Post COVID-19 Vaccination-Associated Neurological Complications

Abstract

Purpose: Neurological sequelae after COVID-19 vaccination are rare. We investigated the possible pathogenesis behind the development of neurological complications within a short period after Saudi residents received a COVID-19 vaccine.

Patients and methods: We evaluated 18 patients who recently received a COVID-19 vaccine (Comirnaty and Vaxzevria vaccines) and presented with neurological complications to the Saudi German Hospitals in Jeddah, Saudi Arabia. Neurologists assessed the patients' clinical presentation, radiological investigations, and laboratory findings.

Results: Three patients who received the first dose of the Vaxzevria vaccine experienced severe cerebral venous thrombosis, two of them were complicated by intracranial hemorrhage. Their laboratory investigations showed very high d-dimers and severe thrombocytopenia, which have been linked to higher mortality and poor outcome. Ischemic stroke occurred in eight cases (44.4%) with a predominance in older male patients. Three patients presented with seizures, two had optic neuritis. Guillain-Barré syndrome (GBS) and Miller Fisher syndrome (MFS) occurred in two male patients following vaccination with Comirnaty.

Conclusion: Neurological complications after COVID-19 vaccinations are very rare, and only a few cases have been reported worldwide. The shared pathophysiological basis between COVID-19 viral infection and COVID-19 vaccines stands behind the very rare neurological complications resulting from the hypercoagulable state triggered by the general inflammatory condition. We suspect some differences in the pathogenesis of ischemic stroke caused by COVID-19 infection and COVID-19 vaccines, which render COVID-19 vaccine-associated ischemic stroke more responsive to treatment. To date, no definitive association between the vaccine and GBS has been proven by any strong evidence, but it has recently been added as a very rare side effect of the Janssen COVID-19 vaccine. No possible links of Miller Fisher syndrome to COVID-19 vaccines have been reported before the one reported in this study.

Keywords: cerebral venous thrombosis; ischemic stroke; optic neuritis; seizures; vaccine.

Figure 1

Timing of presenting with neurological complications post COVID-19 vaccination (days). The number of days between receiving the vaccine and presenting patients with the various neurological complications ranged 4–25 days with average 10 days. 4th, 7th, and 10th day post vaccination were the days with the most encountered neurological complications.

Figure 2

Radiological brain imaging of case, 1, 2 and 3 presenting with Cerebral venous thrombosis. (A) CT Brain case 1, showing right cortical hemorrhage (arrow); (B) CT Brain case 2, showing intracerebral (headarrow) and intraventricular (arrow) hemorrhage; (C) MRI GRE case 3 showing right temporal blooming suggestive of hemorrhage within venous infarction (arrow); (D) MRI GRE case 1, showing blooming within cortical veins suggesting thrombosis (headarrows); (E) MR venography case 2, showing non visualized most of cerebral venous sinus (arrows) indicating extensive thrombosis; (F) CT venography case 3, showing filling defect within right sigmoid sinus (arrow).

Figure 3

Radiological brain imaging of case number 5, 7, 11 and 12 presenting with Cerebral venous thrombosis. (A) MRI DWI case 12, showing diffusion restriction within right middle cerebral artery territory(arrow); (B) MRI DWI case 11, showing diffusion restriction within left cerebellum (arrow); (C) MRI DWI case 5, showing diffusion restriction within right frontal cortex (arrow); (D) MRI DWI case 7, showing diffusion restriction within pons (arrow); (E) Cerebral angiography case 12, showing proximal M1 occlusion of right MCA; (F) MRA case 11, showing left PICA occlusion (arrow); (G) MRA case 5, showing multiple stenotic lesions (headarrows) within right ICA and MCA; (H) MRA case 7, showing normal wall of posterior circulation represent perforators ischemia.