Cerebral venous sinus thrombosis after ChAdOx1 nCov-19 vaccination with a misleading first cerebral MRI scan

Abstract

Vaccine-induced immune thrombotic thrombocytopenia (VITT) and cerebral venous sinus thrombosis (CVST) have been recently described as rare complications following vaccination against SARS-CoV-2 with vector vaccines. We report a case of a young woman who presented with VITT and cerebral CVST 7 days following vaccination with ChAdOx1 nCov-19 (AstraZeneca). While the initial MRI was considered void of pathological findings, MRI 3 days later revealed extensive CVST of the transversal and sigmoidal sinus with intracerebral haemorrhage. Diagnostic tests including a platelet-factor-4-induced platelet activation assay confirmed the diagnosis of VITT. Treatment with intravenous immunoglobulins and argatroban resulted in a normalisation of platelet counts and remission of CVST.

Keywords: COVID-19; MRI; blood platelets; complication; haemorrhage.

Figure 1

A time course of clinical characteristics and laboratory results following vaccination. Platelet count is depicted in red. The value of day 9 prior to second presentation in our hospital was provided by the generalist. Headache intensity is shown in black according to the Numerical Rating Scale. (B) Serial cerebral MRI scans. Upper row: axial T2* sequence of the infratentorial brain; lower row: coronal T1w sequence of the cerebellum, temporal lobe and sinus transversus. (B-1) MRI scan at first presentation in our emergency department with thrombocytopenia and headache. At first look, the MRI scan was without a clear sign for CVST. Retrospectively (red arrows), a slight irregularity as indicator of beginning thrombosis may be discussed. (B-2) First follow-up MRI 3 days later revealed a CVST of the left transverse and sigmoidal sinus (red arrows) with a left-temporal and left cerebellar intracerebral haemorrhage (asterisks). (B-3) Most recent follow-up MRI showing a persisting CVST and intracerebral haemorrhage with a slightly progressive perifocal oedema. Volume of cerebellar haemorrhage slightly decreased. CVST, cerebral venous sinus thrombosis; ER, emergency room; HIPA, heparin-induced platelet activation assay; HIT, heparin-induced thrombocytopenia; IVIG, intravenous immunoglobulin; PIPA, platelet-factor-4-induced platelet activation assay.