Cerebral venous sinus thrombosis after Vaccine-induced Immune Thrombotic Thrombocytopenia

1. infection a) usually local,e.g.otitis media(leading to the now obsolete term otitic hydrocephalus), sinusitis, peritonsillar abscess, paranasal sinusitis: in the pre-antibiotic era, CVT was most commonly associated with chronic suppurative infection

b) meningitis

2. pregnancy & puerperium:

3. oral contraceptives† (birth control pills (BCP)))

4. dehydration and cachexia (marantic thrombosis): includes burns and cachexia of neoplastic disease

5. cardiac disease (including CHF)

6. ulcerative colitis (UC): 1% of UC patients have some thrombotic complication (not necessarily all intracranial), and this is the cause of ≈ 33% of deaths (usually pulmonary embolism, PE)

7. periarteritis nodosa

8. sickle cell trait

9. trauma: including closed head injury . iatrogenic:e.g.S/P radical neck surgery,transvenous pacemaker placement,post-craniotomy, internal jugular vein catheterization

see Posttraumatic cerebral venous sinus thrombosis.

It is a rare form of stroke found most often in young women of reproductive age, often associated with oral contraceptive use, genetic or acquired thrombophilia, pregnancy, dehydration, or infection, causing 0.5% of all strokes only, several mechanisms might be involved in forming the thrombosis, including closed head injury.

One factor can be retractor over the falx in interhemispheric approach.

The majority of cases of Cerebral Venous Sinus Thrombosis in Closed Head Injury presented with loss of consciousness or decreased GCS (41%), followed by headache (26%), scalp abrasions/lacerations (21%), paralysis (18%), visual disturbance (18%), nystagmus (15%), and agitation (15%). The most commonly used diagnostic method was angiography. Thrombosis was the most frequently reported radiological finding among all the cases (26/34, 76%). Comparisons of outcomes between patients who underwent surgical intervention and those who did not undergo surgery revealed a significant difference in outcome favoring non-surgical treatment (p < 0.005, odds ratio (OR) 0.04, (95% CI) 0.003 - 0.30).

Non-surgical outcomes were better than surgical outcomes. However, no significant difference was seen comparing anti-coagulation versus conservative management (supportive without anticoagulation), single versus multi-sinuses (≥2 sinuses) involvement, and between any of the sinuses involved ¹⁾.

Posterior fossa dural venous sinus thrombus is a well-described complication of head trauma, especially when fracture crosses the dural sinus grooves or in association with epidural hemorrhage. We have found that post-traumatic posterior fossa epidural hematoma compressing a dural venous sinus can mimic dural venous thrombus.

In four children in whom a posterior fossa epidural hemorrhage mimicked dural venous sinus thrombus. Routine CT head and CT venography were obtained on Toshiba volume and helical CT scanners. MRI and MR venography were performed on a Philips scanner.

In all cases, there was medial displacement and compression of the posterior fossa dural venous sinuses without intraluminal thrombosis. The epidural hemorrhage was seen tracking along sinus grooves in the occipital bone, peeling the dura containing the sinuses from the calvarium and compressing the sinus, simulating thrombosis on axial CT views.

Both venous sinus thrombosis and posterior fossa epidural hemorrhages in children are well-described complications of head trauma. Posterior fossa epidural hemorrhage can mimic a sinus thrombus by compressing and displacing the sinuses. It is important to recognize this pitfall because treatment of a suspected thrombus with anticoagulation can worsen epidural hemorrhage ²⁾.

Cerebral venous thrombosis caused by vaccine-induced immune thrombotic thrombocytopenia (VITT-CVT) is a rare adverse effect of adenovirus-based SARS-COV2 vaccines. In March 2021, after autoimmune pathogenesis of VITT was discovered, treatment recommendations were developed. This comprised immunomodulation, nonheparin anticoagulants, and avoidance of platelet transfusion. The aim of the study was to evaluate adherence to these recommendations and their association with mortality.

Scutelnic et al. used data from an international prospective registry of patients with CVT after adenovirus-based SARS-CoV-2 vaccination. We analyzed possible, probable, or definite VITT-CVT cases included until 18 January 2022. Immunomodulation entailed the administration of intravenous immunoglobulins and/or plasmapheresis.

99 VITT-CVT patients from 71 hospitals in 17 countries were analyzed. Five of 38 (13%), 11/24 (46%), and 28/37 (76%) of patients diagnosed in March, April, and from May onwards, respectively, were treated in-line with VITT recommendations (p<0.001). Overall, treatment according to recommendations had no statistically significant influence on mortality (14/44 (32%) vs 29/55 (52%), adjusted OR 0.43 (95%CI 0.16-1.19)). However, patients who received immunomodulation had lower mortality (19/65 (29%) vs 24/34 (70%), adjusted OR 0.19 (95%CI 0.06-0.58)). Treatment with non-heparin anticoagulants instead of heparins was not associated with lower mortality (17/51 (33%) vs 13/35 (37%), adjusted OR 0.70 (95%CI 0.24-2.04)). Mortality was also not significantly influenced by platelet transfusion (17/27 (63%) vs 26/72 (36%), adjusted OR 2.19 (95%CI 0.74-6.54)).

In VITT-CVT patients, adherence to VITT treatment recommendations improved over time. Immunomodulation seems crucial for reducing mortality of VITT-CVT ³⁾.