Table 1.
Clinical, magnetic resonance imaging findings, and outcome details of patients who developed cerebral venous sinus thrombosis after vaccination against SARS-CoV-2
| Reference | Neurological complications | Country | Age/sex | Vaccine type | Duration of onset after vaccination | Clinical features | Neuroimaging | Treatment given |
|---|---|---|---|---|---|---|---|---|
| Castelli et al. [18] | Cerebral venous sinus thrombosis | Italy | 50/M | COVID-19 vaccine AstraZeneca | 10 days | Severe headache, right hemiparesis, unsteady gait, and visual impairment of 4 days Patient needed ICU care and mechanical ventilation | Intra-parenchymal hemorrhage CT angiography = left transverse and sigmoid venous sinuses thrombosis | Fibrinogen concentrate (10 g total) and platelet (4 units total) a bilateral decompressive craniectomy |
| D’Agostino et al. [19] | Cerebral venous thrombosis and disseminated intravascular coagulation | Italy | 54/F | The AstraZeneca vaccine | 12 days | Altered sensorium and hemiparesis Myocardial infarction | Multiple subacute lobar hemorrhages basilar artery thrombosis associated with the superior sagittal sinus thrombosis Bilateral adrenal hemorrhage | Intensive care unit |
| Scully et al. (report of 23 patients) [20] | Thrombocytopenia (23 patients) Cerebral venous thrombosis (13 patients) | London | 12 years (Median) | ChAdOx1 nCoV-19 vaccine (AstraZeneca) | 6 to 24 days | 13 patients with cerebral venous thrombosis | Not available | Not available |
| Franchini et al. [21] | Cerebral venous thrombosis | Italy | 50/M | COVID-19 vaccine AstraZeneca | 7 days | Coma thrombocytopenia | Intra-parenchymal hemorrhage Angiography cerebral venous sinus thrombosis | Intensive care unit |
| Mehta et al. [22] | Cerebral venous sinus thrombosis | UK | 32/M | Vaxzevria vaccine | 9 days | Thunderclap headache Left hemiparesis, left-sided incoordination Thrombocytopenia and rapidly evolving coma | Superior sagittal sinus and cortical vein thrombosis and significant cortical edema with small areas of parenchymal and subarachnoid hemorrhage | Intensive care unit |
| 25/M | Vaxzevria vaccine | 6 days | Headache hemiparesis, left hemisensory loss Seizures, agitation, decerebrate posturing, reduced GCS Thrombocytopenia | Superior sagittal sinus thrombosis with extension into the cortical veins and hemorrhage in lobar and sub-arachnoid locations | Intensive care unit | |||
| Bersinger et al. [23] | Cerebral venous sinus thrombosis | France | 21/F | ChAdOx1 nCoV-19 vaccine | 9 days | Headaches, seizures, hemiplegia, expressive aphasia, and no pupillary abnormalities and altered sensorium The platelet count was 61,000 per cubic millimeter | CT of the head showed massive thrombosis in the deep and superficial cerebral veins, thrombosis of the left jugular vein, and left frontoparietal venous hemorrhagic infarction | A selective arterial embolization was performed immediately after decompressive craniectomy IV immunoglobulin Fondaparinux |
| Ramdeny et al. [24] | Cerebral venous sinus thrombosis | United Kingdom | 54/M | COVID-19 Vaccine AstraZeneca | 21 days | Worsening headache, bruising and unilateral right calf swelling Thrombocytopenia D-dimer = 60,000 ng/ml Anti-platelet factor 4 | Cerebral venous sinus thrombosis | Intravenous immunoglobulin |
| Zakaria et al. [25] | Cerebral venous sinus thrombosis | Malaysia | 49/M | First dose of mRNA SARS-CoV-2 vaccine | 16 days | New onset of mild to moderate headache and giddiness | CT) of the brain showed cordlike hyperattenuation within the left transverse and sigmoid sinus suggestive of cord or dense clot sign CT cerebral venography a long segment-filling defect and empty delta sign within the superior sagittal sinus extending into the torcula Herophili, left transverse sinus, and sigmoid sinus to proximal internal jugular vein | Subcutaneous Clexane improved |
| Ryan et al. [26] | Cerebral venous sinus thrombosis | Ireland | 35/F | AZD1222 (COVID-19 Vaccine AstraZeneca) | 10 days | Headache thrombocytopenia bruising and petechiae Antibody to platelet factor 4 | MR venogram showed cerebral venous sinus thrombosis | Apixaban |
| Graf et al. [27] | Cerebral venous sinus thrombosis | Germany | 29/M | ChAdOx1 nCov-19, AstraZeneca | 9 days | Severe headache and hematemesis thrombocytopenia | Complete thrombosis of the left transverse and sigmoid sinus down to the left proximal jugular vein Temporo-parietal intracranial hemorrhage CT angiography revealed extensive thrombosis of the mesenteric and portal vein | High-dose immunoglobulins Argatroban |
| George et al. [28] | Cerebral venous sinus thrombosis | USA | 40/F | ChAdOx1 nCov-19, AstraZeneca | 7 days | Headache thrombocytopenia Antibody to platelet factor 4 | Venous thrombosis involving the left transverse sigmoid sinus and internal jugular vein | A direct thrombin inhibitor (bivalirudin) Intravenous immune globulin (IVIG) |
| Jamme et al. [29] | Cerebral venous sinus thrombosis | France | 69/F | First dose of Oxford–AstraZeneca vaccine | 11 days | Headache associated with behavioral symptoms | Bilateral frontal hemorrhage cerebral venous thrombosis of the left internal jugular vein, sigmoid sinus, and superior sagittal sinus | None |
| Tiede et al. (report of 5 patients) [30] | Cerebral venous sinus thrombosis | Germany | 41 and 67 years All females | ChAdOx1 COVID-19 vaccine (AZD1222, Vaxzevria) | 5 to 11 days after first vaccination | Cerebral venous sinus thrombosis (CVST), splanchnic vein thrombosis (SVT), arterial cerebral thromboembolism, and thrombotic microangiopathy thrombocytopenia Autoantibodies against platelet factor 4 | Brain hematomas infarcts, presence of thrombi in major vessels | Intravenous immunoglobulin or corticosteroids Argatroban |
| Schulz et al. (report of 45 cases) [31] | Cerebral venous thrombosis | Germany | 46.5 years (mean)/35 females | BNT162b2, ChAdOx1, and mRNA-1273 | Within 30 days of vaccination | Thrombocytopenia in all patients | Cerebral venous thrombosis | Intravenous immunoglobulins, plasmapheresis, corticosteroids, anticoagulants |
| Bourguignon et al. [32] | A report three patients one had cerebral venous sinus thrombosis | Canada | 69/M | ChAdOx1 nCov-19, AstraZeneca | 12 days | Diabetes mellitus, hypertension, obstructive sleep apnea, recently diagnosed prostate cancer Headache and confusion left-sided weakness Thrombocytopenia Autoantibodies against platelet factor 4 | Right middle cerebral-artery stroke with hemorrhagic transformation Right cerebral transverse and sigmoid sinuses, right internal jugular vein, hepatic vein, and distal lower-limb vein; pulmonary embolism | Intravenous immunoglobulin Plasmapheresis |
| Gattringer et al. [33] | Cerebral venous sinus thrombosis | Austria | 39/F | The first vaccination with ChAdOx1 nCov-19 (AstraZeneca) | 8 days | Headache since 2 days thrombocytopenia (84 × 10 [8]/L) | Left sigmoid/transverse sinus thrombosis without brain parenchymal involvement | Intravenous immunoglobulin |
| Ikenberg et al. [34] | Cerebral venous sinus thrombosis | Germany | early 30 s/F | The first dose of ChAdOx1 nCov-19 (AstraZeneca) | Headache Gait ataxia, and amnestic difficulties as well as aphasia Thrombocytopenia of 37 000/µL | CVST of the left transverse and sigmoidal sinus with a left-temporal and left-cerebellar intracerebral hemorrhage | Intravenous immunoglobulin argatroban | |
| Clark et al. [35] | Cerebral venous sinus thrombosis | USA | 40/F | The Ad26.COV2.S (Johnson & Johnson/ Jansen) vaccine | 5 days | Worsening headaches thrombocytopenia | Cerebral venous sinus thrombosis involving the left transverse and sigmoid sinuses, extending into the left internal jugular vein | Bivalirudin infusion Intravenous immunoglobulin |
| Bonato et al. [36] | Cerebral venous sinus thrombosis | Italy | 26/F | ChAdOx1 nCoV-19 vaccine | 14 days | headache non-responsive to drugs right-sided weakness and visual disturbances rapidly deteriorated with decreased consciousness | Multifocal venous thrombosis with bilateral occlusion of parietal cortical veins, straight sinus, vein of Galen, internal cerebral veins, and inferior sagittal sinus. Right parietal and left frontoparietal lobes an extensive venous infarction with hemorrhagic transformation Platelet-factor 4 (PF4)–heparin IgG antibodies – elevated thrombocytopenia | Dexamethasone Intravenous immunoglobulin argatroban |
| Wang et al. [37] | Cerebral venous sinus thrombosis | Taiwan | 41/F | First vaccination with ChAdOx1 nCoV-19 | 7 days | Fever and headache thrombocytopenia positive anti-PF4 antibodies | MR venography revealed cerebral venous sinus thrombosis | Intravenous immunoglobulin |
| Dutta et al. [38] | Cerebral venous sinus thrombosis | India | 51/M | First-dose of COVISHIELD | 6 days | Headache double vision papilledema Platelet count was normal | MR venography revealed thrombosis in superior sagittal sinus and transverse sinus | Low-molecular-weight heparin |
| Aladdin et al. [39] | Cerebral venous sinus thrombosis | Saudi Arabia | 36/F | First dose of the ChAdOx1 nCoV-19 vaccine | 14 days | Vomiting and severe headache left upper limb weakness thrombocytopenia Disseminated intravascular coagulation | Brain computed tomography (CT) scan showed superior sagittal thrombosis with thickened cortical veins and bilateral hypodensities in the parietal lobes | Low-molecular-weight heparin ICU care |
| Lavin et al. (a series of 4 patients) [40] | Cerebral venous sinus thrombosis | Ireland | 29/F 38/M 50/F 35/F | Vaxzevria vaccine (ChAdOx1 nCoV-19, AstraZeneca) | 10 days 16 days 23 days 14 days | Visual disturbance followed by a headache, nausea, vomiting, bruising and petechiae severe thunderclap headache, nausea and vomiting headache, persistent bruising and petechiae all had thrombocytopenia | Dural venous sinus thrombosis in one patient only other had abdominal abnormalities | Intravenous immunoglobulin |
| Tølbøll Sørensen et al. [41] | Cerebral venous sinus thrombosis | UK | 30/F | ChAdOx1 nCoV-19 | Headache and general malaise portal vein thrombosis thrombocytopenia and consumption coagulopathy Anti-platelet antibodies were detected | Normal | Tinzaparin | |
| Fan et al. [42] (a series of 3 patients) | Cerebral venous sinus thrombosis | Singapore | 54/M 62/F 60/F | BNT162b2 mRNA vaccination | 1 day 9 days 8 days | Severe headache and vomiting and acute left hemiparesis Headache and vomiting Right ataxic hemiparesis There was no thrombocytopenia | A large right temporo-parietal lobe intraparenchymal hemorrhage Acute right cerebral bleed involving occipital and temporal lobes associated with subarachnoid hemorrhage Venous infarct in bilateral perirolandic gyri Venogram confirmed cerebral venous sinus thrombosis in all three | Low-molecular-weight heparin decompressive craniectomy |
| Suresh and Petchey [43] | Cerebral venous sinus thrombosis | UK | 27/M | ChAdOx1 nCOV-19 vaccine | 2 days | Worsening headache and new homonymous hemianopia Thrombocytopenia Anti-platelet antibodies were detected | Acute parenchymal bleed with subdural extension CT venogram confirmed significant cerebral venous sinus thrombosis | Dabigatran and intravenous immunoglobulins |
| Dias et al. (a series of 2 patients) [44] | Cerebral venous sinus thrombosis | Portugal | 47/F 67/F | BNT162b2 mRNA SARS-CoV-2 vaccine | 6 days 3 days | Headache, nausea and photophobia a sudden left motor deficit Sudden right lower limb clonic movements, followed by motor deficit, loss of consciousness and headache There was no thrombocytopenia Anti-platelet antibodies were not detected | MRI with venography revealed thrombosis of superior sagittal, right lateral, transverse, sigmoid sinuses, and jugular vein and left sigmoid sinus, together with right frontal subarachnoid hemorrhage and a cortical venous infarct Brain MRI showed thrombosis of high convexity cortical veins, superior sagittal, right transverse, and sigmoid sinus and jugular vein | Acetazolamide and enoxaparin Levetiracetam 500 mg bid and enoxaparin |
| Guan et al. [45] | Cerebral venous sinus thrombosis | Taiwan | 52/M | The first dose of ChAdOx1 nCov-19 (AstraZeneca) | 10 days | Nausea and thunderclap headache thrombocytopenia Platelet factor 4 antibodies detected | Hyperdensity of the sinus, including cord sign and dense vein sign at the left transverse and sigmoid sinuses CT venogram revealed CVST at the left transverse sinus and sigmoid sinuses and thrombosis of the left internal jugular vein | Apixaban Outcome not provided |
| Varona et al. [46] | Cerebral venous sinus thrombosis and primary adrenal insufficiency | Spain | 47/M | Adenoviral (ChAdOx1) vector-based COVID-19 vaccine | 10 days | Headache, somnolence, and mild confusion Blateral segmentary pulmonary embolism Thrombocytopenia Anti-platelet antibodies were detected | Consistent with cerebral venous thrombosis | Intravenous immunoglobulins and subcutaneous fondaparinux hydrocortisone Patient improved |