Thrombosis, seizure, right venous cortical infarct, then cardiorespiratory arrest AFTER COVID VACCINE
48-year-old man
- 13 days after receiving the 1st dose of the #CovidVaccine (AstraZeneca): haematuria (blood in the urine), rash & headache ⇒ transverse sinus thrombosis, seizure, right venous cortical infarct, then cardiorespiratory arrest, resuscitated https://casereports.bmj.com/content/14/10/e245440Haematuria, a widespread petechial rash, and headaches following the Oxford AstraZeneca ChAdOx1 nCoV-19 Vaccination
Case presentation
We present the case of a 48-year-old man who, 13 days after receiving the first dose of his Oxford AstraZeneca ChAdOx1 nCoV-19 vaccine, attended with a sudden onset of frank haematuria and a widespread fine petechial rash. He also complained of an evolving generalised headache.
A CT scan of the brain with contrast venography demonstrated an extensive thrombosis of the superior sagittal sinus and the superficial cortical veins, with no intracranial haemorrhage (figure 1). The patient had no focal neurology at this time, and was transferred to the haematology services for treatment of a suspected idiopathic thrombocytopaenic purpura.
Learning points
Vaccine-induced thrombotic thrombocytopaenia (VITT) commonly manifests as cerebral venous sinus thrombosis and presents with headaches, but be alert to alternative presentations that may point to VITT in other sites. If suspecting VITT, refer to the clear guidelines on managing VITT to avoid confusion and minimise risks to the patient.
Triage patients using platelet count and the time frame of presentation following inoculation with the Oxford AstraZeneca ChAdOx1 nCoV-19 vaccine or other adenovirus vector vaccines. After triaging, diagnoses can be worked up using D-dimer and fibrinogen levels, and confirmed through appropriate imaging and the heparin-induced thrombocytopaenia ELISA assay. This assay is widely available and there should be a low threshold to request it.
Immediate treatment comprises urgent IVIGs and full non-heparin-based anticoagulation. Also replace fibrinogen and involve local haematology for further treatment.
Heparin should be avoided in patients with VITT, and there is no consensus on the risks or benefits of platelet transfusions.
Mechanical thrombectomy may be needed. Patients with VITT should thus be cared for in centres that offer urgent neurosurgical and interventional radiology services, with early transfers to these centres recommended if appropriate.
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