Neurosurgical Considerations Regarding Decompressive Craniectomy for Intracerebral Hemorrhage after SARS-CoV-2-Vaccination in Vaccine Induced Thrombotic Thrombocytopenia—VITT

Abstract

Given the ongoing global SARS-CoV-2-vaccination efforts, clinical awareness needs to be raised regarding the possibility of an increased incidence of SARS-CoV-2-vaccine-related immune-mediated thrombocytopenia in patients with intracerebral hemorrhage (ICH) secondary to cerebral sinus and vein thrombosis (CVT) requiring (emergency) neurosurgical treatment in the context of vaccine-induced immune thrombotic thrombocytopenia (VITT). Only recently, an association of vaccinations and cerebral sinus and vein thrombosis has been described. In a number of cases, neurosurgical treatment is warranted for these patients and special considerations are warranted when addressing the perioperative coagulation. We, herein, describe the past management of patients with VITT and established a literature-guided algorithm for the treatment of patients when addressing the impaired coagulation in these patients. Increasing insights addressing the pathophysiology of SARS-CoV-2-vaccine-related immune-mediated thrombocytopenia guide physicians in developing an interdisciplinary algorithm taking into account the special considerations of this disease.

Endovascular treatment for vaccine-induced cerebral venous sinus thrombosis and thrombocytopenia following ChAdOx1 nCoV-19 vaccination: a report of three cases

“…[2][3][4][5][6] Cerebral venous sinus thrombosis (CVST) is overrepresented in VITT 7 with poor outcomes despite best medical and surgical management 5 including death described following decompressive craniectomy. 8 Endovascular treatment (EVT) as established in conventional CVST 9 has a role, but its utility in VITT has hitherto not been reviewed.…”

Symptomatic peduncular, cavernous bleeding following SARS-CoV-2 vaccination induced immune thrombocytopenia

“…The presented patient is interesting for bleeding of a cavernoma presumably triggered by a SARS-CoV-2 vaccination induced ITP and thrombocyte dysfunction. Bleeding has been repeatedly reported as a complication of SARS-CoV-2 vaccinations 3 . The EudraVigilance European database listed 33 respectively 151 serious adverse events (SAE) with regard to ITP bleeding per one million doses in the BNT162b2 vaccine 4 .…”

Cerebral Coagulation Complications Following COVID-19 Adenoviral Vector Vaccines: A Systematic Review

“…Mainly seen in women of childbearing age, CVST is often difficult to diagnose due to heterogeneous and non-specific neurological manifestations such as headache, seizure, altered consciousness, and focal neurological signs [ 56 , 57 ]. Most CVST patients (73-82.6%) have relevant risk factors [ 56 ] including thrombophilia, oral contraceptives, fasting, malignancy, infection, trauma, pregnancy, puerperium [ 58 - 61 ], lumbar puncture, neurosurgical procedures, tumor compression, and endocrine disturbances [ 31 , 62 ].…”

“…Moreover, in CVST patients with an impending herniation neurosurgical intervention may be necessary with decompressive craniotomy [ 31 ]. Platelet transfusion should be avoided in CVST patients associated with VITT who are also positive for anti-PF4 antibody due to the risk of further antibody-mediated platelet activation and coagulopathy, but should be considered before any intervention [ 31 ].…”