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Coutinho JM, van de Munckhof A, Aguiar de Sousa D, Poli S, Aaron S, Arauz A, Conforto AB, Krzywicka K, Hiltunen S, Lindgren E, Sánchez van Kammen M, Shu L, Bakchoul T, Belder R, van den Berg R, Boumans E, Cannegieter S, Cano-Nigenda V, Field TS, Fragata I, Heldner MR, Hernández-Pérez M, Klok FA, Leker RR, Lucas-Neto L, Molad J, Nguyen TN, Saaltink DJ, Saposnik G, Sharma P, Stam J, Thijs V, van der Vaart M, Werring DJ, Wong Ramos D, Yaghi S, Yeşilot N, Tatlisumak T, Putaala J, Jood K, Arnold M, Ferro JM. Reducing the global burden of cerebral venous thrombosis: An international research agenda. Int J Stroke 2024:17474930241242266. [PMID: 38494462 DOI: 10.1177/17474930241242266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Due to the rarity of cerebral venous thrombosis (CVT), performing high-quality scientific research in this field is challenging. Providing answers to unresolved research questions will improve prevention, diagnosis, and treatment, and ultimately translate to a better outcome of patients with CVT. We present an international research agenda, in which the most important research questions in the field of CVT are prioritized. AIMS This research agenda has three distinct goals: (1) to provide inspiration and focus to research on CVT for the coming years, (2) to reinforce international collaboration, and (3) to facilitate the acquisition of research funding. SUMMARY OF REVIEW This international research agenda is the result of a research summit organized by the International Cerebral Venous Thrombosis Consortium in Amsterdam, the Netherlands, in June 2023. The summit brought together 45 participants from 15 countries including clinical researchers from various disciplines, patients who previously suffered from CVT, and delegates from industry and non-profit funding organizations. The research agenda is categorized into six pre-specified themes: (1) epidemiology and clinical features, (2) life after CVT, (3) neuroimaging and diagnosis, (4) pathophysiology, (5) medical treatment, and (6) endovascular treatment. For each theme, we present two to four research questions, followed by a brief substantiation per question. The research questions were prioritized by the participants of the summit through consensus discussion. CONCLUSIONS This international research agenda provides an overview of the most burning research questions on CVT. Answering these questions will advance our understanding and management of CVT, which will ultimately lead to improved outcomes for CVT patients worldwide.
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Affiliation(s)
- Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- Stroke Center, Centro Hospitalar Universitário Lisboa Central, Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, and L Lopes Lab, Instituto de Medicina Molecular JLA, Lisbon, Portugal
| | - Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | | | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Adriana B Conforto
- LIM-44, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Sini Hiltunen
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Liqi Shu
- Brown University, Providence, RI, USA
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Rosalie Belder
- Netherlands Thrombosis Foundation, Voorschoten, The Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Suzanne Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vanessa Cano-Nigenda
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Isabel Fragata
- Stroke Center, Centro Hospitalar Universitário Lisboa Central, Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, and L Lopes Lab, Instituto de Medicina Molecular JLA, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Mirjam R Heldner
- Inselspital Bern, University Hospital and University of Bern, Bern, Switzerland
| | | | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronen R Leker
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Lia Lucas-Neto
- North Lisbon University Hospital Center and Lisbon Medical School, Lisbon, Portugal
| | | | | | | | - Gustavo Saposnik
- Stroke Outcomes & Decision Neuroscience Research Unit, University of Toronto, Toronto, ON, Canada
| | - Pankaj Sharma
- Royal Holloway University of London, London, United Kingdom
| | - Jan Stam
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | | | - David J Werring
- UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Diana Wong Ramos
- Portugal AVC-União de Sobreviventes, Familiares e Amigos, Portugal
| | | | - Nilüfer Yeşilot
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jukka Putaala
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Marcel Arnold
- Inselspital Bern, University Hospital and University of Bern, Bern, Switzerland
| | - José M Ferro
- Hospital da Luz, University of Lisbon, Lisbon, Portugal
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Scutelnic A, van de Munckhof A, Miraclin AT, Aaron S, Hameed S, Wasay M, Grosu O, Krzywicka K, Sánchez van Kammen M, Lindgren E, Moreira T, Acampora R, Negro A, Karapanayiotides T, Yaghi S, Revert A, Cuadrado Godia E, Garcia-Madrona S, La Spina P, Grillo F, Giammello F, Nguyen TN, Abdalkader M, Buture A, Sofia Cotelli M, Raposo N, Tsivgoulis G, Candelaresi P, Ciacciarelli A, Mbroh J, Batenkova T, Scoppettuolo P, Zedde M, Pascarella R, Antonenko K, Kristoffersen ES, Kremer Hovinga JA, Jood K, Aguiar de Sousa D, Poli S, Tatlisumak T, Putaala J, Coutinho JM, Ferro JM, Arnold M, Heldner MR. Characteristics and outcomes of cerebral venous thrombosis associated with COVID-19. Eur Stroke J 2024:23969873241241885. [PMID: 38572798 DOI: 10.1177/23969873241241885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
INTRODUCTION Previous reports and meta-analyses derived from small case series reported a mortality rate of up to 40% in patients with coronavirus disease 2019 associated cerebral venous thrombosis (COVID-CVT). We assessed the clinical characteristics and outcomes in an international cohort of patients with COVID-CVT. PATIENTS AND METHODS This was a registry study of consecutive COVID-CVT patients diagnosed between March 2020 and March 2023. Data collected by the International Cerebral Venous Thrombosis Consortium from patients with CVT diagnosed between 2017 and 2018 served as a comparison. Outcome analyses were adjusted for age and sex. RESULTS We included 70 patients with COVID-CVT from 23 hospitals in 15 countries and 206 controls from 14 hospitals in 13 countries. The proportion of women was smaller in the COVID-CVT group (50% vs 68%, p < 0.01). A higher proportion of COVID-CVT patients presented with altered mental state (44% vs 25%, p < 0.01), the median thrombus load was higher in COVID-CVT patients (3 [IQR 2-4] vs 2 [1-3], p < 0.01) and the length of hospital stay was longer compared to controls (11 days [IQR 7-20] vs 8 [4-15], p = 0.02). In-hospital mortality did not differ (5/67 [7%, 95% CI 3-16] vs 7/206 [3%, 2-7], aOR 2.6 [95% CI 0.7-9]), nor did the frequency of functional independence after 6 months (modified Rankin Scale 0-2; 45/58 [78%, 95% CI 65-86] vs 161/185 [87%, 81-91], aOR 0.5 [95% CI 0.2-1.02]). CONCLUSION In contrast to previous studies, the in-hospital mortality rate and functional outcomes during follow-up did not differ between COVID-CVT patients and the pre-COVID-19 controls.
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Affiliation(s)
- Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Angel T Miraclin
- Department of Neurosciences, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Department of Neurosciences, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | | | | | - Oxana Grosu
- Institute of Neurology and Neurosurgery "Diomid Gherman," Chisinau, Republic of Moldova
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Tiago Moreira
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Roberto Acampora
- Department of Neurology and Stroke Unit, Ospedale del Mare Hospital, Naples, Italy
| | - Alberto Negro
- Department of Neurology and Stroke Unit, Ospedale del Mare Hospital, Naples, Italy
| | - Theodoros Karapanayiotides
- 2nd Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital, Greece
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI, USA
| | - Anna Revert
- Hospital del Mar, Faculty of Medicine and Life Sciences, Pompeu Fabra University Barcelona, Spain
| | - Elisa Cuadrado Godia
- Hospital del Mar, Faculty of Medicine and Life Sciences, Pompeu Fabra University Barcelona, Spain
| | | | - Paolino La Spina
- Translational Molecular Medicine and Surgery 36th Cycle, Department of BIOMORF, Stroke Unit, Department of Clinical and Experimental Medicine, University Hospital G. Martino, Messina, Italy
| | - Francesco Grillo
- Translational Molecular Medicine and Surgery 36th Cycle, Department of BIOMORF, Stroke Unit, Department of Clinical and Experimental Medicine, University Hospital G. Martino, Messina, Italy
| | - Fabrizio Giammello
- Translational Molecular Medicine and Surgery 36th Cycle, Department of BIOMORF, Stroke Unit, Department of Clinical and Experimental Medicine, University Hospital G. Martino, Messina, Italy
| | - Thanh N Nguyen
- Neurology, Boston Medical Center, MA, USA
- Radiology, Boston Medical Center, MA, USA
| | | | - Alina Buture
- Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Nicolas Raposo
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, "Attikon University Hospital", Athens, Greece
| | | | - Antonio Ciacciarelli
- Neurology Division, Santa Maria Goretti Hospital, Latina, Italy
- Department of Translation and Precision Medicine, Sapienza University of Rome, Italy
| | - Joshua Mbroh
- Department of Neurology & Stroke, University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
| | | | - Pasquale Scoppettuolo
- Neurology Department, Cliniques Universitaires Saint Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Azienda Unità Sanitaria-IRCCS di Reggio Emilia, Italy
| | - Kateryna Antonenko
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Johanna A Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Diana Aguiar de Sousa
- Lisbon Central University Hospital and Faculdade de Medicina da Universidade de Lisboa, Portugal
| | - Sven Poli
- Department of Neurology & Stroke, University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Jukka Putaala
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - José M Ferro
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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3
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Weller J, Krzywicka K, van de Munckhof A, Dorn F, Althaus K, Bode FJ, Bandettini di Poggio M, Buck B, Kleinig T, Cordonnier C, Dizonno V, Duan J, Elkady A, Chew BLA, Garcia-Esperon C, Field TS, Legault C, Morin Martin M, Michalski D, Pelz J, Schoenenberger S, Nagel S, Petruzzellis M, Raposo N, Skjelland M, Zimatore DS, Aaron S, Sanchez van Kammen M, Aguiar de Sousa D, Lindgren E, Jood K, Scutelnic A, Heldner MR, Poli S, Arauz A, Conforto AB, Putaala J, Tatlisumak T, Arnold M, Coutinho JM, Günther A, Zimmermann J, Ferro JM. Endovascular treatment of cerebral sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia. Eur Stroke J 2024; 9:105-113. [PMID: 37771138 PMCID: PMC10916823 DOI: 10.1177/23969873231202363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/03/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION There is little data on the role of endovascular treatment (EVT) of cerebral venous sinus thrombosis (CVST) due to vaccine-induced immune thrombotic thrombocytopenia (VITT). Here, we describe clinical characteristics and outcomes of CVST-VITT patients who were treated with EVT. PATIENTS AND METHODS We report data from an international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 6 March 2023. VITT was defined according to the Pavord criteria. RESULTS EVT was performed in 18/136 (13%) patients with CVST-VITT (92% aspiration and/or stent retrieval, 8% local thrombolysis). Most common indications were extensive thrombosis and clinical or radiological deterioration. Compared to non-EVT patients, those receiving EVT had a higher median thrombus load (4.5 vs 3). Following EVT, local blood flow was improved in 83% (10/12, 95% confidence interval [CI] 54-96). One (6%) asymptomatic sinus perforation occurred. Eight (44%) patients treated with EVT also underwent decompressive surgery. Mortality was 50% (9/18, 95% CI 29-71) and 88% (8/9, 95% CI 25-66) of surviving EVT patients achieved functional independence with a modified Rankin Scale score of 0-2 at follow-up. In multivariable analysis, EVT was not associated with increased mortality (adjusted odds ratio, 0.66, 95% CI 0.16-2.58). DISCUSSION AND CONCLUSION We describe the largest cohort of CVST-VITT patients receiving EVT. Half of the patients receiving EVT died during hospital admission, but most survivors achieved functional independence.
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Affiliation(s)
- Johannes Weller
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | | | - Felix J Bode
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | | | - Brian Buck
- Division of Neurology, University of Alberta Hospital, Edmonton, AB, Canada
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, Lille, France
| | - Vanessa Dizonno
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jiangang Duan
- Department of Neurology and Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ahmed Elkady
- Department of Neurology, Saudi German Hospital, Jeddah, Saudi Arabia
| | | | | | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Catherine Legault
- Division of Neurology, McGill University Health Centre, Montreal, QC, Canada
| | - Mar Morin Martin
- Department of Neurology, Hospital Complex of Toledo, Toledo, Spain
| | | | - Johann Pelz
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | | | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Marco Petruzzellis
- Neuroradiology Unit, Azienda Ospedaliera Consorziale Policlinico di Bari, Italy
| | - Nicolas Raposo
- Department of Neurology, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France and Inserm, Toulouse NeuroImaging Center, Université de Toulouse, Toulouse, France
| | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | | | - Sanjith Aaron
- Neurology Unit, Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mayte Sanchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Stroke Centre, Lisbon Central University Hospital, Lisbon, Portugal
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia, Mexico City, Mexico
| | - Adriana B Conforto
- Hospital das Clinicas/São Paulo University and Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - José M Ferro
- Centro de Estudas Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal
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4
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Scutelnic A, van de Munckhof A, Krzywicka K, van Kammen MS, Lindgren E, Cordonnier C, Kleinig TJ, Field TS, Poli S, Lemmens R, Middeldorp S, Aaron S, Borhani-Haghighi A, Arauz A, Kremer Hovinga JA, Günther A, Putaala J, Wasay M, Conforto AB, de Sousa DA, Jood K, Tatlisumak T, Ferro JM, Coutinho JM, Arnold M, Heldner MR. Sex differences in cerebral venous sinus thrombosis after adenoviral vaccination against COVID-19. Eur Stroke J 2023; 8:1001-1010. [PMID: 37434312 PMCID: PMC10345391 DOI: 10.1177/23969873231185213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 06/13/2023] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION Cerebral venous sinus thrombosis associated with vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) is a severe disease with high mortality. There are few data on sex differences in CVST-VITT. The aim of our study was to investigate the differences in presentation, treatment, clinical course, complications, and outcome of CVST-VITT between women and men. PATIENTS AND METHODS We used data from an ongoing international registry on CVST-VITT. VITT was diagnosed according to the Pavord criteria. We compared the characteristics of CVST-VITT in women and men. RESULTS Of 133 patients with possible, probable, or definite CVST-VITT, 102 (77%) were women. Women were slightly younger [median age 42 (IQR 28-54) vs 45 (28-56)], presented more often with coma (26% vs 10%) and had a lower platelet count at presentation [median (IQR) 50x109/L (28-79) vs 68 (30-125)] than men. The nadir platelet count was lower in women [median (IQR) 34 (19-62) vs 53 (20-92)]. More women received endovascular treatment than men (15% vs 6%). Rates of treatment with intravenous immunoglobulins were similar (63% vs 66%), as were new venous thromboembolic events (14% vs 14%) and major bleeding complications (30% vs 20%). Rates of good functional outcome (modified Rankin Scale 0-2, 42% vs 45%) and in-hospital death (39% vs 41%) did not differ. DISCUSSION AND CONCLUSIONS Three quarters of CVST-VITT patients in this study were women. Women were more severely affected at presentation, but clinical course and outcome did not differ between women and men. VITT-specific treatments were overall similar, but more women received endovascular treatment.
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Affiliation(s)
- Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Thalia S Field
- Devision of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, Canada
| | - Sven Poli
- Department of Neurology & Stroke, University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sanjith Aaron
- Department of Neurosciences, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | | | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suárez, Mexico City
| | - Johanna A Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | | | - Diana Aguiar de Sousa
- Lisbon Central University Hospital and Faculdade de Medicina da Universidade de Lisboa, Portugal
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - José M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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5
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van de Munckhof A, Borhani-Haghighi A, Aaron S, Krzywicka K, van Kammen MS, Cordonnier C, Kleinig TJ, Field TS, Poli S, Lemmens R, Scutelnic A, Lindgren E, Duan J, Arslan Y, van Gorp ECM, Kremer Hovinga JA, Günther A, Jood K, Tatlisumak T, Putaala J, Heldner MR, Arnold M, de Sousa DA, Wasay M, Arauz A, Conforto AB, Ferro JM, Coutinho JM. Cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia in middle-income countries. Int J Stroke 2023; 18:1112-1120. [PMID: 37277922 PMCID: PMC10614174 DOI: 10.1177/17474930231182901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/26/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Adenovirus-based COVID-19 vaccines are extensively used in low- and middle-income countries (LMICs). Remarkably, cases of cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) have rarely been reported from LMICs. AIMS We studied the frequency, manifestations, treatment, and outcomes of CVST-VITT in LMICs. METHODS We report data from an international registry on CVST after COVID-19 vaccination. VITT was classified according to the Pavord criteria. We compared CVST-VITT cases from LMICs to cases from high-income countries (HICs). RESULTS Until August 2022, 228 CVST cases were reported, of which 63 were from LMICs (all middle-income countries [MICs]: Brazil, China, India, Iran, Mexico, Pakistan, Turkey). Of these 63, 32 (51%) met the VITT criteria, compared to 103 of 165 (62%) from HICs. Only 5 of the 32 (16%) CVST-VITT cases from MICs had definite VITT, mostly because anti-platelet factor 4 antibodies were often not tested. The median age was 26 (interquartile range [IQR] 20-37) versus 47 (IQR 32-58) years, and the proportion of women was 25 of 32 (78%) versus 77 of 103 (75%) in MICs versus HICs, respectively. Patients from MICs were diagnosed later than patients from HICs (1/32 [3%] vs. 65/103 [63%] diagnosed before May 2021). Clinical manifestations, including intracranial hemorrhage, were largely similar as was intravenous immunoglobulin use. In-hospital mortality was lower in MICs (7/31 [23%, 95% confidence interval (CI) 11-40]) than in HICs (44/102 [43%, 95% CI 34-53], p = 0.039). CONCLUSIONS The number of CVST-VITT cases reported from LMICs was small despite the widespread use of adenoviral vaccines. Clinical manifestations and treatment of CVST-VITT cases were largely similar in MICs and HICs, while mortality was lower in patients from MICs.
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Affiliation(s)
- Anita van de Munckhof
- Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Katarzyna Krzywicka
- Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Mayte Sánchez van Kammen
- Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172—LilNCog—Lille Neuroscience & Cognition, Lille, France
| | | | | | - Sven Poli
- University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
| | | | - Adrian Scutelnic
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Erik Lindgren
- Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jiangang Duan
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yıldız Arslan
- Medicana İzmir International Hospital, Izmir, Turkey
| | | | | | | | - Katarina Jood
- Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jukka Putaala
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mirjam R Heldner
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - Antonio Arauz
- National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - José M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Jonathan M Coutinho
- Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
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6
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van de Munckhof A, Sánchez van Kammen M, Krzywicka K, Aaron S, Aguiar de Sousa D, Antochi F, Arauz A, Barboza MA, Conforto AB, Dentali F, Galdames Contreras D, Ji X, Jood K, Heldner MR, Hernández-Pérez M, Kam W, Kleinig TJ, Kristoffersen ES, Leker RR, Lemmens R, Poli S, Yeşilot N, Wasay M, Wu TY, Arnold M, Lucas-Neto L, Middeldorp S, Putaala J, Tatlisumak T, Ferro JM, Coutinho JM. Direct oral anticoagulants for the treatment of cerebral venous thrombosis - a protocol of an international phase IV study. Front Neurol 2023; 14:1251581. [PMID: 37780701 PMCID: PMC10539579 DOI: 10.3389/fneur.2023.1251581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction Current guidelines recommend that patients with cerebral venous thrombosis (CVT) should be treated with vitamin K antagonists (VKAs) for 3-12 months. Direct oral anticoagulants (DOACs), however, are increasingly used in clinical practice. An exploratory randomized controlled trial including 120 patients with CVT suggested that the efficacy and safety profile of dabigatran (a DOAC) is similar to VKAs for the treatment of CVT, but large-scale prospective studies from a real-world setting are lacking. Methods DOAC-CVT is an international, prospective, observational cohort study comparing DOACs to VKAs for the prevention of recurrent venous thrombotic events after acute CVT. Patients are eligible if they are 18 years or older, have a radiologically confirmed CVT, and have started oral anticoagulant treatment (DOAC or VKA) within 30 days of CVT diagnosis. Patients with an absolute contra-indication for DOACs, such as pregnancy or severe renal insufficiency, are excluded from the study. We aim to recruit at least 500 patients within a three-year recruitment period. The primary endpoint is a composite of recurrent venous thrombosis and major bleeding at 6 months of follow-up. We will calculate an adjusted odds ratio for the primary endpoint using propensity score inverse probability treatment weighting. Discussion DOAC-CVT will provide real-world data on the comparative efficacy and safety of DOACs versus VKAs for the treatment of CVT. Clinical trial registration ClinicalTrials.gov, NCT04660747.
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Affiliation(s)
- Anita van de Munckhof
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Sanjith Aaron
- Department of Neurology, Christian Medical College, Vellore, India
| | - Diana Aguiar de Sousa
- Department of Neurology, Stroke Center, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Florina Antochi
- Department of Neurology, Spitalul Universitar de Urgenţă Bucureşti, Bucharest, Romania
| | - Antonio Arauz
- Department of Neurology, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Miguel A. Barboza
- Department of Neurology, Rafael Angel Calderon Guardia Hospital, San José, Costa Rica
| | - Adriana B. Conforto
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Xunming Ji
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | | | - Wayneho Kam
- Department of Neurology, Duke University Hospital, Durham, NC, United States
| | - Timothy J. Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Ronen R. Leker
- Department of Neurology, Hadassah – Hebrew University Medical Center, Jerusalem, Israel
| | | | - Sven Poli
- Department of Neurology, Tübingen University Hospital, Tübingen, Germany
| | - Nilüfer Yeşilot
- Department of Neurology, Istanbul Tip Fakültesi, Istanbul, Turkey
| | - Mohammad Wasay
- Department of Neurology, Aga Khan University, Karachi, Pakistan
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Lia Lucas-Neto
- Department of Neuroradiology, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - José M. Ferro
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
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7
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Krzywicka K, Aguiar de Sousa D, Cordonnier C, Bode FJ, Field TS, Michalski D, Pelz J, Skjelland M, Wiedmann M, Zimmermann J, Wittstock M, Zanotti B, Ciccone A, Bandettini di Poggio M, Borhani-Haghighi A, Chatterton S, Aujayeb A, Devroye A, Dizonno V, Geeraerts T, Giammello F, Günther A, Ichaporia NR, Kleinig T, Kristoffersen ES, Lemmens R, De Maistre E, Mirzaasgari Z, Payen JF, Putaala J, Petruzzellis M, Raposo N, Sadeghi-Hokmabadi E, Schoenenberger S, Umaiorubahan M, Sylaja PN, van de Munckhof A, Sánchez van Kammen M, Lindgren E, Jood K, Scutelnic A, Heldner MR, Poli S, Kruip MJHA, Arauz A, Conforto AB, Aaron S, Middeldorp S, Tatlisumak T, Arnold M, Coutinho JM, Ferro JM. Decompressive surgery in cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia. Eur J Neurol 2023; 30:1335-1345. [PMID: 36773014 DOI: 10.1111/ene.15735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/22/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND AND PURPOSE Cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) is an adverse drug reaction occurring after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. CVST-VITT patients often present with large intracerebral haemorrhages and a high proportion undergoes decompressive surgery. Clinical characteristics, therapeutic management and outcomes of CVST-VITT patients who underwent decompressive surgery are described and predictors of in-hospital mortality in these patients are explored. METHODS Data from an ongoing international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 10 May 2022, were used. Definite, probable and possible VITT cases, as defined by Pavord et al. (N Engl J Med 2021; 385: 1680-1689), were included. RESULTS Decompressive surgery was performed in 34/128 (27%) patients with CVST-VITT. In-hospital mortality was 22/34 (65%) in the surgical and 27/94 (29%) in the non-surgical group (p < 0.001). In all surgical cases, the cause of death was brain herniation. The highest mortality rates were found amongst patients with preoperative coma (17/18, 94% vs. 4/14, 29% in the non-comatose; p < 0.001) and bilaterally absent pupillary reflexes (7/7, 100% vs. 6/9, 67% with unilaterally reactive pupil, and 4/11, 36% with bilaterally reactive pupils; p = 0.023). Postoperative imaging revealed worsening of index haemorrhagic lesion in 19 (70%) patients and new haemorrhagic lesions in 16 (59%) patients. At a median follow-up of 6 months, 8/10 of surgical CVST-VITT who survived admission were functionally independent. CONCLUSIONS Almost two-thirds of surgical CVST-VITT patients died during hospital admission. Preoperative coma and bilateral absence of pupillary responses were associated with higher mortality rates. Survivors often achieved functional independence.
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Affiliation(s)
- Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- Stroke Centre, Lisbon Central University Hospital Center, Lisbon, Portugal.,CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Charlotte Cordonnier
- INSERM, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, University of Lille, Lille, France
| | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dominik Michalski
- Department of Neurology, Leipzig University Hospital, Leipzig, Germany
| | - Johann Pelz
- Department of Neurology, Leipzig University Hospital, Leipzig, Germany
| | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Markus Wiedmann
- Department of Surgery, Oslo University Hospital, Oslo, Norway
| | | | | | - Bruno Zanotti
- Department of Neuroscience, Neurology with Neurosurgical Activity, C. Poma Hospital, ASST di Mantova, Mantua, Italy
| | - Alfonso Ciccone
- Department of Neuroscience, Neurology with Neurosurgical Activity, C. Poma Hospital, ASST di Mantova, Mantua, Italy
| | | | | | - Sophie Chatterton
- Department of Neurology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Annemie Devroye
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Vanessa Dizonno
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas Geeraerts
- Department of Anesthesiology and Critical Care, University Toulouse 3-Paul-Sabatier, University Hospital of Toulouse, Hôpital Pierre-Paul Riquet, CHU Toulouse-Purpan, Toulouse, France
| | - Fabrizio Giammello
- Translational Molecular Medicine and Surgery, XXXVI Cycle, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.,Stroke Unit, Department of Clinical and Experimental Medicine, Polyclinic Hospital G. Martino, Messina, Italy
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Espen S Kristoffersen
- Department of Neurology, Akershus University Hospital, Oslo, Norway.,Department of General Practice, University of Oslo, Oslo, Norway
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Emmanuel De Maistre
- Laboratoire d'Hématologie-Hémostase, Centre Hospitalier Universitaire Dijon, Dijon, France
| | - Zahra Mirzaasgari
- Department of Neurology, Firoozgar Hospital, School of Medicine, Iran University of Medical Science, Tehran, Iran
| | - Jean-Francois Payen
- Department of Anaesthesia and Intensive Care, Grenoble Alpes University Hospital, and Grenoble Alpes University, Grenoble Institut des Neurosciences, INSERM U1216, Grenoble, France
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marco Petruzzellis
- Department of Neurology, AOU Consorziale Policlinico di Bari, Bari, Italy
| | - Nicolas Raposo
- Department of Neurology, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Inserm, Toulouse NeuroImaging Center, Université de Toulouse, Toulouse, France
| | - Elyar Sadeghi-Hokmabadi
- Department of Neurology, Imam-Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | | | - Padmavathy N Sylaja
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Antonio Arauz
- National Institute of Neurology and Surgery Manuel Velasco Suarez, Mexico City, Mexico
| | - Adriana B Conforto
- Hospital das Clinicas/São Paulo University and Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Sanjith Aaron
- Neurology Unit, Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - José M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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8
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van de Munckhof A, Borhani-Haghighi A, Aaron S, Krzywicka K, Poli S, Cordonnier C, Kleinig TJ, Lemmens R, Sanchez van Kammen M, Scutelnic A, Lindgren E, Mbroh J, Ciccone A, Wittstock M, Zimmermann J, Bode FJ, Skjelland M, Devroye A, Duan J, Hiltunen S, Petruzzellis M, Kremer Hovinga JA, Günther A, Jood K, Tatlisumak T, Putaala J, Heldner M, Arnold M, Aguiar De Sousa D, Wasay M, Arauz A, Conforto AB, Ferro JM, Coutinho JM. Abstract 112: Cerebral Venous Sinus Thrombosis Due To Vaccine-induced Immune Thrombotic Thrombocytopenia In Middle-Income Countries. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Adenovirus-based COVID-19 vaccines are extensively used in low- and middle-income countries (LMICs). In India alone, 1.67 billion ChAdOx1 nCoV-19 vaccines have been administered by August 23, 2022. Surprisingly however, there are only few reports of cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) from LMICs. We aimed to gain insight into the frequency, manifestations, treatment, and outcomes of CVST-VITT in LMICs.
Methods:
We report data from an international registry on CVST after COVID-19 vaccination. VITT was classified according to the Pavord criteria. We compared characteristics of CVST-VITT cases from LMICs to cases from high-income countries (HICs).
Results:
By August 15, 2022, 228 CVST cases after vaccination were reported, of which 63 cases from LMICs (all middle-income countries [MICs]: Brazil, China, India, Iran, Mexico, Pakistan, and Turkiye). Of these, 32/63 (51%) met the criteria for definite, probable or possible VITT. Only 5/32 (16%) CVST-VITT cases from MICs had definite VITT, mostly because anti-PF4 antibodies were not tested in 21/32 (66%) cases. Patients from MICs were diagnosed in a later time period than patients from HICs (1/32 [3%] vs 65/103 [63%] cases diagnosed before May 2021, respectively). Median age was 26 (IQR 20-37) vs 47 (IQR 32-58) years, and proportion of women was 25/32 (78%) vs 77/103 (75%) in MICs vs HICs, respectively. Clinical manifestations, such as focal neurologic deficits, coma, seizures, and intracranial hemorrhages, were similar. Concomitant venous thromboembolism was less frequent in MICs (3/31 [10%] vs 26/97 [27%]). Median platelet count nadir was higher in the MICs than the HICs group (65 x10
9
/L [IQR 36-115] vs 33 x10
9
/L [IQR 18-55],
p
=0.001). Intravenous immunoglobulin use was similar (19/30 [63%] vs 63/99 [64%]). In-hospital mortality was lower in the MICs than the HICs group (7/32 [22%, 95%CI 11-39] vs 44/102 [43%, 95%CI 34-53],
p
=0.031).
Conclusions:
The absolute number of CVST-VITT cases reported from LMICs was small despite the widespread use of adenoviral vaccines in these countries. Clinical manifestations and treatment of CVST-VITT cases were largely similar in MICs and HICs, while mortality was lower in patients from MICs.
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Affiliation(s)
| | | | | | | | - Sven Poli
- Dept of Neurology & Stroke, Hertie Institute for Clinical Brain Rsch, Tuebingen, Germany
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | | | | | | | | | | | - Joshua Mbroh
- Dept of Neurology & Stroke, Eberhard-Karls Univ, Tuebingen, Germany
| | - Alfonso Ciccone
- Carlo Poma Hosp, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy
| | | | | | - Felix J Bode
- Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | | | | | - Jiangang Duan
- Neurology, Xuanwu Hosp, Capital Med Univ, Beijing, China
| | | | | | | | | | | | | | - Jukka Putaala
- Helsinki Univ Hosp and Univ of Helsinki, Helsinki, Finland
| | - Mirjam Heldner
- Inselspital, Bern Univ Hosp, Univ of Bern, Bern, Switzerland
| | - Marcel Arnold
- Inselspital, Bern Univ Hosp, Univ of Bern, Bern, Switzerland
| | | | | | - Antonio Arauz
- Instituto Nacional de Neurologia, Mexico City, Mexico
| | | | - Jose M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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9
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van de Munckhof A, Lindgren E, Kleinig TJ, Field TS, Cordonnier C, Krzywicka K, Poli S, Sánchez van Kammen M, Borhani-Haghighi A, Lemmens R, Scutelnic A, Ciccone A, Gattringer T, Wittstock M, Dizonno V, Devroye A, Elkady A, Günther A, Cervera A, Mengel A, Chew BLA, Buck B, Zanferrari C, Garcia-Esperon C, Jacobi C, Soriano C, Michalski D, Zamani Z, Blacquiere D, Johansson E, Cuadrado-Godia E, Vuillier F, Bode FJ, Caparros F, Maier F, Tsivgoulis G, Katzberg HD, Duan J, Burrow J, Pelz J, Mbroh J, Oen J, Schouten J, Zimmermann J, Ng K, Garambois K, Petruzzellis M, Carvalho Dias M, Ghiasian M, Romoli M, Miranda M, Wronski M, Skjelland M, Almasi-Dooghaee M, Cuisenier P, Murphy S, Timsit S, Coutts SB, Schönenberger S, Nagel S, Hiltunen S, Chatterton S, Cox T, Bartsch T, Shaygannejad V, Mirzaasgari Z, Middeldorp S, Levi MM, Kremer Hovinga JA, Jood K, Tatlisumak T, Putaala J, Heldner MR, Arnold M, Aguiar de Sousa D, Ferro JM, Coutinho JM. Outcomes of Cerebral Venous Thrombosis due to Vaccine-Induced Immune Thrombotic Thrombocytopenia After the Acute Phase. Stroke 2022; 53:3206-3210. [PMID: 36082668 PMCID: PMC9508952 DOI: 10.1161/strokeaha.122.039575] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cerebral venous thrombosis (CVT) due to vaccine-induced immune thrombotic thrombocytopenia (VITT) is a severe condition, with high in-hospital mortality rates. Here, we report clinical outcomes of patients with CVT-VITT after SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) vaccination who survived initial hospitalization. METHODS We used data from an international registry of patients who developed CVT within 28 days of SARS-CoV-2 vaccination, collected until February 10, 2022. VITT diagnosis was classified based on the Pavord criteria. Outcomes were mortality, functional independence (modified Rankin Scale score 0-2), VITT relapse, new thrombosis, and bleeding events (all after discharge from initial hospitalization). RESULTS Of 107 CVT-VITT cases, 43 (40%) died during initial hospitalization. Of the remaining 64 patients, follow-up data were available for 60 (94%) patients (37 definite VITT, 9 probable VITT, and 14 possible VITT). Median age was 40 years and 45/60 (75%) patients were women. Median follow-up time was 150 days (interquartile range, 94-194). Two patients died during follow-up (3% [95% CI, 1%-11%). Functional independence was achieved by 53/60 (88% [95% CI, 78%-94%]) patients. No new venous or arterial thrombotic events were reported. One patient developed a major bleeding during follow-up (fatal intracerebral bleed). CONCLUSIONS In contrast to the high mortality of CVT-VITT in the acute phase, mortality among patients who survived the initial hospitalization was low, new thrombotic events did not occur, and bleeding events were rare. Approximately 9 out of 10 CVT-VITT patients who survived the acute phase were functionally independent at follow-up.
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Affiliation(s)
- Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands. (A.v.d.M., K.K., M.S.v.K., J.M.C.)
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.L., K.J., T.T.).,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (E.L., K.J., T.T.)
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia (T.J.K.)
| | - Thalia S Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, Canada (T.S.F., V.D.)
| | - Charlotte Cordonnier
- University Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, France (C.C., F.C.)
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands. (A.v.d.M., K.K., M.S.v.K., J.M.C.)
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital Tuebingen, Eberhard-Karls University, Germany. (S.P., A.M., J.M.).,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Germany. (S.P., J.M.)
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands. (A.v.d.M., K.K., M.S.v.K., J.M.C.)
| | | | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Belgium (R.L., A.D.)
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland. (A.S., M.R.H., M.A.)
| | - Alfonso Ciccone
- Department of Neurology, Carlo Poma Hospital, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy (A. Ciccone)
| | | | - Matthias Wittstock
- Department of Neurology, University Hospital Rostock, Germany (M. Wittstock)
| | - Vanessa Dizonno
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, Canada (T.S.F., V.D.)
| | - Annemie Devroye
- Department of Neurology, University Hospitals Leuven, Belgium (R.L., A.D.)
| | - Ahmed Elkady
- Department of Neurology, Saudi German Hospital, Jeddah, Saudi Arabia (A.E.)
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Germany (A.G.)
| | - Alvaro Cervera
- Royal Darwin Hospital, Darwin, Northern Territory, Australia (A. Cervera)
| | - Annerose Mengel
- Department of Neurology and Stroke, University Hospital Tuebingen, Eberhard-Karls University, Germany. (S.P., A.M., J.M.)
| | - Beng Lim Alvin Chew
- Department of Neurology, John Hunter Hospital, Newcastle, Australia (B.L.A.C., C.G.-E.)
| | - Brian Buck
- Division of Neurology, University of Alberta Hospital, Edmonton, Canada (B.B.)
| | - Carla Zanferrari
- Department of Neurology, Azienda Ospedaliera di Melegnano e della Martesana, Italy (C.Z.)
| | - Carlos Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, Australia (B.L.A.C., C.G.-E.)
| | - Christian Jacobi
- Department of Neurology, Krankenhaus Nordwest, Frankfurt am Main, Germany (C.J.)
| | - Cristina Soriano
- Department of Neurology, Hospital General de Castellón, Castelló, Spain (C.S.)
| | - Dominik Michalski
- Department of Neurology, Leipzig University Hospital, Germany (D.M., J. Pelz)
| | - Zohreh Zamani
- Department of Neurology, Firoozabadi Hospital, Firoozgar Hospital, School of Medicine, Iran University of Medical Sciences, Tehran. (Z.Z.)
| | | | - Elias Johansson
- Department Clinical Science, Wallenberg Center for Molecular Medicine (WCMM), Umeå University, Sweden (E.J.)
| | - Elisa Cuadrado-Godia
- Department of Neurology, University Hospital del Mar, Barcelona, Spain (E.C.-G.)
| | | | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Germany (F.J.B., J.Z.)
| | - François Caparros
- University Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, France (C.C., F.C.)
| | - Frank Maier
- Department of Neurology, Caritas Hospital Saarbrücken, Germany (F.M.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Greece (G.T.)
| | - Hans D Katzberg
- Department of Neuromuscular Medicine, Toronto General Hospital, Canada (H.D.K.)
| | - Jiangang Duan
- Department of Neurology and Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China (J.D.)
| | - Jim Burrow
- Department of Neurology, Royal Darwin Hospital, Tiwi, Australia (J.B.)
| | - Johann Pelz
- Department of Neurology, Leipzig University Hospital, Germany (D.M., J. Pelz)
| | - Joshua Mbroh
- Department of Neurology and Stroke, University Hospital Tuebingen, Eberhard-Karls University, Germany. (S.P., A.M., J.M.).,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Germany. (S.P., J.M.)
| | - Joyce Oen
- Department of Neurology, Antonius Ziekenhuis, Sneek, the Netherlands (J.O.)
| | - Judith Schouten
- Department of Neurology, Rijnstate Hospital Arnhem, the Netherlands (J.S.)
| | - Julian Zimmermann
- Department of Neurology, Universitätsklinikum Bonn, Germany (F.J.B., J.Z.)
| | - Karl Ng
- Department of Neurology, Royal North Shore Hospital, Sydney, Australia (K.N., M. Wronski, S.C.)
| | - Katia Garambois
- Department of Neurology, CHU Grenoble Alpes, France (K.G., P.C.)
| | - Marco Petruzzellis
- Department of Neurology, AOU Consorziale Policlinico di Bari, Italy (M.P.)
| | - Mariana Carvalho Dias
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte, University of Lisbon, Portugal (M.C.D.)
| | - Masoud Ghiasian
- Department of Neurology, Sina Hospital, Hamadan University of Medical Science, Iran (M.G.)
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy (M.R.)
| | - Miguel Miranda
- Department of Neurology, Hospital de Cascais Dr. José de Almeida, Cascais, Portugal (M.M.)
| | - Miriam Wronski
- Department of Neurology, Royal North Shore Hospital, Sydney, Australia (K.N., M. Wronski, S.C.)
| | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Norway (M.S.)
| | | | | | - Seán Murphy
- Acute Stroke Service, Mater Misericordiae University Hospital, UCD School of Medicine and RCSI Medical School, Dublin, Ireland (S. Murphy)
| | - Serge Timsit
- Department of Neurology, Stroke Unit, Hôpital de la Cavale Blanche, CHRU de Brest (University Hospital), Université de Bretagne Occidentale, Inserm 1078, Brest, France (S.T.)
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Foothills Medical Centre, Calgary, Canada (S.B.C.)
| | | | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Germany (S.S., S.N.)
| | - Sini Hiltunen
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Finland (S.H., T.T., J. Putaala)
| | - Sophie Chatterton
- Department of Neurology, Royal North Shore Hospital, Sydney, Australia (K.N., M. Wronski, S.C.)
| | - Thomas Cox
- Department of Neurology, University Hospital Southampton NHS Foundation Trust, United Kingdom (T.C.)
| | - Thorsten Bartsch
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Germany (T.B.)
| | - Vahid Shaygannejad
- Isfahan University of Medical Sciences (IUMS), Isfahan Neurosciences Research Center (INRC), Iran (V.S.).,Department of Internal (INRC), Iran (V.S.)
| | - Zahra Mirzaasgari
- Department of Neurology, Firoozgar Hospital, School of Medicine, Iran University of Medical Sciences, Tehran. (M.A.-D., Z.M.)
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (S. Middeldorp)
| | - Marcel M Levi
- Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands. (M.M.L.).,National Institute for Health Research, University College London Hospitals (UCLH), Biomedical Research Centre, London, United Kingdom (M.M.L.)
| | - Johanna A Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Switzerland. (J.A.K.H.)
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.L., K.J., T.T.).,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (E.L., K.J., T.T.)
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.L., K.J., T.T.).,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (E.L., K.J., T.T.).,Department of Neurology, Helsinki University Hospital, University of Helsinki, Finland (S.H., T.T., J. Putaala)
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Finland (S.H., T.T., J. Putaala)
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland. (A.S., M.R.H., M.A.)
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland. (A.S., M.R.H., M.A.)
| | - Diana Aguiar de Sousa
- Stroke Centre, Lisbon Central University Hospital Centre, Portugal (D.A.d.S.).,Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Portugal (D.A.d.S., J.M.F.)
| | - José M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Portugal (D.A.d.S., J.M.F.)
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands. (A.v.d.M., K.K., M.S.v.K., J.M.C.)
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10
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Scutelnic A, Krzywicka K, Mbroh J, van de Munckhof A, van Kammen MS, de Sousa DA, Lindgren E, Jood K, Günther A, Hiltunen S, Putaala J, Tiede A, Maier F, Kern R, Bartsch T, Althaus K, Ciccone A, Wiedmann M, Skjelland M, Medina A, Cuadrado-Godia E, Cox T, Aujayeb A, Raposo N, Garambois K, Payen JF, Vuillier F, Franchineau G, Timsit S, Bougon D, Dubois MC, Tawa A, Tracol C, De Maistre E, Bonneville F, Vayne C, Mengel A, Michalski D, Pelz J, Wittstock M, Bode F, Zimmermann J, Schouten J, Buture A, Murphy S, Palma V, Negro A, Gutschalk A, Nagel S, Schoenenberger S, Frisullo G, Zanferrari C, Grillo F, Giammello F, Martin MM, Cervera A, Burrow J, Esperon CG, Chew BLA, Kleinig TJ, Soriano C, Zimatore DS, Petruzzellis M, Elkady A, Miranda MS, Fernandes J, Vogel ÅH, Johansson E, Philip AP, Coutts SB, Bal S, Buck B, Legault C, Blacquiere D, Katzberg HD, Field TS, Dizonno V, Gattringer T, Jacobi C, Devroye A, Lemmens R, Kristoffersen ES, di Poggio MB, Ghiasian M, Karapanayiotides T, Chatterton S, Wronski M, Ng K, Kahnis R, Geeraerts T, Reiner P, Cordonnier C, Middeldorp S, Levi M, van Gorp ECM, van de Beek D, Brodard J, Kremer Hovinga JA, Kruip MJHA, Tatlisumak T, Ferro JM, Coutinho JM, Arnold M, Poli S, Heldner MR. Management of Cerebral Venous Thrombosis Due to Adenoviral COVID-19 Vaccination. Ann Neurol 2022; 92:562-573. [PMID: 35689346 PMCID: PMC9349982 DOI: 10.1002/ana.26431] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/21/2022] [Accepted: 05/27/2022] [Indexed: 01/01/2023]
Abstract
Objective Cerebral venous thrombosis (CVT) caused by vaccine‐induced immune thrombotic thrombocytopenia (VITT) is a rare adverse effect of adenovirus‐based severe acute respiratory syndrome‐coronavirus 2 (SARS‐CoV‐2) vaccines. In March 2021, after autoimmune pathogenesis of VITT was discovered, treatment recommendations were developed. These comprised immunomodulation, non‐heparin anticoagulants, and avoidance of platelet transfusion. The aim of this study was to evaluate adherence to these recommendations and its association with mortality. Methods We used data from an international prospective registry of patients with CVT after the adenovirus‐based SARS‐CoV‐2 vaccination. We analyzed possible, probable, or definite VITT‐CVT cases included until January 18, 2022. Immunomodulation entailed administration of intravenous immunoglobulins and/or plasmapheresis. Results Ninety‐nine patients with VITT‐CVT from 71 hospitals in 17 countries were analyzed. Five of 38 (13%), 11 of 24 (46%), and 28 of 37 (76%) of the patients diagnosed in March, April, and from May onward, respectively, were treated in‐line with VITT recommendations (p < 0.001). Overall, treatment according to recommendations had no statistically significant influence on mortality (14/44 [32%] vs 29/55 [52%], adjusted odds ratio [OR] = 0.43, 95% confidence interval [CI] = 0.16–1.19). However, patients who received immunomodulation had lower mortality (19/65 [29%] vs 24/34 [70%], adjusted OR = 0.19, 95% CI = 0.06–0.58). Treatment with non‐heparin anticoagulants instead of heparins was not associated with lower mortality (17/51 [33%] vs 13/35 [37%], adjusted OR = 0.70, 95% CI = 0.24–2.04). Mortality was also not significantly influenced by platelet transfusion (17/27 [63%] vs 26/72 [36%], adjusted OR = 2.19, 95% CI = 0.74–6.54). Conclusions In patients with VITT‐CVT, adherence to VITT treatment recommendations improved over time. Immunomodulation seems crucial for reducing mortality of VITT‐CVT. ANN NEUROL 2022;92:562–573
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Affiliation(s)
- Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Joshua Mbroh
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany.,Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sini Hiltunen
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Andreas Tiede
- Clinic for Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Frank Maier
- Department of Neurology, Caritas Hospital Saarbrücken, Saarbrücken, Germany
| | - Rolf Kern
- Department of Neurology, Kempten Hospital, Kempten, Germany
| | - Thorsten Bartsch
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | - Alfonso Ciccone
- Department of Neurology, Carlo Poma Hospital, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy
| | - Markus Wiedmann
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Mona Skjelland
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Antonio Medina
- Department of Neurology, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | | | - Thomas Cox
- Department of Neurology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Nicolas Raposo
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Katia Garambois
- Stroke Unit, University Hospital of Grenoble, Grenoble, France
| | | | | | - Guillaume Franchineau
- Department of Intensive Care, Centre Hospitalier Intercommunal de Poissy Saint Germain en Laye, Poissy, France
| | - Serge Timsit
- Neurology and Stroke Unit, Centre Hospitalier Universitaire de Brest, CHU Brest, Brest, France
| | - David Bougon
- Department of Critical Care, Annecy Genevois Hospital, Annecy, France
| | - Marie-Cécile Dubois
- Department of Anesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France
| | - Audrey Tawa
- Department of Anesthesia and Intensive Care, University Hospital of Rennes, Rennes, France
| | | | | | - Fabrice Bonneville
- Department of Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Caroline Vayne
- Department of Hematology and Hemostasis, Tours University Hospital, Tours, France
| | - Annerose Mengel
- Department of Neurology and Stroke, Eberhard-Karls University, Tuebingen, Germany
| | - Dominik Michalski
- Department of Neurology, Leipzig University Hospital, Leipzig, Germany
| | - Johann Pelz
- Department of Neurology, Leipzig University Hospital, Leipzig, Germany
| | | | - Felix Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Judith Schouten
- Department of Neurology, Rijnstate Hospital Arnhem, Arnhem, The Netherlands
| | - Alina Buture
- Acute Stroke Service, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Murphy
- Acute Stroke Service, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Vincenzo Palma
- Department of Neuroradiology, Ospedale del Mare, Naples, Italy
| | - Alberto Negro
- Department of Neuroradiology, Ospedale del Mare, Naples, Italy
| | - Alexander Gutschalk
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Giovanni Frisullo
- Department of Neurology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carla Zanferrari
- Department of Neurology, Azienda Ospedaliera di Melegnano e della Martesana, Melegnano, Italy
| | - Francesco Grillo
- Stroke Unit, Department of Clinical and Experimental Medicine, University Hospital G. Martino, Messina, Italy
| | - Fabrizio Giammello
- Translational Molecular Medicine and Surgery, XXXV Cycle, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Mar Morin Martin
- Department of Neurology, Hospital Complex of Toledo, Toledo, Spain
| | - Alvaro Cervera
- Department of Neurology, Royal Darwin Hospital, Tiwi, Northern Territory, Australia
| | - Jim Burrow
- Department of Neurology, Royal Darwin Hospital, Tiwi, Northern Territory, Australia
| | - Carlos Garcia Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Beng Lim Alvin Chew
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Cristina Soriano
- Department of Neurology, Hospital General de Castellón, Castelló, Spain
| | | | - Marco Petruzzellis
- Department of Neurology, AOU Consorziale Policlinico di Bari, Bari, Italy
| | - Ahmed Elkady
- Department of Neurology, Saudi German Hospital, Jeddah, Saudi Arabia
| | - Miguel S Miranda
- Department of Neurology, Hospital de Cascais Dr José de Almeida, Cascais, Portugal
| | - João Fernandes
- Department of Neurology, Norra Älvsborgs Länssjukhus, Trollhattan, Sweden
| | | | - Elias Johansson
- Clinical Science, Neurosciences, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå, Sweden
| | | | - Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Simerpreet Bal
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Brian Buck
- Division of Neurology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Catherine Legault
- Department of Neurology and Neurosurgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dylan Blacquiere
- Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hans D Katzberg
- Department of Neuromuscular Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thalia S Field
- Division of Neurology, University of British Columbia, Vancouver Stroke Program, Vancouver, British Columbia, Canada
| | - Vanessa Dizonno
- Division of Neurology, University of British Columbia, Vancouver Stroke Program, Vancouver, British Columbia, Canada
| | | | - Christian Jacobi
- Department of Neurology, Nordwest Hospital, Frankfurt am Main, Germany
| | - Annemie Devroye
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Masoud Ghiasian
- Department of Neurology, Sina Hospital, Hamadan University of Medical Science, Hamadan, Iran
| | | | - Sophie Chatterton
- Department of Neurology, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Miriam Wronski
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Karl Ng
- Department of Neurology and Clinical Neurophysiology, Royal North Shore Hospital and The University of Sydney, Sydney, New South Wales, Australia
| | - Robert Kahnis
- Department of Neurology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Thomas Geeraerts
- Department of Anaesthesiology and Critical Care, University Toulouse 3-Paul-Sabatier, University Hospital of Toulouse, Hôpital Pierre-Paul Riquet, CHU Toulouse-Purpan, Toulouse, France
| | - Peggy Reiner
- Service de neurologie, hôpital Lariboisière Université Paris-7, AP-HP, Paris Cedex 10, France
| | - Charlotte Cordonnier
- University of Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - Saskia Middeldorp
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel Levi
- National Institute for Health Research University College London Hospitals (UCLH) Biomedical Research Centre, London, UK.,Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Eric C M van Gorp
- Department of Viroscience, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Justine Brodard
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Turgut Tatlisumak
- Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany
| | - José M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Poli
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany.,Department of Neurology & Stroke, Eberhard-Karls University, Tuebingen, Germany
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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11
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Krzywicka K, van de Munckhof A, Zimmermann J, Bode FJ, Frisullo G, Karapanayiotides T, Pötzsch B, Sánchez van Kammen M, Heldner MR, Arnold M, Kremer Hovinga JA, Ferro JM, Aguiar de Sousa D, Coutinho JM. Cerebral venous thrombosis due to vaccine-induced immune thrombotic thrombocytopenia after a second ChAdOx1 nCoV-19 dose. Blood 2022; 139:2720-2724. [PMID: 35263427 PMCID: PMC9047988 DOI: 10.1182/blood.2021015329] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/23/2022] [Indexed: 11/23/2022] Open
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT), a rare but life-threatening complication of adenoviral vaccination against COVID-19, has been reported almost entirely following the first dose. Krzywicka and colleagues report on 124 patients with VITT in a multinational registry diagnosed after dose 2; no specific events were observed after dose 1. These patients had early presentation, and two of the patients died.
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Affiliation(s)
- Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Felix J. Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | - Giovanni Frisullo
- Department of Neurology, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Theodoros Karapanayiotides
- Second Department of Neurology, School of Medicine and Faculty of Health Sciences, Aristotle University of Thessaloniki, American Hellenic Educational Progressive Association University Hospital, Thessaloniki, Greece
| | - Bernd Pötzsch
- Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn, Germany
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Johanna A. Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - José M. Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina
| | - Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte, Universidade de Lisboa, Lisbon, Portugal
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - for the Cerebral Venous Sinus Thrombosis With Thrombocytopenia Syndrome Study Group
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
- Department of Neurology, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
- Second Department of Neurology, School of Medicine and Faculty of Health Sciences, Aristotle University of Thessaloniki, American Hellenic Educational Progressive Association University Hospital, Thessaloniki, Greece
- Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn, Germany
- Department of Neurology
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte, Universidade de Lisboa, Lisbon, Portugal
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Krzywicka K, van de Munckhof A, Sanchez van Kammen M, Heldner MR, Jood K, Lindgren E, Tatlisumak T, Putaala J, Kremer Hovinga JA, Middeldorp S, Levi MM, Cordonnier C, Arnold M, Zwinderman AH, Ferro JM, Coutinho JM, Aguiar de Sousa D. Abstract 51: Age Stratified Risk Of Cerebral Venous Sinus Thrombosis After Sars-Cov-2 Vaccination. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Cerebral Venous Sinus Thrombosis (CVST) as a part of the thrombosis and thrombocytopenia syndrome is a rare adverse drug reaction of SARS-CoV-2 vaccination. The estimated background rate of CVST in adults is around 1 case per million per month, and CVST with thrombocytopenia accounts for 8% of all CVST. We assessed the age-stratified risk of CVST with and without thrombocytopenia after SARS-CoV-2 vaccination.
Methods:
We estimated the absolute risk of any CVST, CVST with thrombocytopenia, and CVST without thrombocytopenia, within 28 days of first dose SARS-CoV-2 vaccination, using data from the European Medicines Agency’s EudraVigilance database (until 13 June 2021). As a denominator, we used data on vaccine delivery from 31 European countries. For 22.8 million adults from 25 countries we estimated the absolute risk of CVST after the first dose of ChAdOx1 nCov-19 per age category.
Results:
The absolute risk of CVST within 28 days of first dose vaccination was 7.5 (95%CI 6.9-8.3), 0.7 (95%CI 0.2-2.4), 0.6 (95%CI 0.5-0.7) and 0.6 (95%CI 0.3-1.1) per million of first doses of ChAdOx1 nCov-19, Ad26.COV2.S, BNT162b2 and mRNA-1273, respectively. The absolute risk of CVST with thrombocytopenia within 28 days of first dose vaccination was 4.4 (95%CI 3.9-4.9), 0.7 (95%CI 0.2-2.4), 0.0 (95%CI 0.0-0.1) and 0.0 (95%CI 0.0-0.2) per million of first doses of ChAdOx1 nCov-19, Ad26.COV2.S, BNT162b2 and mRNA-1273, respectively. In recipients of ChAdOx1 nCov-19, the risk of CVST, both with and without thrombocytopenia, was the highest in the 18-24 years age group (7.3 per million, 95%CI 2.8-18.8 and 3.7, 95%CI 1.0-13.3, respectively). The risk of CVST with thrombocytopenia was the lowest in ChAdOx1 nCov-19 recipients ≥70 years (0.2, 95%CI 0.0-1.3). Age <60 compared to ≥60 was a predictor for CVST with thrombocytopenia (incidence rate ratio 5.79; 95%CI 2.98-11.24, p<0.001).
Discussion:
The risk of CVST with thrombocytopenia within 28 days of first dose vaccination with ChAdOx1 nCov-19 was higher in younger age groups. The risk of CVST with thrombocytopenia was slightly increased in patients receiving Ad26.COV2.S, comparing with the estimated background risk. The risk of CVST with thrombocytopenia was not increased in recipients of mRNA vaccines for SARS-CoV-2.
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Affiliation(s)
- Katarzyna Krzywicka
- Dept of Neurology, Amsterdam Univ Med Cntrs, Univ of Amsterdam, Amsterdam, Netherlands
| | - Anita van de Munckhof
- Dept of Neurology, Amsterdam Univ Med Cntrs, Univ of Amsterdam, Amsterdam, Netherlands
| | | | - Mirjam R Heldner
- Dept of Neurology, Inselspital, Bern Univ Hosp, Univ of Bern, Bern, Switzerland
| | - Katarina Jood
- Dept of Neurology, Sahlgrenska Univ Hosp, and Dept of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the Univ of Gothenburg, Gothenburg, Sweden
| | - Erik Lindgren
- Dept of Neurology, Sahlgrenska Univ Hosp, Sweden and Dept of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at Univ of Gothenburg, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Dept of Neurology, Sahlgrenska Univ Hosp, and Dept of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at Univ of Gothenburg, Gothenburg, Sweden
| | - Jukka Putaala
- Dept of Neurology, Helsinki Univ Hosp and Univ of Helsinki, Helsinki, Finland
| | | | - Saskia Middeldorp
- Dept of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud Univ Med Cntr, Nijmegen, Netherlands
| | - Marcel M Levi
- National Institute for Health Rsch Univ College London Hosps (UCLH) Biomedical Rsch Cntr, London, UK, Amsterdam, Netherlands
| | - Charlotte Cordonnier
- 8 Univ of Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, Lille, France
| | - Marcel Arnold
- , Inselspital, Bern Univ Hosp, Univ of Bern, Bern, Switzerland
| | - Aeilko H Zwinderman
- Dept of Clinical Epidemiology and Biostatistics, Academic Med Cntr, Univ of Amsterdam, Amsterdam, Netherlands
| | - Jose M Ferro
- Dept of Neurosciences and Mental Health, Neurology Service, Hosp de Santa Maria/CHULN, Univ of Lisbon, Lisboa, Portugal
| | - Jonathan M Coutinho
- Dept of Neurology, Amsterdam Univ Med Cntrs, Univ of Amsterdam, Amsterdam, Netherlands
| | - Diana Aguiar de Sousa
- Dept of Neurosciences and Mental Health, Neurology Service, Hosp de Santa Maria/CHULN, Univ of Lisbon, Lisbon, Portugal
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Krzywicka K, van de Munckhof A, Sánchez van Kammen M, Heldner MR, Jood K, Lindgren E, Tatlisumak T, Putaala J, Kremer Hovinga JA, Middeldorp S, Levi MM, Cordonnier C, Arnold M, Zwinderman AH, Ferro JM, Coutinho JM, Aguiar de Sousa D. Age-Stratified Risk of Cerebral Venous Sinus Thrombosis After SARS-CoV-2 Vaccination. Neurology 2021; 98:e759-e768. [PMID: 34921101 DOI: 10.1212/wnl.0000000000013148] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/23/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cerebral Venous Sinus Thrombosis (CVST) as a part of the thrombosis and thrombocytopenia syndrome is a rare adverse drug reaction of SARS-CoV-2 vaccination. Estimated background rate of CVST with thrombocytopenia is 0.1 per million per month. We assessed the age-stratified risk of CVST with and without thrombocytopenia after SARS-CoV-2 vaccination. METHODS We estimated the absolute risk of CVST with and without thrombocytopenia within 28 days of first dose of four SARS-CoV-2 vaccinations, using data from the European Medicines Agency's EudraVigilance database (until 13 June 2021). As a denominator, we used data on vaccine delivery from 31 European countries. For 22.8 million adults from 25 countries, we estimated the absolute risk of CVST after the first dose of ChAdOx1 nCov-19 per age category. RESULTS The absolute risk of CVST within 28 days of first dose vaccination was 7.5 (95%CI 6.9-8.3), 0.7 (95%CI 0.2-2.4), 0.6 (95%CI 0.5-0.7) and 0.6 (95%CI 0.3-1.1) per million of first doses of ChAdOx1 nCov-19, Ad26.COV2.S, BNT162b2 and mRNA-1273, respectively. The absolute risk of CVST with thrombocytopenia within 28 days of first dose vaccination was 4.4 (95%CI 3.9-4.9), 0.7 (95%CI 0.2-2.4), 0.0 (95%CI 0.0-0.1) and 0.0 (95%CI 0.0-0.2) per million of first doses of ChAdOx1 nCov-19, Ad26.COV2.S, BNT162b2 and mRNA-1273, respectively. In recipients of ChAdOx1 nCov-19, the absolute risk of CVST, both with and without thrombocytopenia, was the highest in the 18-24 years age group (7.3 per million, 95%CI 2.8-18.8 and 3.7 per million, 95%CI 1.0-13.3, respectively). The risk of CVST with thrombocytopenia in ChAdOx1 nCov-19 recipients was the lowest in the age group≥70 years (0.2, 95%CI 0.0-1.3). Age <60 compared to ≥60 was a predictor for CVST with thrombocytopenia (incidence rate ratio 5.79; 95%CI 2.98-11.24, p<0.001). DISCUSSION The risk of CVST with thrombocytopenia within 28 days of first dose vaccination with ChAdOx1 nCov-19 was higher in younger age groups. The risk of CVST with thrombocytopenia was slightly increased in patients receiving Ad26.COV2.S, compared with the estimated background risk. The risk of CVST with thrombocytopenia was not increased in recipients of SARS-CoV-2 mRNA vaccines.
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Affiliation(s)
- Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Johanna A Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Saskia Middeldorp
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marcel M Levi
- National Institute for Health Research University College London Hospitals (UCLH) Biomedical Research Centre, London, UK and Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charlotte Cordonnier
- University of Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam
| | - José M Ferro
- Department of Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/CHULN, University of Lisbon, Portugal
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/CHULN, University of Lisbon, Portugal
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14
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Sánchez van Kammen M, Aguiar de Sousa D, Poli S, Cordonnier C, Heldner MR, van de Munckhof A, Krzywicka K, van Haaps T, Ciccone A, Middeldorp S, Levi MM, Kremer Hovinga JA, Silvis S, Hiltunen S, Mansour M, Arauz A, Barboza MA, Field TS, Tsivgoulis G, Nagel S, Lindgren E, Tatlisumak T, Jood K, Putaala J, Ferro JM, Arnold M, Coutinho JM, Sharma AR, Elkady A, Negro A, Günther A, Gutschalk A, Schönenberger S, Buture A, Murphy S, Paiva Nunes A, Tiede A, Puthuppallil Philip A, Mengel A, Medina A, Hellström Vogel Å, Tawa A, Aujayeb A, Casolla B, Buck B, Zanferrari C, Garcia-Esperon C, Vayne C, Legault C, Pfrepper C, Tracol C, Soriano C, Guisado-Alonso D, Bougon D, Zimatore DS, Michalski D, Blacquiere D, Johansson E, Cuadrado-Godia E, De Maistre E, Carrera E, Vuillier F, Bonneville F, Giammello F, Bode FJ, Zimmerman J, d'Onofrio F, Grillo F, Cotton F, Caparros F, Puy L, Maier F, Gulli G, Frisullo G, Polkinghorne G, Franchineau G, Cangür H, Katzberg H, Sibon I, Baharoglu I, Brar J, Payen JF, Burrow J, Fernandes J, Schouten J, Althaus K, Garambois K, Derex L, Humbertjean L, Lebrato Hernandez L, Kellermair L, Morin Martin M, Petruzzellis M, Cotelli M, Dubois MC, Carvalho M, Wittstock M, Miranda M, Skjelland M, Bandettini di Poggio M, Scholz MJ, Raposo N, Kahnis R, Kruyt N, Huet O, Sharma P, Candelaresi P, Reiner P, Vieira R, Acampora R, Kern R, Leker R, Coutts S, Bal S, Sharma SS, Susen S, Cox T, Geeraerts T, Gattringer T, Bartsch T, Kleinig TJ, Dizonno V, Arslan Y. Characteristics and Outcomes of Patients With Cerebral Venous Sinus Thrombosis in SARS-CoV-2 Vaccine-Induced Immune Thrombotic Thrombocytopenia. JAMA Neurol 2021; 78:1314-1323. [PMID: 34581763 DOI: 10.1001/jamaneurol.2021.3619] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Thrombosis with thrombocytopenia syndrome (TTS) has been reported after vaccination with the SARS-CoV-2 vaccines ChAdOx1 nCov-19 (Oxford-AstraZeneca) and Ad26.COV2.S (Janssen/Johnson & Johnson). Objective To describe the clinical characteristics and outcome of patients with cerebral venous sinus thrombosis (CVST) after SARS-CoV-2 vaccination with and without TTS. Design, Setting, and Participants This cohort study used data from an international registry of consecutive patients with CVST within 28 days of SARS-CoV-2 vaccination included between March 29 and June 18, 2021, from 81 hospitals in 19 countries. For reference, data from patients with CVST between 2015 and 2018 were derived from an existing international registry. Clinical characteristics and mortality rate were described for adults with (1) CVST in the setting of SARS-CoV-2 vaccine-induced immune thrombotic thrombocytopenia, (2) CVST after SARS-CoV-2 vaccination not fulling criteria for TTS, and (3) CVST unrelated to SARS-CoV-2 vaccination. Exposures Patients were classified as having TTS if they had new-onset thrombocytopenia without recent exposure to heparin, in accordance with the Brighton Collaboration interim criteria. Main Outcomes and Measures Clinical characteristics and mortality rate. Results Of 116 patients with postvaccination CVST, 78 (67.2%) had TTS, of whom 76 had been vaccinated with ChAdOx1 nCov-19; 38 (32.8%) had no indication of TTS. The control group included 207 patients with CVST before the COVID-19 pandemic. A total of 63 of 78 (81%), 30 of 38 (79%), and 145 of 207 (70.0%) patients, respectively, were female, and the mean (SD) age was 45 (14), 55 (20), and 42 (16) years, respectively. Concomitant thromboembolism occurred in 25 of 70 patients (36%) in the TTS group, 2 of 35 (6%) in the no TTS group, and 10 of 206 (4.9%) in the control group, and in-hospital mortality rates were 47% (36 of 76; 95% CI, 37-58), 5% (2 of 37; 95% CI, 1-18), and 3.9% (8 of 207; 95% CI, 2.0-7.4), respectively. The mortality rate was 61% (14 of 23) among patients in the TTS group diagnosed before the condition garnered attention in the scientific community and 42% (22 of 53) among patients diagnosed later. Conclusions and Relevance In this cohort study of patients with CVST, a distinct clinical profile and high mortality rate was observed in patients meeting criteria for TTS after SARS-CoV-2 vaccination.
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Affiliation(s)
- Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte, University of Lisbon, Lisbon, Portugal
| | - Sven Poli
- Department of Neurology and Stroke, Eberhard-Karls University, Tuebingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Charlotte Cordonnier
- Department of Neurosciences and Cognition, Lille University Hospital, Lille, France
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Thijs van Haaps
- Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Alfonso Ciccone
- Department of Neurology, Carlo Poma Hospital, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marcel M Levi
- National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Johanna A Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Suzanne Silvis
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Sini Hiltunen
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Maryam Mansour
- Sina Hospital, Hamadan University of Medical Science, Hamadan, Iran
| | - Antonio Arauz
- National Institute of Neurology and Neurosurgery Manuel Velasco Suarez, Mexico City, Mexico
| | - Miguel A Barboza
- Neurosciences Department, Hospital Dr R.A. Calderón Guardia, San José, Costa Rica
| | - Thalia S Field
- Division of Neurology, University of British Columbia, Vancouver Stroke Program, Vancouver, British Columbia, Canada
| | - Georgios Tsivgoulis
- Second Department of Neurology in National, Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jose M Ferro
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte, University of Lisbon, Lisbon, Portugal
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Aarti R Sharma
- Imperial College London School of Medicine, Imperial College London, London, United Kingdom
| | - Ahmed Elkady
- Department of Neurology, Saudi German Hospital, Jeddah, Saudi Arabia
| | - Alberto Negro
- Department of Neuroradiology, Ospedale del Mare, Naples, Italy
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Alexander Gutschalk
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Alina Buture
- Acute Stroke Service, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Murphy
- Acute Stroke Service, Mater Misericordiae University Hospital, Dublin, Ireland.,UCD School of Medicine, University College Dublin, Dublin, Ireland.,School of Medicine, University of Medicine and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ana Paiva Nunes
- Department of Neurology, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Andreas Tiede
- Clinic for Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | - Annerose Mengel
- Department of Neurology and Stroke, University Hospital Tuebingen, Tuebingen, Germany
| | - Antonio Medina
- Department of Neurology, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | | | - Audrey Tawa
- Department of Anesthesia and Intensive Care, University Hospital of Rennes, Rennes, France
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, Cramlington, United Kingdom
| | - Barbara Casolla
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, Cramlington, United Kingdom.,Stroke Unit, Hôpital Pasteur 2, URRIS - UR2CA, Unité de Recherche Clinique Cote d'Azur, Cote d'Azur University, Nice, France
| | - Brian Buck
- Division of Neurology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Carla Zanferrari
- Department of Neurology, Azienda Ospedaliera di Melegnano e della Martesana, Melegnano, Italy
| | | | - Caroline Vayne
- Department of Hematology and Hemostasis, Tours University Hospital, Tours, France
| | - Catherine Legault
- Department of Neurology and Neurosurgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Christian Pfrepper
- Division of Hemostaseology, Leipzig University Hospital, Leipzig, Germany
| | | | - Cristina Soriano
- Department of Neurology, Hospital General de Castellón, Castelló, Spain
| | | | - David Bougon
- Department of Critical Care, Annecy Genevois Hospital, Annecy, France
| | | | - Dominik Michalski
- Department of Neurology, Leipzig University Hospital, Leipzig, Germany
| | - Dylan Blacquiere
- Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Elias Johansson
- Department Clinical Science, Wallenberg Center for Molecular Medicine, Umeå University, Umeå, Sweden
| | | | | | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Fabrice Bonneville
- Department of Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Fabrizio Giammello
- Translational Molecular Medicine and Surgery, XXXV Cycle, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | - Julian Zimmerman
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Francesco Grillo
- Stroke Unit, Department of Clinical and Experimental Medicine, University Hospital G. Martino, Messina, Italy
| | - Francois Cotton
- Department of Radiology, Lyon University Hospital, Lyon, France
| | - François Caparros
- Department of Neurosciences and Cognition, Lille University Hospital, Lille, France
| | - Laurent Puy
- Department of Neurosciences and Cognition, Lille University Hospital, Lille, France
| | - Frank Maier
- Department of Neurology, Caritas Hospital Saarbrücken, Saarbrücken, Germany
| | - Giosue Gulli
- Department of Medicine, Ashford and St Peters Hospital NHS Foundation Trust, Surrey, United Kingdom
| | - Giovanni Frisullo
- Department of Neurology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Guillaume Franchineau
- Department of Intensive Care, Centre Hospitalier Intercommunal de Poissy Saint Germain en Laye, Poissy, France
| | - Hakan Cangür
- Department of Neurology, Hospital of the City of Wolfsburg, Wolfsburg, Germany
| | - Hans Katzberg
- Department of Neuromuscular Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Igor Sibon
- Department of Neurology, Bordeaux University Hospital, Bordeaux, France
| | - Irem Baharoglu
- Department of Neurology, Haga Hospital, The Hague, the Netherlands
| | - Jaskiran Brar
- Department of Neurology, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | | | - Jim Burrow
- Department of Neurology, Royal Darwin Hospital, Tiwi, Australia
| | - João Fernandes
- Department of Neurology, Norra Älvsborgs Länssjukhus, Trollhattan, Sweden
| | - Judith Schouten
- Department of Neurology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
| | | | - Katia Garambois
- Stroke Unit, University Hospital of Grenoble, Grenoble, France
| | - Laurent Derex
- Department of Neurology, Hospices Civils de Lyon, Lyon, France
| | | | | | - Lukas Kellermair
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Mar Morin Martin
- Department of Neurology, Hospital Complex of Toledo, Toledo, Spain
| | - Marco Petruzzellis
- Department of Neurology, AOU Consorziale Policlinico di Bari, Bari, Italy
| | - Maria Cotelli
- Department of Neurology, ASL Vallecamonica-Sebino, Breno, Italy
| | - Marie-Cécile Dubois
- Department of Anesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France
| | - Marta Carvalho
- Department of Neurology, Centro Hospitalar Universitário de São João, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - Miguel Miranda
- Department of Neurology, Hospital de Cascais Dr José de Almeida, Cascais, Portugal
| | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | | | - Moritz J Scholz
- Department of Neurology, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Nicolas Raposo
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Robert Kahnis
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Nyika Kruyt
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Olivier Huet
- UFR de Bio-médecine, Hospital de la Cavale Blanche, CHRU de Brest, Brest, France
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway University of London, London, United Kingdom
| | - Paolo Candelaresi
- Department of Neurology and Stroke, Cardarelli Hospital, Naples, Italy
| | - Peggy Reiner
- Department of Neurology, Lariboisière Hospital, Paris, France
| | - Ricardo Vieira
- Department of Hematology, Universidade Federal do Cariri, Juazeiro do Norte, Brazil
| | | | - Rolf Kern
- Department of Neurology, Kempten Hospital, Kempten, Germany
| | - Ronen Leker
- Department of Neurology, Hadassah University Medical Center, Jerusalem, Israel
| | - Shelagh Coutts
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Simerpreet Bal
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Shyam S Sharma
- Edinburgh Medical School, University of Edinburgh, Edinburgh, United Kingdom
| | - Sophie Susen
- Department of Hematology and Transfusion, Lille University Hospital, Lille, France
| | - Thomas Cox
- Department of Neurology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Thomas Geeraerts
- Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France
| | | | - Thorsten Bartsch
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Vanessa Dizonno
- Division of Neurology, University of British Columbia, Vancouver Stroke Program, Vancouver, British Columbia, Canada
| | - Yildiz Arslan
- Neurology Clinic, Medicana İzmir International Hospital, Izmir, Turkey
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15
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van de Munckhof A, Krzywicka K, Aguiar de Sousa D, Sánchez van Kammen M, Heldner MR, Jood K, Lindgren E, Tatlisumak T, Putaala J, Kremer Hovinga JA, Middeldorp S, Levi M, Arnold M, Ferro JM, Coutinho JM. Declining mortality of cerebral venous sinus thrombosis with thrombocytopenia after SARS-CoV-2 vaccination. Eur J Neurol 2021; 29:339-344. [PMID: 34536256 PMCID: PMC8652752 DOI: 10.1111/ene.15113] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/06/2021] [Accepted: 09/09/2021] [Indexed: 01/29/2023]
Abstract
Background and purpose High mortality rates have been reported in patients with cerebral venous sinus thrombosis (CVST) due to vaccine‐induced immune thrombotic thrombocytopenia (VITT) after vaccination with adenoviral vector SARS‐CoV‐2 vaccines. The aim of this study was to evaluate whether the mortality of patients with CVST‐VITT has decreased over time. Methods The EudraVigilance database of the European Medicines Agency was used to identify cases of CVST with concomitant thrombocytopenia occurring within 28 days of SARS‐CoV‐2 vaccination. Vaccines were grouped based on vaccine type (adenoviral or mRNA). Cases with CVST onset until 28 March were compared to cases after 28 March 2021, which was the day when the first scientific paper on VITT was published. Results In total, 270 cases of CVST with thrombocytopenia were identified, of which 266 (99%) occurred after adenoviral vector SARS‐CoV‐2 vaccination (ChAdOx1 nCoV‐19, n = 243; Ad26.COV2.S, n = 23). The reported mortality amongst adenoviral cases with onset up to 28 March 2021 was 47/99 (47%, 95% confidence interval 37%–58%) compared to 36/167 (22%, 95% confidence interval 16%–29%) in cases with onset after 28 March (p < 0.001). None of the four cases of CVST with thrombocytopenia occurring after mRNA vaccination died. Conclusion The reported mortality of CVST with thrombocytopenia after vaccination with adenoviral vector‐based SARS‐CoV‐2 vaccines has significantly decreased over time, which may indicate a beneficial effect of earlier recognition and/or improved treatment on outcome after VITT.
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Affiliation(s)
- Anita van de Munckhof
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/CHULN, University of Lisbon, Lisbon, Portugal
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Johanna A Kremer Hovinga
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel Levi
- Biomedical Research Centre, National Institute for Health Research, University College London Hospitals (UCLH), London, UK.,Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - José M Ferro
- Department of Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/CHULN, University of Lisbon, Lisbon, Portugal
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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