Sinus and cerebral vein thromboses after SARS-CoV-2 vaccination can be prevented
by Dr. Bettina Albers
(21.09.2021) A pioneering work by Charité University Medicine, University Medicine Greifswald and the IGNITE network recently appeared in “The New England Journal of Medicine”. It reports a case series in which those affected presented themselves with severe headaches after vaccination with the AstraZeneca vaccine and met all laboratory criteria for vaccine-induced thrombotic thrombopenia (VITT), but without the dreaded cerebral or sinus vein thrombosis. With early, consistent treatment, thrombotic events could be prevented in the majority of cases.
In March 2021, several cases of sinus vein thrombosis after vaccination with the AstraZeneca active ingredient were reported to the Paul Ehrlich Institute (PEI), whereupon the vaccination campaign with the vaccine was briefly interrupted in Germany. At the end of March, the RKI then issued the recommendation to only use the AstraZeneca vaccine for people aged 60 and over, as this side effect predominantly occurred in younger people. Although the frequency of this vaccination complication was very rare, some people lost their lives, which certainly contributed to uncertainty and general vaccination skepticism.
The underlying cause of this vaccination complication was quickly discovered. Already at the beginning of April  described Prof. Dr. Andreas Greinacher, Head of the Transfusion Medicine Department at the Institute for Immunology and Transfusion Medicine at the University Medical Center Greifswald, and colleagues describe a mechanism that is reminiscent of heparin-induced thrombocytopenia with antibody formation against platelet factor 4 (PF4), but is not identical to this because it was at In the reported cases, after vaccination with vector vaccines, PF4 antibodies were formed without prior exposure to heparin. Accordingly, the clinical picture was referred to as vaccine-induced immunogenic thrombotic thrombocytopenia (VITT). The laboratory tests for diagnosis primarily include the determination of the platelet count, additional coagulation tests with INR, PTT, fibrinogen and D-dimers, and the targeted search for antibodies against platelet factor 4 (PF4) using ELISA (no other HIT search test!), With one Confirmatory platelet activation test.
“Most of those affected presented with severe headaches, which we thought at the time were a consequence of or an accompanying symptom of the cerebral thrombotic events,” explains Prof. Greinacher, corresponding author of the current study.
The current work shows that the severe headache can also be a harbinger and therefore a warning sign of dangerous post-vaccinal thrombosis. The Charité University Medical Center, the University Medical Center Greifswald and other IGNITE centers (Mannheim, Leipzig, Augsburg, Erlangen) describe a case series of eleven patients who, five to 18 days after being vaccinated with the AstraZeneca vaccine, suffered severe headaches combined with thrombocytopenia presented. All also had high D-dimers and high anti-PF4 antibody levels. In no case could a cerebral sinus and venous thrombosis (CSVT) be diagnosed at the first presentation. Only two had a different thrombotic event at the time of admission and fully met the VITT criteria (both were diagnosed with pulmonary embolism). “Overall, it can be stated that there is obviously a pre-VITT syndrome, a VITT without thrombotic manifestations – in which the severe headache is therefore not an accompanying symptom, but a warning symptom for the later development of a VITT, which provides room for maneuver for early, therapeutic interventions “, explains first author Dr. Farid Salih from the Clinic for Neurology at the Charité University Medicine Berlin.
With one exception, all patients who did not develop any thrombosis during the course of the headache had received a VITT-specific therapy with therapeutic anticoagulation, high-dose immunoglobulins or corticosteroids within five days of the onset of the headache. The four remaining patients developed thromboses and thus the full picture of a VITT; three sufferers had intracranial bleeding, two of them CSVT. It was noticeable that these four patients received treatment with a delay – a finding with great relevance for everyday clinical practice. Professor Matthias Endres, Director of the Clinic for Neurology with Experimental Neurology and last author of the current study, derives the following recommendation for action: “If patients present with severe headaches in the typical latency period of five to 30 days after vaccination, further diagnostics should definitely be carried out. If they show thrombocytopenia and increased D-dimers, specific anti-PF4 / heparin IgG antibodies must be tested and treated promptly and consistently. Then we may be able to completely prevent severe thrombotic events as a result. “
As Prof. Julian Bösel, Kassel, President of the German Society for Neuro-Intensive and Emergency Medicine eV (DGNI) explains, this finding is of considerable medical importance and could significantly reduce the rate of dreaded vaccination complications. Prof. Peter Berlit, DGN General Secretary, also emphasizes the safety aspect: “We are constantly learning new things in dealing with vaccines. If we can prevent serious vaccine damage in this way, it should also help to get more people to vaccinate. The benefits are obvious; the risks, which are very rare anyway, can be better managed through rapid diagnosis and therapy. “
About the DGN
The German Society for Neurology eV (DGN), as a scientific specialist society, has a social responsibility to secure and improve neurological health care in Germany with its more than 10,000 members. To this end, the DGN promotes science and research as well as teaching, advanced and advanced training in neurology. She participates in the health policy discussion. The DGN was founded in Dresden in 1907. The office is based in Berlin. www.dgn.org
DOI: 10.1056 / NEJMc2112974.