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

BACKGROUND

Cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) is an adverse drug reaction occurring after SARS-CoV-2 vaccination. CVST-VITT patients often present with large intracerebral hemorrhages and a high proportion undergoes decompressive surgery. We describe clinical characteristics, therapeutic management and outcomes of CVST-VITT patients who underwent decompressive surgery, and explore predictors of in-hospital mortality in these patients.

METHODS

We used 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. We included definite, probable and possible VITT cases, as defined by Pavord et al. 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 among 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 bilateral reactive pupils; p=0.023). Postoperative imaging revealed worsening of index hemorrhagic lesion in 19 (70%) patients and new hemorrhagic lesions in 16 (59%) patients. At 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.