Cerebral venous sinus thrombosis is an extremely rare manifestation of cerebrovascular disease.
In the last few days, this pathology has sadly gained fame due to its association with two vector-based vaccines against SARR COV19.
These are Ad26.COV2.S (Johnson & Johnson) and ChAdOx1 nCoV-19 (AstraZeneca). There have not been any reports of thrombosis or thrombocytopenia from the 182 million shot with RNA based vaccines (Pfizer/Moderna).
While we wait for more data, it seems prudent to discuss the diagnosis and treatment of this post vaccination adverse event.
Symptoms are varied and depend on the affected sinus, but basically, they can be divided into 4 syndromes: isolated headache or endocranial hypertension signs, neurological focus, subacute encephalopathy, and cavernous sinus syndrome with cranial pair neuropathy.
Headache presented in 90% of the population. Another distinctive characteristic is its progressive nature.
Symptoms start off between 5 to 20 days after vaccination, mainly in young women. The most common symptom of thrombosis affects the cerebral venous sinus, but it might appear or be associated to thrombosis in any other territory (deep vein thrombosis, pulmonary thromboembolism, portal thrombosis, etc.)
In case there were clinical signs of thrombosis of the venous sinus, both an MRI and a CT scan with venous times will confirm the diagnosis.
A complete coagulation profile must be obtained, with platelet count, D-dimers, and platelet factor 4 antiplatelet antibodies by Elisa.
The recommended treatment is similar to that of heparin induced thrombocytopenia (HIT): high endovenous doses of immunoglobulins (1 gr/kg) for 2 days once we have obtained a sample of platelet factor 4 antiplatelet antibodies and anticoagulants (NEVER heparin) such as bivalirudin, argatroban, fondaparinux, or direct anticoagulants. Anticoagulants should be administered but not in case of severe thrombocytopenia (<20000/mm3) or low fibrinogen. Platelet transfusion should be avoided.
Once the acute phase is overcome and platelet count is recovered, it is recommended to continue with oral anticoagulation.
More studies are required to find out the real risk of this adverse event associated to vaccines, if there is such association. Today, it is clear that vaccination has to continue.
Original Title: Diagnosis and management of cerebral venous sinus thrombosis with vaccine-induced immune thrombotic thrombocytopenia.
Reference: Karen L. Furie et al. Stroke. 2021 Apr 29. Online ahead of print. doi:10.1161/STROKEAHA.121.035564.