Malignant middle cerebral artery syndrome with thrombotic thrombocytopenia following vaccination against SARS-CoV-2

Carmen Jacob; Khairil Amir Rani; Patrick James Holton; Sara Rosalind Boyce; Nicolas Ulrick Weir; Colin Roderick Griffith; Colin Andrew Eynon

doi:10.1177/17511437211027496

Malignant middle cerebral artery syndrome with thrombotic thrombocytopenia following vaccination against SARS-CoV-2

J Intensive Care Soc. 2022 Nov;23(4):479-484. doi: 10.1177/17511437211027496. Epub 2021 Jun 24.

Authors

Carmen Jacob^{1

2}, Khairil Amir Rani³, Patrick James Holton⁴, Sara Rosalind Boyce⁵, Nicolas Ulrick Weir³, Colin Roderick Griffith⁴, Colin Andrew Eynon^{1

6}

Affiliations

¹ Neurosciences ICU, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
² Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
³ Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
⁴ Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
⁵ Department of Haematology, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
⁶ Faculty of Medicine, University of Southampton, Southampton, UK.

Abstract

Cases of thromboses at unusual sites with thrombocytopenia have been reported following vaccination against Sars-CoV-2. This new syndrome, christened vaccine-induced thrombotic thrombocytopenia (VITT), mainly results in venous thromboses. We report the case of a young woman with a right middle cerebral artery stroke following vaccination with ChAdOx1 nCoV-19. A diagnosis of VITT was made and platelet counts began to recover shortly after commencing treatment with argatroban, intravenous immunoglobulins and corticosteroids. On day 6 following admission, the patient deteriorated neurologically and decision made to proceed with decompressive hemicraniectomy. There were no perioperative complications and anticoagulation with argatroban was reinitiated on the first postoperative day. VITT is a rare condition resembling auto-immune heparin-induced thrombocytopenia. All critical care staff should be aware of the rare link between vaccination against SARS-CoV-2 and VITT and the need to rapidly commence both anticoagulation, using heparin alternatives, and immunomodulation.

Keywords: Vaccine-induced immune thrombotic thrombocytopenia; decompressive hemicraniectomy; malignant MCA syndrome; vaccination against SARS-CoV-2.