Arterial intracranial thrombosis as the first manifestation of vaccine-induced immune thrombotic thrombocytopenia (VITT): a case report

Abstract

Objective: We describe a severe case of vaccine-induced immune thrombotic thrombocytopenia (VITT) after the first dose of the ChAdOx1 nCoV-19 vaccine leading to massive ischemic stroke.

Methods: A 42-year-old woman developed acute left hemiparesis (NIHSS 12) 9 days after the first vaccine dose.

Results: The blood tests revealed low platelets (70 10³/μL) and severe increment of D-dimer (70,745 ng/mL FEU). Brain non-contrast computed tomography and multiphasic CT angiography demonstrated a right middle cerebral artery occlusion. The patient was treated with primary thrombectomy, steroids, immunoglobulin, and fondaparinux. Despite the treatment, the neurological status deteriorated and underwent decompressive hemicraniectomy. She was transferred to the rehab's unit 52 days after the onset.

Discussion: Healthcare providers should be aware of the possibility of ischemic stroke as a manifestation of VITT. Awareness on this very rare and possibly fatal complication should be reinforced on both the vaccine recipients and general practitioners.

Keywords: COVID-19; Stroke; Thrombocytopenia; VITT; Vaccine.

Fig. 1

Non-contrast computed tomography at basal ganglia (a) and lateral ventricles level (a1) showed early signs of ischemia (loss of gray-white matter differentiation) involving the right middle temporal gyrus, insula, and putamen. (b) Multiphasic CT angiography demonstrates the right MCA occlusion (arrow) with good collateral circulation (b1). (c) CT perfusion maps: the reduction of cerebral blood volume (CBV) confirms the areas of irreversibly infarcted tissue; the largest area of increased the mean transit time (MTT) (c1) borders the penumbra area as the mismatch with CBV map

Fig. 2

(a) The digital subtraction angiography (DSA) in frontal view confirms the occlusion of the right MCA (arrow). During the endovascular procedure (a1), the distal tip of the aspiration catheter (arrow) engages the thrombus with complete MCA recanalization (a2). In the box, the macroscopic aspect of the removed clot is shown. (b) DSA in lateral view reveals the occlusion of the A3 segment of the anterior cerebral artery (arrow). A combined technique with a stent retriever positioning thought thrombus in the pericallosal artery (arrow) and distal tip of aspiration catheter (arrowhead) at the origin of the vessel (b1) allows the ACA recanalization (b2). (c) DSA in lateral view: after the recanalization of intracranial vessels a right ophthalmic artery occlusion appeared (arrow). Micro-catheterization with intra-arterial alteplase infusion was performed (c1) with flow restoration (c2). (d) DSA in frontal and lateral view demonstrates the formation of further thrombi (arrows) with re-occlusion of the ACA

Fig. 3

Platelet count response to treatments. Dex, dexamethasone; i.v.-Ig, intravenous immunoglobulins; D-D, d-dimer; Fg, fibrinogen