Table 1.
Summary of the demographics, clinical features, laboratory investigations, neuroimaging findings, and treatment of the two cases. “-” denotes that the test was not performed, owing to no samples being available. *Patient was being weaned off budesonide for suspected autoimmune hepatitis, as the diagnosis was subsequently revised to primary sclerosing cholangitis, based on immunological and histological results.
| Case 1 | Case 2 | ||
|---|---|---|---|
| Age, Gender (M/F), Ethnicity | 32, M, White | 25, M, White | |
| Past medical history | Nil | Primary sclerosing cholangitis, Migraines | |
| Regular medications | Nil | Ursodeoxycholic acid, Budesonide,*Sumatriptan, Amitriptyline | |
| Family history of autoimmune or clotting disorder | No | No | |
| Smoking history | Ex-smoker | Smoker | |
| Time of onset after vaccination (days) | 9 | 6 | |
| Initial symptom | Thunderclap headache | Meningitic headache | |
| Other symptoms | Left hemiparesis, left-sided incoordination | Photophobia, vomiting, petechial rash, gum bleeding, left hemiparesis, left hemisensory loss | |
| Deterioration during admission | Seizures, reduced GCS, decerebrate posturing, dilated unreactive pupils | Seizures, agitation, decerebrate posturing, reduced GCS | |
| Lab parameters | Platelets on admission (x109/L; 150–450) | 30 | 19 |
| Haemoglobin on admission (x109/L; 133–167) | 146 | 148 | |
| Fibrinogen (g/L; 1.5–4.5) | 1.4 | 1.3 | |
| Bilirubin (µmol/L; 3–20) | 9 | 9 | |
| Lactate dehydrogenase (IU/L; 〈2 4 0) | – | 192 | |
| Blood film | Thrombocytopenia, no cell fragments | Thrombocytopenia, no cell fragments | |
| Antiphospholipid antibodies | – | Negative | |
| ADAMTS-13 | – | Normal | |
| Paroxysmal nocturnal haemoglobinuria test | – | Negative | |
| Thrombophilia DNA | – | Factor V Leiden: heterozygous for the c.1601G > A (p.Arg534Gln) variant | |
| Platelet factor-4 antibodies | – | Positive | |
| Creatinine on admission (µmol/L; 45–120) | 71 | 58 | |
| CRP on admission (mg/L; <5) | 47 | 4 | |
| SARS-CoV2 PCR | Negative | Negative | |
| Imaging | Sinuses involved | Superior sagittal sinus | Superior sagittal sinus |
| Cortical veins involved | Diffuse; prominently involving the right superficial anastomotic vein | Diffuse | |
| Clot burden | Heavy; significant venous expansion | Heavy; significant venous expansion | |
| Subarachnoid haemorrhage | Mainly cortical | Cortical and basal cisterns | |
| Intraparenchymal haemorrhage | Extensive (venous distribution) | Extensive (venous distribution) | |
| Treatment | Low molecular weight heparin | No | No |
| Unfractionated heparin | No | Yes | |
| Steroids | No | Dexamethasone 40 mg once daily | |
| Intravenous immunoglobulin | No | Yes (1 g/kg) | |
| Platelet transfusions | No | Yes | |