Ferro José M, de Sousa Diana Aguiar, Coutinho Jonathan M, Martinelli Ida
Serviço de Neurologia, Departamento de Neurociências e Saúde Mental, Hospital Santa Maria/Centro Hospitalar Lisboa Norte, Lisboa, Portugal.
Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
Eur Stroke J. 2021 Sep;6(3):CXVI-CXXI. doi: 10.1177/23969873211030842. Epub 2021 Jul 20.
Severe cases of cerebral venous thrombosis (CVT) with thrombocytopenia and anti-platelet factor 4 (PF4) antibodies occurring after adenoviral vector anti-SARS-CoV-2 vaccines have been recently reported. We aim to present a guidance document on the diagnosis and treatment of patients presenting with CVT after vaccination against SARS-CoV-2 infection. We reviewed the available evidence which consists on case reports, small case series, expert opinion and analogy with heparin-induced thrombocytopenia (HIT) management. Because of the low level of evidence, this is an interim document, based only on expert opinion consensus. In patients presenting with CVT after being vaccinated against SARS-CoV-2 infection, if there is thrombocytopenia a reliable HIT PF4 Antibody ELISA test should be performed, to confirm vaccine-induced immune thrombotic thrombocytopenia (VITT). In patients with CVT and thrombocytopenia, in whom VITT is suspected or confirmed, heparin (unfractionated or low molecular weight) should be avoided and non-heparin anticoagulants are preferred. If possible, platelet transfusions should be avoided. If the diagnosis of VITT is confirmed or suspected, early intravenous immunoglobulins are indicated. This expert opinion is supported by low quality evidence. It should be periodically updated, or changed to a formal guideline, as new and higher quality evidence is eventually produced. Because of their potential unfavourable clinical course, patients developing symptoms and signs suggestive of CVT after being vaccinated against SARS-CoV-2 virus should undergo urgent clinical and neuroimaging evaluation. In cases of suspected or confirmed VITT, non-heparin anticoagulants should be used, platelet transfusions avoided and intravenous immunoglobulin started early.
近期有报道称，接种腺病毒载体抗SARS-CoV-2疫苗后出现严重脑静脉血栓形成（CVT）并伴有血小板减少及抗血小板因子4（PF4）抗体的病例。我们旨在提供一份关于接种抗SARS-CoV-2感染疫苗后出现CVT患者的诊断和治疗指导文件。我们回顾了现有证据，这些证据包括病例报告、小型病例系列、专家意见以及与肝素诱导的血小板减少症（HIT）管理的类比。由于证据水平较低，这是一份仅基于专家意见共识的临时文件。对于接种抗SARS-CoV-2感染疫苗后出现CVT的患者，若存在血小板减少，应进行可靠的HIT PF4抗体ELISA检测，以确诊疫苗诱导的免疫性血栓性血小板减少症（VITT）。对于疑似或确诊VITT的CVT和血小板减少患者，应避免使用肝素（普通肝素或低分子肝素），优先选择非肝素抗凝剂。若可能，应避免输注血小板。若VITT诊断得到证实或疑似，应尽早使用静脉注射免疫球蛋白。该专家意见得到了低质量证据的支持。随着最终产生新的更高质量证据，应定期更新该意见，或将其转变为正式指南。由于其潜在的不良临床病程，接种抗SARS-CoV-2病毒疫苗后出现提示CVT症状和体征的患者应接受紧急临床和神经影像学评估。对于疑似或确诊VITT的病例，应使用非肝素抗凝剂，避免输注血小板，并尽早开始静脉注射免疫球蛋白。
