Introduction
Cerebral venous sinus thrombosis (CVST) is a rare form of stroke generally occurring in younger patients (typically < 50 years old), predominantly women and amounting to 0.5–1% of all strokes. Incidence is about 5–16 cases per 1 million people per year [1,2,3]. CVST has been reported in COVID-19 patients associated with thrombocytopenia [4, 5]; on March 15, 2021, the Paul Ehrlich Institut (Federal Institute for vaccines and biomedicines) reported CVST in seven patients 20–50 years old after vaccination with COVID-19 vaccine AstraZeneca. We report about a previously healthy 50-year-old Caucasian man admitted to the city hospital of Mantua on March 15, 2021, with severe headache during the previous four days, slight deviation of the right buccal rim, loss of strength in the right lower limb, unstable walking and slight visual impairment. On March 4, 2021, he had received the first dose of the anti-COVID-19 AstraZeneca vaccine with no immediate adverse reaction. On examination, he was apyretic, arterial pressure 150/80 mmHg and heart rate 80/min, SpO2 99% in room air, GCS 15, pain numerical rating scale 8/10. Laboratory blood tests showed marked abnormalities in blood coagulation (Table 1). The patient was a volunteer blood donor, and previous routine blood tests had repeatedly reported normal platelet counts. SARS-CoV-2 Buffer (RT-PCR) and Anti-SARS-CoV-2 Antibody Search were negative. A brain CT scan showed intra-parenchymal haemorrhage in the left hemisphere, while CT angiography showed multiple bleeding spots within the parenchymal haemorrhage and lack of opacification of the left transverse and sigmoid sinuses, suggesting thrombosis of the venous sinuses (Fig. 1). Four hours after admission, the patient had deteriorated to GCS 8, right hemiplegia, localization of the painful stimulus to the left, no execution of orders nor verbal production. He showed isochoric, isocyclic pupils and vomiting. The patient was transferred to the intensive care unit (ICU), and a thromboelastogram (TEG6S, Haemonetics) showed a prolonged reaction time, a decreased platelet function and lack of fibrinogen, with marked reduction of maximum amplitude of the clot; fibrinogen concentrate (10 g total) and platelet (4 units total) were administered.
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