments for a causal relationship are: VST was time-linked to vaccination in the three patients; VST was previously reported after SARS-CoV-2 vaccination; SARS-CoV-2 infections can be complicated by VST; and SARS-CoV-2 can be associated with hypercoagulability. The fact that no hypercoagulability occurred in a pilot study after SARS-CoV-2 vaccination and that there has been no evidence of an increased prevalence/incidence of VST after vaccination since the introduction of the SARS-CoV-2 vaccination speak against a causal relationship. CONCLUSIONS: SARS-CoV-2 vaccinations can occasionally be followed by a VST. There are more arguments for than against a causal relationship.

Meaningful use of imaging resources to rule out cerebral venous sinus thrombosis after ChAdOx1 COVID-19 vaccination: Evaluation of the AHA diagnostic algorithm with a clinical cohort and a systematic data review.

Vaccine-induced immune thrombotic thrombocytopenia (VITT) with cerebral venous thrombosis (CVST) is an improbable (0.0005%), however potentially lethal complication after ChAdOx1 vaccination. On the other hand, headache is among the most frequent side effects of ChAdOx1 (29.3%). In September 2021, the American Heart Association (AHA) suggested a diagnostic workflow to facilitate risk-adapted use of imaging resources for patients with neurological symptoms after ChAdOx1. We aimed to evaluate the AHA workflow in a retrospective patient cohort presenting at four primary care hospitals in Germany for neurological complaints after ChAdOx1. Scientific literature was screened for case reports of VITT with CVST after ChAdOx1, published until September 1st, 2021. One-hundred-thirteen consecutive patients (77 female, mean age 38.7 +/- 11.9 years) were evaluated at our institutes, including one case of VITT with CVST. Further 228 case reports of VITT with CVST are published in recent literature, which share thrombocytopenia (225/227 reported) and elevated d-dimer levels (100/101 reported). The AHA workflow would have recognized all VITT cases with CVST (100% sensitivity), the number needed to diagnose (NND) was 1:113. Initial evaluation of thrombocytopenia or elevated d-dimer levels would have lowered the NND to 1:68, without cost of sensitivity. Hence, we suggest that in case of normal thrombocyte and d-dimer levels, the access to further diagnostics should be limited by the established clinical considerations regardless of vaccination history.

Cerebral venous sinus thrombosis in the setting of COVID-19 vaccination: a systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Cerebral venous sinus thrombosis (CVST) has been reported as a rare adverse event in association with thrombosis-thrombocytopenia syndrome (TTS) following COVID-19 vaccination. METHODS:  We performed a systematic review and meta-analysis of investigator-initiated registries including confirmed CVST cases, with the aim to calculate (1) the odds ratio of TTS-CVST versus non-TTS-CVST after vector-based vaccines and (2) after non-vector-based vaccines, (3) the in-hospital mortality ratio of TTS-CVST compared to non-TTS-CVST; and (4) the dependency or death at discharge among TTS-CVST compared to non-TTS-CVST cases. RESULTS: Two eligible studies were included in the meta-analysis, comprising a total of 211 patients with CVST associated with COVID-19 vaccination. Vector-based COVID-19 vaccination was associated with a higher likelihood of TTS-associated CVST than with non-TTS-CVST (OR: 52.34, 95% CI 9.58-285.98). TTS-CVST was also associated with higher likelihood of in-hospital mortality (OR: 13.29; 95% CI 3.96-44.60) and death or dependency at discharge compared to non-TTS-CVST (OR: 6.70; 95% CI 3.15-14.26). TTS-CVST was recorded with a shorter interval between vaccination and symptom onset [Mean Difference (MD):-6.54 days; 95% CI - 12.64 to - 0.45], affecting younger patients (MD:-9.00 years; 95% CI - 14.02 to - 3.99) without risk factors for thromboses (OR:2.34; 95% CI 1.26-4.33), and was complicated more frequently with intracerebral hemorrhage (OR:3.60; 95% CI 1.31-9.87) and concomitant thromboses in other sites (OR:11.85; 95% CI 3.51-39.98) compared to non-TTS-CVST cases. CONCLUSIONS: TTS-CVST following COVID-19 vaccination has distinct risk factor profile, clinical phenotype and prognosis compared to non-TTS-CVST. Further epidemiological data are required to evaluate the impact of different treatment strategies on outcome of TTS-CVST cases following COVID-19 vaccination.

A Rare Case of Coronavirus Disease 2019 Vaccine-Associated Cerebral Venous Sinus Thrombosis Treated with Mechanical Thrombectomy.

BACKGROUND Vaccine-related thrombosis and thrombocytopenia syndrome (TTS) is a rare life-threatening syndrome reported after vaccination against COVID-19. CASE REPORT We describe a case of 56-year-old postmenopausal, obese woman with hypothyroidism and hyperlipidemia, who presented to the Emergency Department (ED) with fluctuating mental status and left-side weakness for 5 days. She received her first and second dose of mRNA-1273 vaccine (Moderna) at 12 and 8 weeks, respectively, prior to presentation. She was found to have multiple hemorrhages and infarcts on a computed tomography (CT) scan of the head. She was intubated in the ED for airway protection and mechanically ventilated. Magnetic resonance angiogram and venogram showed multiple infarcts in right frontal, parietal, and left parietal lobes, along with occlusion of left-side transverse sinus, sagittal sinuses, and left internal jugular vein, suggesting cerebral venous sinus thrombosis (CVST). Despite anticoagulation, her clinical condition continued to worsen, and she was referred for emergent endovascular thrombectomy. Her clinical condition improved after thrombectomy, and she was discharged on warfarin. At 4-month follow-up, she was able to walk with an assistive device and able to carry out activities of daily living with assistance. She is planned for further work-up for hypercoagulable state at follow-up. CONCLUSIONS This case highlights the occurrence of vaccine-related thrombosis 3 months after vaccine administration. Only 2 cases of TTS have been reported so far after mRNA-1273 vaccination (Moderna). To the best of our knowledge, this is the first reported case of CVST presenting 3 months after the first dose of COVID-19 mRNA-1273 vaccine (Moderna).

First dose ChAdOx1 and BNT162b2 COVID-19 vaccinations and cerebral venous sinus thrombosis: A pooled self-controlled case series study of 11.6 million individuals in England, Scotland, and Wales.

BACKGROUND: Several countries restricted the administration of ChAdOx1 to older age groups in 2021 over safety concerns following case reports and observed versus expected analyses suggesting a possible association with cerebral venous sinus thrombosis (CVST). Large datasets are required to precisely estimate the association between Coronavirus Disease 2019 (COVID-19) vaccination and CVST due to the extreme rarity of this event. We aimed to accomplish this by combining national data from England, Scotland, and Wales. METHODS AND FINDINGS: We created data platforms consisting of linked primary care, secondary care, mortality, and virological testing data in each of England, Scotland, and Wales, with a combined cohort of 11,637,157 people and 6,808,293 person years of follow-up. The cohort start date was December 8, 2020, and the end date was June 30, 2021. The outcome measure we examined was incident CVST events recorded in either primary or secondary care records. We carried out a self-controlled case series (SCCS) analysis of this outcome following first dose vaccination with ChAdOx1 and BNT162b2. The observation period consisted of an initial 90-day reference period, followed by a 2-week prerisk period directly prior to vaccination, and a 4-week risk period following vaccination. Counts of CVST cases from each country were tallied, then expanded into a full dataset with 1 row for each individual and observation time period. There was a combined total of 201 incident CVST events in the cohorts (29.5 per million person years). There were 81 CVST events in the observation period among those who a received first dose of ChAdOx1 (approximately 16.34 per million doses) and 40 for those who received a first dose of BNT162b2 (approximately 12.60 per million doses). We fitted conditional Poisson models to estimate incidence rate ratios (IRRs). Vaccination with ChAdOx1 was associated with an elevated risk of incident CVST events in the 28 days following vaccination, IRR = 1.93 (95% confidence interval (CI) 1.20 to 3.11). We did not find an association between BNT162b2 and CVST in the 28 days following vaccination, IRR = 0.78 (95% CI 0.34 to 1.77). Our study had some limitations. The SCCS study design implicitly controls for variables that are constant over the observation period, but also assumes that outcome events are independent of exposure. This assumption may not be satisfied in the case of CVST, firstly because it is a serious adverse event, and secondly because the vaccination programme in the United Kingdom prioritised the clinically extremely vulnerable and those with underlying health conditions, which may have caused a selection effect for individuals more prone to CVST. Although we pooled data from several large datasets, there was still a low number of events, which may have caused imprecision in our estimates. CONCLUSIONS: In this study, we observed a small elevated risk of CVST events following vaccination with ChAdOx1, but not BNT162b2. Our analysis pooled information from large datasets from England, Scotland, and Wales. This evidence may be useful in risk-benefit analyses of vaccine policies and in providing quantification of risks associated with vaccination to the general public.

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.

[A case of cerebral venous sinus thrombosis following the vaccination with Tozinameran].

A 31-year-old man visited our hospital due to experiencing severe headaches, vomiting, and hypesthesia in the left side of his body. He had no past illnesses and had had no severe headaches before. The symptoms started the day after receiving the coronavirus disease 2019 (COVID-19) vaccination with Tozinameran. An MRI revealed cerebral venous sinus thrombosis and high intensity (DWI & FLAIR) of the right thalamus. Anticoagulant therapy was initiated, and his symptoms improved gradually. The follow-up MRI showed recanalization in a large part of the occluded venous sinuses. Most of the coagulation tests were normal, except for slightly high value of D-dimer, and the polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was negative. Further cases are needed to judge if there is some sort of relationship between the vaccination and the cerebral venous sinus thrombosis.

Cerebral Venous Sinus Thrombosis Following COVID-19 Vaccination: A Systematic Review.

INTRODUCTION: COVID-19 vaccines became available after being carefully monitored in clinical trials with safety and efficacy on the human body. However, a few recipients developed unusual side effects, including cerebral venous sinus thrombosis (CVST). We aim to systematically review the baseline features, clinical characteristics, treatment, and outcomes in patients developing CVST post-COVID-19 vaccination. METHODS: This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) 2020 guideline. Investigators independently searched PubMed, Embase, and Google Scholar for English language articles published from inception up until September 10, 2021, reporting the incidence of CVST post-COVID-19 vaccines. We analyzed CVST patients' baseline data, type of vaccines, clinical findings, treatment, and outcomes. Our systematic review process yielded patient-level data. RESULT: The final analysis included 25 studies that identified 80 patients who developed CVST after the COVID-19 vaccination. Of the 80 CVST cases, 31 (39.24%) patients died. There was no significant relationship between mortality and age (P = .733), sex (P = .095), vaccine type (P = .798), platelet count (P = .93), and comorbidities such as hypertension (P = .734) and diabetes mellitus (P = .758). However, mortality was associated with the duration of onset of CVST symptoms after vaccination (P = .022). Patients with CVST post-COVID-19 vaccination were more likely to survive if treated with an anticoagulant (P = .039). Patients who developed intracranial hemorrhage (P = .012) or thrombosis in the cortical vein (P = .021) were more likely to die. CONCLUSION: COVID-19 vaccine-associated CVST is associated with high mortality rate. Timely diagnosis and management can be lifesaving for patients.

Histological and immunohistochemical findings in a fatal case of thrombotic thrombocytopenia after ChAdOx1 nCov-19 vaccination.

This case report describes a fatal case of a young woman with superior sagittal, transverse and sigmoid sinus thrombosis after administration of the ChAdOx1 nCov-19 vaccination. Eleven days post-vaccination she was found unconscious and transferred to the Emergency Department. Blood parameters showed low platelets, and a CT scan showed an extensive left intracranial hemorrhage and the presence of an occlusive thrombus of the superior sagittal sinus. She under-went a craniectomy, but after the intervention, she remained in a comatose state. After a few days, her clinical conditions worsened, and she died. A complete autopsy was performed which showed a thrombosis of the cerebral venous district, of the upper and lower limbs. A blood sample was also performed to carry out a gene study about the predisposition to thrombosis. The organ samples were studied through light microscope both in hematoxylin-eosin and immunohistochemical examination, and showed a strong inflammatory response in all samples and at the site of thrombosis. Our study aims to provide a proper autopsy technique to study the entire cerebral venous system through a multidisciplinary approach (anatomical dissection and neurosurgery) in post-vaccine venous thrombosis.