Italy, 1 November 2021, Bonato et al, Haematolgica
We describe an Italian case of severe VITT-related cerebral venous thrombosis (CVT) and bi-hemispheric hemorrhage, which was treated with argatroban, intravenous immunoglobulin (IVIG) and corticosteroids.
A previously healthy 26-year-old female presented to the emergency department 14 days after the first injection of ChAdOx1 nCoV-19 vaccine with a headache nonresponsive to anti-inflammatory drugs. On admission, she had right-sided weakness and visual disturbances. She has been on combined (estrogen-progestogen) contraceptives for more than 10 years but her past medical history was otherwise unremarkable and there was no prior exposure to heparin.
While general examination and vital signs were normal, neurological examination found a severe right-sided weakness but no visual field defects. Computerised tomography (CT) scan at admission showed a hyperdense rectus sinus and vein of Galen (Figure 1A). Magnetic resonance imaging (MRI) venography showed multifocal venous thrombosis with bilateral occlusion of parietal cortical veins, straight sinus, vein of Galen, internal cerebral veins and inferior sagittal sinus. Transverse sinuses were also partially involved but still patent (Figure 1B). At the right parietal and left frontoparietal lobes an extensive venous infarction with hemorrhagic transformation was present (Figure 1C). D-dimer was dramatically raised to 12,204 mg/L (reference value <500 mg/L) and the platelet count was 134×109/L. Given her recent exposure to ChAdOx1 nCoV-19 and clinical presentation, she was first treated with fondaparinux (5 mg subcutaneously) and admitted her to the intensive care unit. Her clinical condition rapidly deteriorated with decreased consciousness, right-sided hemiplegia and complete Balint syndrome. Owing to the possible need for a sudden decompressive neurosurgical intervention, anticoagulation with fondaparinux was replaced by the short-acting drug argatroban