Case Of Cerebral Venous Thrombosis Research Articles

Association of cerebral venous thrombosis with recent COVID-19 vaccination: case-crossover study using ascertainment through neuroimaging in Scotland

BackgroundTo investigate the association of primary acute cerebral venous thrombosis (CVT) with COVID-19 vaccination through complete ascertainment of all diagnosed CVT in the population of Scotland.MethodsCase-crossover study comparing cases of CVT recently exposed to vaccination (1–14 days after vaccination) with cases less recently exposed. Cases in Scotland from 1 December 2020 were ascertained through neuroimaging studies up to 17 May 2021 and diagnostic coding of hospital discharges up to 28 April 2021, linked to national vaccination records. The main outcome measure was primary acute CVT.ResultsOf 50 primary acute CVT cases, 29 were ascertained only from neuroimaging studies, 2 were ascertained only from hospital discharges, and 19 were ascertained from both sources. Of these 50 cases, 14 had received the Astra-Zeneca ChAdOx1 vaccine and 3 the Pfizer BNT162b2 vaccine. The incidence of CVT per million doses in the first 14 days after vaccination was 2.2 (95% credible interval 0.9 to 4.1) for ChAdOx1 and 1 (95% credible interval 0.1 to 2.9) for BNT162b2. The rate ratio for CVT associated with exposure to ChAdOx1 in the first 14 days compared with exposure 15-84 days after vaccination was 3.2 (95% credible interval 1.1 to 9.5).ConclusionsThese findings support a causal association between CVT and the AstraZeneca vaccine. The absolute risk of post-vaccination CVT in this population-wide study in Scotland was lower than has been reported for populations in Scandinavia and Germany; the explanation for this is not clear.

Церебральний венозний тромбоз (клінічний випадок)

Тромбоз мозкових вен і венозний тромбоз мозкових синусів зустрічається рідко (до 1 % від усіх випадків інфарктів мозку). За даними ISCVT (International Study on Cerebral Vein and Dural Sinus Thrombosis, 2004), захворюваність щорічно становить 3–4 випадки на 1 млн у дорослих. Летальність при даному захворюванні становить від 5 до 30 %. Міжнародне дослідження тромбозу мозкових вен та венозних синусів (ISCVT) визначало частоту оклюзій за локалізацією так: поперечний синус — 86 %, верхній сагітальний синус — 62 %, прямий синус — 18 %, кортикальні вени — 17 %, внутрішні яремні вени — 12 %, вена Галена і внутрішні мозкові вени — 11 %. Основними факторами ризику розвитку тромбозу мозкових вен і венозного тромбозу мозкових синусів у популяції є інфекційні запальні процеси (отити, мастоїдити, синусити, септичні стани) і неінфекційні причини: черепно-мозкова травма, пухлини, хірургічні втручання в ділянці голови та шиї, а також імплантація кардіостимулятора чи постановка центрального венозного катетера. Захворювання, що сприяють даній патології: порушення гемодинаміки (застійна серцева недостатність, зневоднення організму), захворювання крові (поліцитемія, серпоподібноклітинна анемія, тромбоцитопенія) і коагулопатії (синдром дисемінованого внутрішньосудинного згортання крові, дефіцит антитромбіну, протеїну С і S), а також тромбофілітичні стани, пов’язані з вагітністю, родами та прийомом пероральних контрацептивів, антифосфоліпідний синдром, системні васкуліти. При цьому в 15 % випадків причина розвитку синус-тромбозу залишається невстановленою. Венозний тромбоз мозкових синусів характеризується дуже різноманітним клінічним перебігом, складною діагностикою, різноманітною етіологією і прогнозом. Одним з ускладнень тромбозу синусів є інсульт, що спостерігається приблизно в 30 % хворих та часто призводить до смерті хворого. У статті подано опис клінічного випадку церебрального венозного тромбозу, що ускладнився несумісним із життям двопівкульним субарахноїдально-паренхіматозним крововиливом.

Endovascular treatment of cerebral venous thrombosis.

The article describes a clinical case of cerebral venous thrombosis involving the deep venous system in a 42-year-old patient suffering from acute lymphoblastic leukemia. As the patient’s condition progressively deteriorated despite anticoagulant therapy, endovascular treatment was attempted. Transvenous thrombectomy and local thrombolysis were performed, which made it possible to achieve only partial recanalization. Further prolonged administration of alteplase into the cerebral sinus through a microcatheter facilitated complete recanalization of the direct and transverse sinuses. The restoration of blood flow was accompanied by regression of neurological deficit. This case is discussed in the context of modern approaches to endovascular treatment of cerebral venous thrombosis.

Brain venography performance following the pause of Ad.26.COV2.S COVID-19 vaccine administration.

Cases of cerebral venous thrombosis (CVT) associated with vaccine induced thrombotic thrombocytopenia (VITT) were reported following administration of the adenoviral vector COVID-19 vaccines, resulting in a pause in Ad.26.COV2.S vaccine administration in the United States, beginning on April 14, 2021. We aimed to quantify and characterize an anticipated increase in brain venograms performed in response to this pause. Brain venogram cases were retrospectively identified during the three-week period following the vaccine pause and during the same calendar period in 2019. For venograms performed in 2021, we compared COVID vaccinated to unvaccinated patients. There was a 262% increase in venograms performed between 2019 (n = 26) and 2021 (n = 94), compared to only a 19% increase in all radiologic studies. Fifty-seven percent of patients in 2021 had a history of COVID-19 vaccination, with the majority being Ad.26.COV2.S. All patients diagnosed with CVT were unvaccinated. COVID vaccinated patients lacked platelet or D-dimer measurements consistent with VITT. Significantly more vaccinated versus unvaccinated patients had a headache (94% vs 70%, p = 0.0014), but otherwise lacked compelling CVT presentations, such as decreased/altered consciousness (7% vs 23%, p = 0.036), neurologic deficit (28% vs 48%, p = 0.049), and current/recent pregnancy (2% vs 28%, p = 0.0003). We found a dramatic increase in brain venograms performed following publicity of rare COVID-19 vaccine associated CVT cases, with no CVTs identified in vaccinated patients. Clinicians should carefully consider if brain venogram performance is indicated in COVID-19 vaccinated patients lacking thrombocytopenia and D-dimer elevation, especially without other compelling CVT risk factors or symptoms.

Abstract 1122‐000044: Endovascular Thrombectomy for Straight Sinus Thrombosis

Introduction : Cerebral venous thrombosis (CVT) is an under‐recognized disease that accounts for roughly 1% of all strokes 1 . It presents a diagnostic challenge due to its varied and ambiguous presentation, which on average, delays diagnosis by 7 days. Pre‐disposing factors include trauma, pregnancy, dehydration, and medications such as oral contraceptives. In one study, 50% of CVT occurred during pregnancy or puerperium 2 . Seven out of 8 cases of CVT presented postpartum among 50,700 deliveries in Canada 3 . Clinical signs and symptoms range from a mild headache to decreased level of consciousness depending on the location of thrombosis. Up to 13% of individuals can have poor outcomes despite anticoagulation therapy. Methods : A 28‐year‐old, 7‐week postpartum female awoke with a headache and difficulty speaking, followed by urinary and bowel incontinence. Her clinical status worsened and was admitted to an outside hospital where CT‐head without contrast revealed right temporal lobe hypodensity. A hyperdense straight sinus sign was present but not recognized at that time. She was transferred to our hospital and MRI brain demonstrated extensive vasogenic edema in the basal ganglia, thalami, and deep white matter with cytotoxic edema in bilateral watershed areas from severe hydrocephalus. MR‐Venography showed extensive cerebral venous thrombosis in the inferior sagittal sinus, vein of Galen, straight sinus, and left transverse and sigmoid sinuses. Upon transfer to our facility, NIHSS was 9 for decreased level of consciousness and aphasia with episodes of left‐sided clonic movements. Despite adequate anticoagulation therapy, she continued to decline with extensor posturing and a comatose state. Results : Since the findings on MRI‐brain were predominantly vasogenic edema, thrombectomy was performed with a stent‐retriever and aspiration, with complete recanalization of her straight sinus. Subsequent MRIs demonstrated improvement and resolution of the edema and hydrocephalus. Hypercoagulable work‐up revealed an elevated protein C and antithrombin III and she was transitioned to enoxaparin and discharged to LTACH. At four‐month follow‐up she was able to speak and walk with physical therapy. Conclusions : We highlight the importance of early recognition of deep venous thrombosis as it commonly affects level of consciousness. A subtle finding, it should be in the differential diagnosis of alteration in level of consciousness without obvious neuroimaging findings. The AAN guidelines for management of CVT do not advocate for thrombectomy in all patients as large randomized controlled trials do not currently exist. However, they recognize that thrombectomy may be considered if deterioration occurs despite intensive anticoagulation treatment. The TO‐ACT trial found no significant difference in mortality between intervention and medical therapy, aggressive intervention with thrombectomy prevented a larger stroke burden in our patient. Therefore, thrombectomy should be considered in patients suffering from CVT, particularly in refractory and extensive cases.

Validity of ICD-10 Codes for Cerebral Venous Thrombosis Depends on Clinical Context.

We examined the accuracy of International Classification of Disease 10th iteration (ICD-10) diagnosis codes within Canadian administrative data in identifying cerebral venous thrombosis (CVT). Of 289 confirmed cases of CVT admitted to our comprehensive stroke center between 2008 and 2018, 239/289 were new diagnoses and 204/239 were acute events with only 75/204 representing symptomatic CVTs not provoked by trauma or structural processes. Using ICD-10 codes in any position, sensitivity was 39.1% and positive predictive value was 94.2% for patients with a current or history of CVT and 84.0% and 52.5% for acute and symptomatic CVTs not provoked by trauma or structural processes.

Hospital-based observational study of neurological disorders in patients recently vaccinated with COVID-19 mRNA vaccines

PurposeWe describe the spectrum of acute neurological disorders among hospitalized patients who recently had COVID-19 mRNA vaccination. MethodWe performed a prospective study at 7 acute hospitals in Singapore. Hospitalized patients who were referred for neurological complaints and had COVID-19 mRNA vaccines, BNT162b2 and mRNA-1273, in the last 6 weeks were classified into central nervous system (CNS) syndromes, cerebrovascular disorders, peripheral nervous system (PNS) disorders, autonomic nervous system (ANS) disorders and immunization stress-related responses (ISRR). ResultsFrom 30 December 2020 to 20 April 2021, 1,398,074 persons (median age 59 years, 54.5% males) received COVID-19 mRNA vaccine (86.7% BNT162b2, 13.3% mRNA-1273); 915,344(65.5%) completed 2 doses. Four hundred and fifty-seven(0.03%) patients were referred for neurological complaints [median age 67(20–97) years, 281(61.5%) males; 95.8% received BNT162b2 and 4.2% mRNA-1273], classified into 73(16.0%) CNS syndromes, 286(62.6%) cerebrovascular disorders, 59(12.9%) PNS disorders, 0 ANS disorders and 39(8.5%) ISRRs. Eleven of 27 patients with cranial mononeuropathy had Bell's palsy. Of 33 patients with seizures, only 4 were unprovoked and occurred within 2 weeks of vaccination. All strokes occurred among individuals with pre-existing cardiovascular risk factors. We recorded 2 cases of cerebral venous thrombosis; none were vaccine-induced thrombotic thrombocytopenia. Five had mild flares of immune-mediated diseases. ConclusionOur observational study does not establish causality of the described disorders to vaccines. Though limited by the lack of baseline incidence data of several conditions, we observed no obvious signal of serious neurological morbidity associated with mRNA vaccination. The benefits of COVID-19 vaccination outweigh concerns over neurological adverse events.

Cerebral Venous Sinus Thrombosis in Patients With SARS-CoV-2

Several neurological manifestations of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported, including cerebral venous sinus thrombosis (CVST). In this report, we discuss two cases of cerebral venous thrombosis in young patients with a recent SARS-CoV-2 infection and otherwise unrevealing workup. Case 1 was a 35-year-old man who was found unresponsive with urinary incontinence and vomitus on the floor. Computed tomography (CT) angiogram of the head revealed evidence of extensive venous thrombosis. Extensive workup for thrombotic disease was unrevealing and SARS-CoV-2 was detected via polymerase chain reaction. Anticoagulation was immediately initiated, and the patient made a good clinical recovery. Case 2 was a 31-year-old man who presented with severe decreased level of consciousness and was found to have extensive cerebral sinus thrombosis. Past medical history was significant for a recent SARS-CoV-2 infection diagnosed 12 days prior. The patient was treated with intravenous heparin and eventually oral anticoagulation with good clinical outcome. CVST is a potential cerebrovascular complication of SARS-CoV-2. We advise clinicians to consider this diagnosis in patients with a recent SARS-CoV-2 infection in the appropriate clinical setting. J Neurol Res. 2021;11(5):94-101 doi: https://doi.org/10.14740/jnr697

Cerebral Venous Sinus Thrombosis in Patients With SARS-CoV-2

Several neurological manifestations of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported, including cerebral venous sinus thrombosis (CVST). In this report, we discuss two cases of cerebral venous thrombosis in young patients with a recent SARS-CoV-2 infection and otherwise unrevealing workup. Case 1 was a 35-year-old man who was found unresponsive with urinary incontinence and vomitus on the floor. Computed tomography (CT) angiogram of the head revealed evidence of extensive venous thrombosis. Extensive workup for thrombotic disease was unrevealing and SARS-CoV-2 was detected via polymerase chain reaction. Anticoagulation was immediately initiated, and the patient made a good clinical recovery. Case 2 was a 31-year-old man who presented with severe decreased level of consciousness and was found to have extensive cerebral sinus thrombosis. Past medical history was significant for a recent SARS-CoV-2 infection diagnosed 12 days prior. The patient was treated with intravenous heparin and eventually oral anticoagulation with good clinical outcome. CVST is a potential cerebrovascular complication of SARS-CoV-2. We advise clinicians to consider this diagnosis in patients with a recent SARS-CoV-2 infection in the appropriate clinical setting.

Delayed headache after COVID-19 vaccination: a red flag for vaccine induced cerebral venous thrombosis

BackgroundHeadache is a frequent symptom following COVID-19 immunization with a typical onset within days post-vaccination. Cases of cerebral venous thrombosis (CVT) have been reported in adenovirus vector-based COVID-19 vaccine recipients.FindingsWe reviewed all vaccine related CVT published cases by April 30, 2021. We assessed demographic, clinical variables and the interval between the vaccination and onset of headache. We assessed whether the presence of headache was associated with higher probability of death or intracranial hemorrhage.We identified 77 cases of CVT after COVID-19 vaccination. Patients’ age was below 60 years in 74/77 (95.8%) cases and 61/68 (89.7%) were women. Headache was described in 38/77 (49.4%) cases, and in 35/38 (92.1%) was associated with other symptoms. Multiple organ thrombosis was reported in 19/77 (24.7%) cases, intracranial hemorrhage in 33/77 (42.9%) cases and 19/77 (24.7%) patients died. The median time between vaccination and CVT-related headache onset was 8 (interquartile range 7.0–9.7) days. The presence of headache was associated with a higher odd of intracranial hemorrhage (OR 7.4; 95% CI: 2.7–20.8, p < 0.001), but not with death (OR: 0.51, 95% CI: 0.18–1.47, p = 0.213).ConclusionDelayed onset of headache following an adenovirus vector-based COVID-19 vaccine is associated with development of CVT. Patients with new-onset headache, 1 week after vaccination with an adenovirus vector-based vaccine, should receive a thorough clinical evaluation and CVT must be ruled out.

Cerebral venous thrombosis and myeloproliferative neoplasms: A three-center study of 74 consecutive cases.

The recent association of cerebral venous thrombosis (CVT) with COVID‐19 vaccinations prompted the current retrospective review of 74 cases of CVT (median age = 44 years, range 15–85; 61% females) associated with myeloproliferative neoplasms (MPNs), seen at the Mayo Clinic, Catholic University of Rome, and University of Florence, between 1991 and 2021. Disease‐specific frequencies were 1.3% (39/2893), 1.2% (21/1811) and 0.2% (3/1888) for essential thrombocythemia, polycythemia vera and primary myelofibrosis, respectively. Cerebral venous thrombosis occurred either prior to (n = 20, 27%), at (n = 32, 44%) or after (n = 22) MPN diagnosis. A total of 72% of patients presented with headaches. Transverse (51%), sagittal (43%) and sigmoid sinuses (35%) were involved with central nervous system hemorrhage noted in 10 (14%) patients. In all, 91% of tested patients harbored JAK2V617F. An underlying thrombophilic condition was identified in 19 (31%) cases and history of thrombosis in 10 (14%). Treatment for CVT included systemic anticoagulation alone (n = 27) or in conjunction with aspirin (n = 24), cytoreductive therapy (n = 14), or both (n = 9). At a median follow‐up of 5.1 years (range 0.1–28.6), recurrent CVT was documented in three (4%) patients while recurrent arterial and venous thromboses and major hemorrhage were recorded in 11%, 9% and 14%, respectively. Follow‐up neurological assessment revealed headaches (n = 9), vision loss (n = 1) and cognitive impairment (n = 1). The current study lends clarity to MPN‐associated CVT and highlights its close association with JAK2V617F, younger age and female gender. Clinical features that distinguish COVID vaccine‐related CVT from MPN‐associated CVT include, in the latter, lower likelihood of concurrent venous thromboses and intracerebral hemorrhage; as a result, MPN‐associated CVT was not fatal.

Genetic Screening of Cerebral Venous Thrombosis Susceptible Women, an Effective Step in Identifying Women at Risk for Obstetric CVT

Introduction: Predisposition to cerebral venous thrombosis (CVT) also has a genetic basis and inherited thrombophilias constitute 22.4 % of the CVT cases. CVT with a varied clinical presentation and pathogenesis is one of the important causes of stroke which is not very common. Inherited thrombophilias with concomitant acquired risk factors like pregnancy may increase the risk of CVT manifold. Identification of a number of genetic variants increasing susceptibility to CVT and related traits opened up opportunity, to screening of women at high risk of developing obstetric CVT.

Nonthrombotic internal jugular venous stenosis may facilitate cerebral venous thrombosis.

AimsTo explore the effect of nonthrombotic internal jugular venous stenosis (IJVS) exerted on cerebral venous thrombosis (CVT).MethodsPatients with imaging confirmed CVT were enrolled into this real‐world case–control study consecutively from January 2018 through April 2021, and were divided into CVT and IJVS‐CVT groups, according to whether or not with non‐thrombotic IJVS. Chi‐square and logistic regression models were utilized for between‐group comparison of thrombotic factors.ResultsA total of 199 eligible patients entered into final analysis, including 92 cases of CVT and 107 cases of IJVS‐CVT. Chi‐square revealed that thrombophilic conditions were found in majority of CVT, while only minority in the IJVS‐CVT group (83.7% vs. 20.6%, p < 0.001). Multivariate logistic regression indicated that most identified thrombophilia were negatively related to IJVS‐CVT (all p < 0.05), including oral contraceptive use (β = −1.38), hyperhomocysteinemia (β = −1.58), hematology (β = −2.05), protein C/S deficiency (β = −2.28), connective tissue disease (β = −1.18) and infection (β = −2.77). All recruited patients underwent standard anticoagulation, 10 cases in IJVS‐CVT group also received jugular angioplasty for IJVS correction. Most participants obtained alleviations during 1‐year follow‐up. However, both clinical and imaging outcomes in IJVS‐CVT group were not as good as those in CVT group (both p < 0.05). Moreover, 8 cases with CVT and 7 cases with IJVS‐CVT were rehospitalized for CVT recurrences and underwent customized treatment.ConclusionNonthrombotic IJVS may be one of the risk factors of CVT. Anticoagulation might need to be suggested for IJVS patients.

Cerebral venous thrombosis after vaccination against COVID-19 in the UK: a multicentre cohort study

BackgroundA new syndrome of vaccine-induced immune thrombotic thrombocytopenia (VITT) has emerged as a rare side-effect of vaccination against COVID-19. Cerebral venous thrombosis is the most common manifestation of this syndrome but, to our knowledge, has not previously been described in detail. We aimed to document the features of post-vaccination cerebral venous thrombosis with and without VITT and to assess whether VITT is associated with poorer outcomes.MethodsFor this multicentre cohort study, clinicians were asked to submit all cases in which COVID-19 vaccination preceded the onset of cerebral venous thrombosis, regardless of the type of vaccine, interval between vaccine and onset of cerebral venous thrombosis symptoms, or blood test results. We collected clinical characteristics, laboratory results (including the results of tests for anti-platelet factor 4 antibodies where available), and radiological features at hospital admission of patients with cerebral venous thrombosis after vaccination against COVID-19, with no exclusion criteria. We defined cerebral venous thrombosis cases as VITT-associated if the lowest platelet count recorded during admission was below 150 × 109 per L and, if the D-dimer was measured, the highest value recorded was greater than 2000 μg/L. We compared the VITT and non-VITT groups for the proportion of patients who had died or were dependent on others to help them with their activities of daily living (modified Rankin score 3–6) at the end of hospital admission (the primary outcome of the study). The VITT group were also compared with a large cohort of patients with cerebral venous thrombosis described in the International Study on Cerebral Vein and Dural Sinus Thrombosis.FindingsBetween April 1 and May 20, 2021, we received data on 99 patients from collaborators in 43 hospitals across the UK. Four patients were excluded because they did not have definitive evidence of cerebral venous thrombosis on imaging. Of the remaining 95 patients, 70 had VITT and 25 did not. The median age of the VITT group (47 years, IQR 32–55) was lower than in the non-VITT group (57 years; 41–62; p=0·0045). Patients with VITT-associated cerebral venous thrombosis had more intracranial veins thrombosed (median three, IQR 2–4) than non-VITT patients (two, 2–3; p=0·041) and more frequently had extracranial thrombosis (31 [44%] of 70 patients) compared with non-VITT patients (one [4%] of 25 patients; p=0·0003). The primary outcome of death or dependency occurred more frequently in patients with VITT-associated cerebral venous thrombosis (33 [47%] of 70 patients) compared with the non-VITT control group (four [16%] of 25 patients; p=0·0061). This adverse outcome was less frequent in patients with VITT who received non-heparin anticoagulants (18 [36%] of 50 patients) compared with those who did not (15 [75%] of 20 patients; p=0·0031), and in those who received intravenous immunoglobulin (22 [40%] of 55 patients) compared with those who did not (11 [73%] of 15 patients; p=0·022).InterpretationCerebral venous thrombosis is more severe in the context of VITT. Non-heparin anticoagulants and immunoglobulin treatment might improve outcomes of VITT-associated cerebral venous thrombosis. Since existing criteria excluded some patients with otherwise typical VITT-associated cerebral venous thrombosis, we propose new diagnostic criteria that are more appropriate.FundingNone.

Headache Attributed to Vaccination Against COVID-19 (Coronavirus SARS-CoV-2) with the ChAdOx1 nCoV-19 (AZD1222) Vaccine: A Multicenter Observational Cohort Study.

IntroductionThe most frequently reported neurological adverse event of ChAdOx1 nCoV-19 (AZD1222) vaccine is headache in 57.5%. Several cases of cerebral venous thrombosis (CVT) have developed after vaccination. Headache is the leading symptom of CVT. For the differential diagnosis of headaches attributed to this vaccine and headaches attributed to CVT, it is of central clinical importance whether and, if so, how the phenotypes and course of these headaches can be differentiated. The study aims to examine in detail the phenotype of headache attributed to this vaccine.MethodsData on the clinical features and corresponding variables were recorded using a standardized online questionnaire in this multicenter observational cohort study. The primary outcomes of this study are the clinical features of headaches after vaccination.FindingsA total of 2464 participants reported headaches after vaccination with the ChAdOx1 nCoV-19 (AZD1222) vaccine. On average, headaches occurred 14.5 ± 21.6 h after vaccination and lasted 16.3 ± 30.4 h. A bilateral location was described by 75.8% of participants. This is most often found on the forehead (40.0%) and temples (31.4%); 50.4% reported a pressing and 37.7% a dull pain character. Headache intensity was most often severe (38.7%), moderate (35.2%), or very severe (15.5%). Accompanying symptoms were most commonly fatigue (44.8%), chills (36.1%), exhaustion (34.9%), and fever (30.4%).ConclusionHeadaches attributed to COVID-19 vaccination with the ChAdOx1 nCoV-19 (AZD1222) vaccine demonstrate an extensive and characteristic complex of symptoms. The findings have several important clinical implications for the differentiation of post-vaccinal headache and other primary as well as secondary headaches.

European stroke organization interim expert opinion on cerebral venous thrombosis occurring after SARS-CoV-2 vaccination.

Severe cases of cerebral venous thrombosis (CVT) with thrombocytopenia and anti-platelet factor 4 (PF4) antibodies occurring after adenoviral vector anti-SARS-CoV-2 vaccines have been recently reported. We aim to present a guidance document on the diagnosis and treatment of patients presenting with CVT after vaccination against SARS-CoV-2 infection. We reviewed the available evidence which consists on case reports, small case series, expert opinion and analogy with heparin-induced thrombocytopenia (HIT) management. Because of the low level of evidence, this is an interim document, based only on expert opinion consensus. In patients presenting with CVT after being vaccinated against SARS-CoV-2 infection, if there is thrombocytopenia a reliable HIT PF4 Antibody ELISA test should be performed, to confirm vaccine-induced immune thrombotic thrombocytopenia (VITT). In patients with CVT and thrombocytopenia, in whom VITT is suspected or confirmed, heparin (unfractionated or low molecular weight) should be avoided and non-heparin anticoagulants are preferred. If possible, platelet transfusions should be avoided. If the diagnosis of VITT is confirmed or suspected, early intravenous immunoglobulins are indicated. This expert opinion is supported by low quality evidence. It should be periodically updated, or changed to a formal guideline, as new and higher quality evidence is eventually produced. Because of their potential unfavourable clinical course, patients developing symptoms and signs suggestive of CVT after being vaccinated against SARS-CoV-2 virus should undergo urgent clinical and neuroimaging evaluation. In cases of suspected or confirmed VITT, non-heparin anticoagulants should be used, platelet transfusions avoided and intravenous immunoglobulin started early.

Prognosis of patients with severe cerebral venous thrombosis treated with decompressive craniectomy

IntroductionDespite the highly favorable prognosis, mortality occurs in nearly 2% of patients with cerebral venous thrombosis (CVT), in which decompressive craniectomy (DC) may be the only way to save the patient's life. The aim of this report is to describe the risk factors, neuroimaging features, in-hospital complications and functional outcome of severe CVT in patients treated with DC. Materials and methodsConsecutive malignant CVT cases treated with DC from a retrospective third-level hospital database were analyzed. Demographic, clinical, and functional outcomes were analyzed. ResultsTwenty-six patients were included (20 female, age 35.4±12.1 years); 53.8% of the patients had acute CVT, with neurological focalization as the most common symptom in 92.3% of the patients. Superior sagittal sinus thromboses were found in 84.6% of cases. Bilateral lesions were present in 10 patients (38.5%). Imaging on admission showed a parenchymal lesion (venous infarction±hemorrhagic lesion)>6cm measured along the longest diameter in 25 patients (96.2%). Mean duration of clinical neurological deterioration was 3.5 days; eleven patients (42.3%) died during hospitalization. ConclusionIn patients with severe forms of CVT, we found higher mortality than previously reported. DC is an effective life-saving treatment with acceptable functional prognosis for survivors.

Cerebral Venous Thrombosis in Nucleophosmin Gene-Mutated Acute Myeloid Leukemia

Association of cancer and thrombotic complications in acute leukemia is not uncommon. The underlying mechanism involved in thrombus formations is largely unknown with limited published data. Our patient was presented with complaints of continuous headache and persistent projectile vomiting. After initial tests, a magnetic resonance imaging of the brain performed revealed cerebral venous sinus thrombosis. Anticoagulant and anticonvulsant prophylaxis was initiated, and further treatment was planned. In such rare cases, early diagnosis and management are desirable. The role of clinicians in identifying the clinically suspicious signs and symptoms can help in identifying such rare conditions before developing severe thromboembolic complications. In the present study, we report a rare case of cerebral venous thrombosis, its associated treatment, and complications in a patient diagnosed with nucleophosmin gene-mutated acute myeloid leukemia. Similar Cases Published: None.

Cerebral Venous Thrombosis after BNT162b2 mRNA SARS-CoV-2 vaccine

The development of SARS-CoV-2 vaccines has raised several concerns regarding venous thromboembolism, namely cerebral venous thrombosis. Although cerebral venous thrombosis has been reported after administration of a viral vector vaccine, due to a possible auto-immune mechanism inducing thrombocytopenia, the same has not happened in mRNA vaccines. We report two cases of cerebral venous thrombosis, shortly after administration of mRNA vaccine. In both patients, there was no evidence of thrombocytopenia or antiplatelet antibodies, and alternative causes for cerebral venous thrombosis were found. As such, despite the temporal relation of both cases to vaccine administration, these types of cerebral venous thrombosis do not seem to be pathophysiological different from cerebral venous thrombosis not associated to SARS-CoV-2 vaccination. Continuous pharmacovigilance is necessary to monitor possible new events and clarify this association.

Cerebral Venous Thrombosis Associated with COVID-19 Infection: An Observational, Multicenter Study

Background and Purpose: Coronavirus disease 2019 (CO­VID-19) has an increased propensity for systemic hypercoagulability and thromboembolism. An association with cerebrovascular diseases, especially cerebral venous thrombosis (CVT), has been reported among these patients. The objective of the present study was to identify risk factors for CVT as well as its presentation and outcome in COVID-19 patients. Methods: This is a multicenter and multinational observational study. Ten centers in 4 countries (Pakistan, Egypt, Singapore, and the United Arab Emirates) participated in this study. The study included patients (aged >18 years) with symptomatic CVT and recent COVID-19 infection. Results: Twenty patients (70% men) were included. Their mean age was 42.4 years, with a male-to-female ratio of 2.3:1. Headache (85%) and seizures (65%) were the common presenting symptoms, with a mean admission Glasgow Coma Scale (GCS) score of 13. CVT was the presenting feature in 13 cases (65%), while 7 patients (35%) developed CVT while being treated for COVID-19 infection. Respiratory symptoms were absent in 45% of the patients. The most common imaging finding was infarction (65%), followed by hemorrhage (20%). The superior sagittal sinus (65%) was the most common site of thrombosis. Acute inflammatory markers were raised, including elevated serum D-dimer (87.5%), erythrocyte sedimentation rate (69%), and C-reactive protein (47%) levels. Homocysteine was elevated in half of the tested cases. The mortality rate was 20% (4 patients). A good functional outcome was seen in the surviving patients, with a mean modified Rankin Scale score at discharge of 1.3. Nine patients (45%) had a modified Rankin Scale score of 0–1 at discharge. Conclusion: COVID-19-related CVT is more common among males at older ages when compared to previously reported non-COVID-19-related CVT cases. CVT should be suspected in COVID-19 patients presenting with headache or seizures. Mortality is high, but functional neurological outcome is good among survivors.