Decompressive surgery in cerebral venous sinus thrombosis due to vaccine‐induced immune thrombotic thrombocytopenia

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.

COVID and Vaccine-related Cerebral Venous Thrombosis

“…84 The VITT-associated COVID vaccine-CVT cohort was also reported to have a higher mortality and higher mRS scores at discharge, with 47% having mRS between 3 and 6 at discharge. 77, 85 VITT-associated COVID vaccine-CVT patients who survived the inpatient hospital stay usually showed better recovery three to six months after decompressive craniectomy. 84 Similarly, endovascular treatment for VITT-associated CVT of three patients has shown good recovery at three to six months.…”

“…Among the patients who survived, 80% were functionally independent at six months follow-up. 85 Therefore surgical management is the preferred early emergency approach in VITT-associated COVID vaccine-CVT patients with impending brain herniation. 87…”

Advances in Cerebral Venous Thrombosis

“…22,23 Even in the unique context of CVT associated with vaccine-induced thrombosis and thrombocytopenia syndrome, where nearly two-thirds of those undergoing surgery did not survive hospitalization, the procedure has often led to functional independence for the survivors. 24…”

Endovascular treatment of cerebral sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia

“…9 Nevertheless, mortality rates in CVST-VITT patients remain high. 10,11 While the current literature suggests that EVT in CVST-VITT patients may be a safe and effective treatment option, the available evidence is anecdotal. [12][13][14][15][16] According to the literature, up to one-fifth of CVST-VITT patients undergo EVT.…”

“…3,17 We hypothesize that because CVST-VITT is a distinct clinical entity with a significantly higher mortality and morbidity, the potential benefit of EVT might be more pronounced in this disease compared to non-VITT CVST. 2,3,11,18 In this study, we aim to provide a descriptive analysis of clinical, laboratory, and imaging characteristics and outcomes of patients with CVST-VITT treated with EVT.…”