Neurology & Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
Cerebrovasc Dis. 2022;51(6):722-734. doi: 10.1159/000524290. Epub 2022 May 5.
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a prothrombotic syndrome observed after adenoviral vector-based vaccines for severe acute respiratory syndrome coronavirus 2. It is characterized by thrombocytopenia, systemic activation of coagulation, extensive venous thrombosis, and anti-platelet factor 4 antibodies. Arterial thrombosis is less common and mainly affects the aorta, peripheral arteries, heart, and brain. Several cases of ischemic stroke have been reported in VITT, often associated with large vessel occlusion (LVO). Here, we describe a case of ischemic stroke with LVO after Ad26.COV2.S vaccine, then we systematically reviewed the published cases of ischemic stroke and VITT following COVID-19 vaccination.
We describe a 58-year-old woman who developed a thrombotic thrombocytopenia syndrome with extensive splanchnic vein thrombosis and ischemic stroke due to right middle cerebral artery (MCA) occlusion, 13 days after receiving Ad26.COV2.S vaccination. Then, we performed a systematic review of the literature until December 3, 2021 using PubMed and EMBASE databases. The following keywords were used: ("COVID-19 vaccine") AND ("stroke"), ("COVID-19 vaccine") AND ("thrombotic thrombocytopenia"). We have selected all cases of ischemic stroke in VITT.
Our study included 24 patients. The majority of the patients were females (79.2%) and younger than 60 years of age (median age 45.5 years). Almost all patients (96%) received the first dose of an adenoviral vector-based vaccine. Ischemic stroke was the presenting symptom in 18 patients (75%). Splanchnic venous thrombosis was found in 10 patients, and cerebral venous thrombosis in 5 patients (21%). Most patients (87.5%) had an anterior circulation stroke, mainly involving MCA. Seventeen patients (71%) had an intracranial LVO. We found a high prevalence of large intraluminal thrombi (7 patients) and free-floating thrombus (3 patients) in extracranial vessels, such as the carotid artery, in the absence of underlying atherosclerotic disease. Acute reperfusion therapy was performed in 7 of the 17 patients with LVO (41%). One patient with a normal platelet count underwent intravenous thrombolysis with alteplase, while 6 patients underwent mechanical thrombectomy. A malignant infarct occurred in 9 patients and decompressive hemicraniectomy was performed in 7 patients. Five patients died (21%).
Our study points out that, in addition to cerebral venous thrombosis, adenoviral vector-based vaccines also appear to have a cerebral arterial thrombotic risk, and clinicians should be aware that ischemic stroke with LVO, although rare, could represent a clinical presentation of VITT.
疫苗诱导的免疫性血栓性血小板减少症（VITT）是一种在严重急性呼吸综合征冠状病毒 2 腺病毒载体疫苗接种后观察到的促血栓形成综合征。其特征为血小板减少、全身性凝血激活、广泛的静脉血栓形成和抗血小板因子 4 抗体。动脉血栓形成较少见，主要影响主动脉、外周动脉、心脏和大脑。VITT 中已有几例缺血性脑卒中的报道，常伴有大血管闭塞（LVO）。在此，我们描述了一例 Ad26.COV2.S 疫苗接种后发生的缺血性脑卒中伴 LVO 的病例，然后我们系统地回顾了 COVID-19 疫苗接种后缺血性脑卒中与 VITT 的相关文献。
我们描述了一例 58 岁女性，在接受 Ad26.COV2.S 疫苗接种 13 天后，因右侧大脑中动脉（MCA）闭塞而发生血栓性血小板减少综合征伴广泛肠系膜静脉血栓形成和缺血性脑卒中。然后，我们使用 PubMed 和 EMBASE 数据库，对截至 2021 年 12 月 3 日的文献进行了系统综述。使用了以下关键词：("COVID-19 疫苗") AND ("stroke")、("COVID-19 疫苗") AND ("thrombotic thrombocytopenia")。我们选择了所有 VITT 中缺血性脑卒中的病例。
我们的研究共纳入 24 例患者。大多数患者为女性（79.2%），年龄小于 60 岁（中位数年龄 45.5 岁）。几乎所有患者（96%）均接受了腺病毒载体疫苗的第一剂接种。18 例患者（75%）以缺血性脑卒中为首发症状。10 例患者发现肠系膜静脉血栓形成，5 例患者（21%）发现脑静脉血栓形成。大多数患者（87.5%）发生前循环脑卒中，主要累及 MCA。17 例患者（71%）存在颅内 LVO。我们发现，在没有潜在动脉粥样硬化疾病的情况下，颅外血管（如颈动脉）中存在大的管腔内血栓（7 例）和游离血栓（3 例）的高发生率。在 17 例 LVO 患者中，有 7 例（41%）接受了急性再灌注治疗。1 例血小板计数正常的患者接受了阿替普酶静脉溶栓治疗，而 6 例患者接受了机械取栓治疗。9 例患者发生恶性梗死，7 例患者行去骨瓣减压术。5 例患者死亡（21%）。
我们的研究指出，除脑静脉血栓形成外，腺病毒载体疫苗似乎也有发生脑动脉血栓形成的风险，临床医生应意识到，尽管罕见，但伴有 LVO 的缺血性脑卒中可能是 VITT 的一种临床表现。
