Cerebral venous sinus thrombosis associated with vaccine-induced thrombotic thrombocytopenia

U.S, 1 August 2021, Firouz Abadi et al, The Neuroradiology Journal

Summary

A woman in her 30s developed headaches 10 days after receiving Ad26.COV2.S Janssen vaccine followed by thrombocytopenia (platelet 80 × 103/μL) and worsening head and neck pain 15 days after vaccination. Head CT was negative for acute infarct or hemorrhage but demonstrated subtle increased density of the right transverse and sigmoid sinuses suspicious for dural venous sinus thrombosis. A week later, she developed left lower extremity pain and weakness. Duplex ultrasound demonstrated acute deep venous thrombosis involving posterior tibialis and popliteal veins. Magnetic resonance venography (Figure 1(b)) and CT venography (Figure 1(c)) performed demonstrated a large near occlusive thrombus in the right transverse sinus extending to the right sigmoid sinus and jugular bulb (‘empty delta sign’). A direct thrombin inhibitor (argatroban) was initiated and the patient was transferred to a tertiary care center with the clinical diagnosis of vaccine-induced thrombotic thrombocytopenia (VITT). On admission, the platelet count had improved to 143 × 103/μL. Heparin PF4-IgG (immunoglobulin G) antibody was positive. The patient received bivalirudin with a rise of the platelet count to 180 × 103/μL and improvement in headache. Intravenous immunoglobulin was not given due to the improvement in platelet count. The patient was discharged home on apixaban.

One week later, she developed chest pain and CT angiography of the chest demonstrated subsegmental pulmonary emboli (Figure 1(e)) with no heart strain. Duplex ultrasound showed resolution of left popliteal vein thrombosis suggestive of clot embolization. Repeat CT venogram demonstrated improvement in dural venous sinus thrombosis with a decrease in clot burden (Figure 1(d)). The patient was instructed to continue apixaban.


                        figure
Images illustrating cerebral and pulmonary venous thrombosis. Axial non-contrast computed tomography (CT) examination of the head. (a) Subtle increased density in the right transverse and sigmoid sinuses. Magnetic resonance venography (b) and CT venography (c) demonstrate large near occlusive thrombus involving the right transverse and sigmoid sinuses extending to the jugular bulb. CT venography (d) following treatment demonstrates improvement in clot burden. CT angiography of the chest (e) illustrates right-sided subsegmental pulmonary emboli.

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