Cerebral Vein Thrombosis With Vaccine-Induced Immune Thrombotic Thrombocytopenia
- 1 September 2021
- journal article
- editorial
- Published by Ovid Technologies (Wolters Kluwer Health) in Stroke
- Vol. 52 (9), 3045-3053
- https://doi.org/10.1161/strokeaha.121.035613
Abstract
In the spring of 2021, reports of rare and unusual venous thrombosis in association with the ChAdOx1 and Ad26.COV2.S adenovirus-based coronavirus vaccines led to a brief suspension of their use by several countries. Thromboses in the cerebral and splanchnic veins among patients vaccinated in the preceding 4 weeks were described in 17 patients out of 7.98 million recipients of the Ad26.COV2.S vaccine (with 3 fatalities related to cerebral vein thrombosis) and 169 cases of cerebral vein thrombosis among 35 million ChAdOx1 recipients. Events were associated with thrombocytopenia and anti-PF4 (antibodies directed against platelet factor 4), leading to the designation vaccine-induced immune thrombotic thrombocytopenia. Unlike the related heparin-induced thrombotic thrombocytopenia, with an estimated incidence of <1:1000 patients treated with heparin, and a mortality rate of 25%, vaccine-induced immune thrombotic thrombocytopenia has been reported in 1:150 000 ChAdOx1 recipients and 1:470 000 Ad26.COV.2 recipients, with a reported mortality rate of 20% to 30%. Early recognition of this complication should prompt testing for anti-PF4 antibodies and acute treatment targeting the autoimmune and prothrombotic processes. Intravenous immunoglobulin (1 g/kg for 2 days), consideration of plasma exchange, and nonheparin anticoagulation (argatroban, fondaparinux) are recommended. In cases of cerebral vein thrombosis, one should monitor for and treat the known complications of venous congestion as they would in patients without vaccine-induced immune thrombotic thrombocytopenia. Now that the Ad26.COV2.S has been reapproved for use in several countries, it remains a critical component of our pharmacological armamentarium in stopping the spread of the human coronavirus and should be strongly recommended to patients. At this time, the patient and community-level benefits of these two adenoviral vaccines vastly outweigh the rare but serious risks of vaccination. Due to the relatively low risk of severe coronavirus disease 2019 (COVID-19) in young women (<50 years), it is reasonable to recommend an alternative vaccine if one is available. Ongoing postmarketing observational studies are important for tracking new vaccine-induced immune thrombotic thrombocytopenia cases and other rare side effects of these emergent interventions.This publication has 51 references indexed in Scilit:
- An interactive web-based dashboard to track COVID-19 in real timeThe Lancet Infectious Diseases, 2020
- American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopeniaBlood Advances, 2018
- Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures: A Scientific Statement From the American Heart AssociationCirculation, 2018
- Risk factors for heparin-induced thrombocytopenia: Focus on Fcγ receptorsThrombosis and Haemostasis, 2016
- Cerebral Venous Thrombosis Associated with Intracranial Hemorrhage and Timing of Anticoagulation after HemicraniectomyJournal of Stroke and Cerebrovascular Diseases, 2016
- Diagnosis and Management of Cerebral Venous ThrombosisStroke, 2011
- Platelet Factor 4/Heparin Antibodies in Blood Bank DonorsAmerican Journal of Clinical Pathology, 2010
- Acquired and Congenital Risk Factors associated with Cerebral Venous Sinus ThrombosisThrombosis Research, 2010
- Safety and Tolerability of High-Intensity Anticoagulation with Bivalirudin During Neuroendovascular ProceduresNeurocritical Care, 2010
- Immune Endothelial-Cell Injury in Heparin-Associated ThrombocytopeniaThe New England Journal of Medicine, 1987