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Table 1 Characteristics and clinical course of two cases of cerebral venous sinus thrombosis post vaccination with ChAdOx1 nCoV-19 presenting at our University hospital and evolving to brain death

From: Cerebral venous sinus thrombosis (CVST) associated with SARS-CoV-2 vaccines: clues for an immunopathogenesis common to CVST observed in COVID-19

 

Patient 1

Patient 2

Age and sex

55-years-old woman

45-year-old man

Preexisting conditions and screening for thrombophilia

No preexisting conditions.

MTHFR A1298C homozygous mutation

Body mass index of 30

Screening negative

Symptoms and timing since vaccine administration

Low-grade fever and headache developed one week after vaccination

History of headaches 23 days after vaccination

Admission clinical picture, platelet count, and D-dimer (reference value 0–0.5ug/ml)

Alert and cooperative, headache

Platelet count: 31,000 per cubic millimeter

D-dimer > 4ug/ml

Acute focal neurologic motor deficit and altered level of consciousness

Platelet count: 125,000 per cubic millimeter

D-dimer > 4ug/ml

Sites of thrombosis during clinical course

Pulmonary subsegmental arteries thrombosis

Thrombosis of the right internal jugular vein, absent signal void at straight sinus and at right transverse sinus (Fig. 1A–D)

Portal vein branch thrombosis and partial thrombosis of inferior cava vein. Extension of thrombosis at mesenteric superior vein, main branches of portal vein, and sovraepatic branches

Massive thrombosis of the right transverse-sigmoid and of superior sagittal sinuses associated with a right intracerebral hemorrhagic infarction and midline shift (Fig. 1E–H)

No signs of thrombosis were found in any other distric.

Therapy and interventions

Methylprednisolone, fondaparinux, intravenous immunoglobulins

Dexamethasone, fondaparinux, intravenous immunoglobulins

Antibodies to platelet factor 4, reference value < 0.400 OD

1.126 OD

2.37 OD

Evolution

Neurological deteriorations on day 2, pupils became anisocoric, Glasgow Coma Scale was 3

Cerebellar hemorrhage and diffuse cerebral edema with transtentorial herniation

Emergency posterior decompressive craniectomy, intracranial pressure monitoring, external ventricular drainage. Refractory intracranial hypertension

Death by neurologic criteria was declared on day 8

Pupils were dilated and fixed and Glasgow Coma Scale was 3. Neurosurgical consult excluded further intervention for futility due to poor grade prognosis

Central venous oxygen saturation was 92%, without clinical signs of sepsis

Death by neurologic criteria was declared on day 3

Organ donation and transplanted organs

Organ donation per previously expressed wish to donate

Kidneys and corneas transplanted

Organ donation per previously expressed wish to donate

Lungs, liver, kidneys. and corneas transplanted

Outcome in organ recipients

Good at 6 months

Good at 6 months