Cerebral Venous Sinus Thrombosis With Thrombocytopenia After J&J Vaccine

Quick Takes

  • Cerebral venous sinus thrombosis and thrombocytopenia can occur after receipt of the Johnson & Johnson COVID-19 vaccine.
  • The mechanism for this new syndrome appears to be similar to autoimmune heparin-induced thrombocytopenia.
  • Diagnosis of this syndrome includes identifying an acute thrombosis AND thrombocytopenia followed by HIT ELISA testing.

Study Questions:

How did patients present with cerebral venous sinus thrombosis (CVST) and thrombocytopenia following receipt of the Ad26.COV2.S coronavirus disease 2019 (COVID-19) vaccine (Janssen/Johnson & Johnson [J&J])?

Methods:

The authors present a case series of 12 patients with CVST and thrombocytopenia following receipt of the Ad26.COV2.S vaccine who were reported to the Vaccine Adverse Event Reporting System (VAERS) between March 2 and April 21, 2021.

Results:

Patients ranged in age from 18 to <60 years of age and all were White women. Seven patients had at least one risk factor for CVST, including obesity (n = 6), hypothyroidism (n = 1), and oral contraceptive use (n = 1). None had prior heparin exposure. Time from Ad26.COV2.S vaccine until symptom onset ranged from 6-15 days. Of the 12 patients, seven also presented with intracerebral hemorrhage and eight had non-CVST thromboses. Platelet nadir ranged from 9-127 x 103/┬Ál. All 11 patients who underwent testing for heparin-platelet factor 4 antibody using an enzyme-linked immunosorbent assay (ELISA) were positive. Only one of nine patients who underwent serotonin release assay (SRA) testing was positive. Death occurred in three patients.

Conclusions:

The authors concluded that the initial 12 cases in the United States of CVST and thrombocytopenia following Ad26.COV2.S vaccine represent serious events.

Perspective:

A newly emerging condition called vaccine-induced thrombotic thrombocytopenia (VITT) or the thrombosis and thrombocytopenia syndrome (TTS) was first described in European patients after receipt of the AstraZeneca vaccine. This manuscript details 12 patients with the same syndrome after receipt of the J&J COVID-19 vaccine. The Centers for Disease Control and Prevention and Food and Drug Administration announced a pause on the J&J vaccine on April 13, 2021, and then resumed its use on April 23, 2021. The key hallmarks of this disease, which is similar to heparin-induced thrombocytopenia (HIT), is the combination of thrombosis (most commonly CVST) and thrombocytopenia with a positive HIT ELISA test despite no prior heparin exposure. The window of risk is relatively narrow, occurring 4-28 days following receipt of the J&J COVID-19 vaccine. This has not been seen following the Pfizer or Moderna mRNA COVID-19 vaccines. Overall, event rates are exceedingly rare (estimated 1-2/million). Rapid diagnosis and management with nonheparin anticoagulants under the direction of a hematologist or vascular/thrombosis specialist is recommended.

Clinical Topics: Anticoagulation Management, Prevention, Vascular Medicine, Statins

Keywords: ACC COVID-19 Podcast, Anticoagulants, Blood Platelets, Cerebral Hemorrhage, Contraceptives, Oral, COVID-19, Coronavirus, Enzyme-Linked Immunosorbent Assay, Heparin, Hypothyroidism, Leukopenia, Obesity, Platelet Factor 4, Primary Prevention, Risk Factors, Serotonin, Sinus Thrombosis, Intracranial, Thrombocytopenia, Thrombosis, Vaccination, Vascular Diseases


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