Since the introduction of both the vector-based and the messenger ribonucleic acid (mRNA)-based SARS-CoV-2 vaccines, adverse reactions have been occasionally reported, either in the medical literature or in public media.[1,2] One of these side effects is venous or arterial thrombosis due to suspected hypercoagulability. Ischaemic stroke shortly after vaccination with a vector-based SARS-CoV-2 vaccine has been only rarely reported.
The patient is a 29-year-old, smoking, human immunodeficiency virus (HIV)-negative female, who was hospitalised at a primary care unit for acute onset vertigo and dysarthria a few hours after sexual intercourse. Cerebral imaging was not performed. She was discharged after improvement of symptoms within 1 day of observation. Vertigo completely resolved within the next 2 days. An outpatient neurologist recommended a cerebral magentic resonance imagign (MRI) which, 11 days after onset, showed a right cerebellar, subacute ischaemic lesion [Figure 1]. She did not carry any classical cardiovascular risk factors except for smoking but 4 days prior to the cerebrovascular event, she had undergone a first vaccination with a vector-based SARS-CoV-2 vaccine. Workup for other possible causes of cerebellar stroke revealed a positive bubble test, suggesting a patient foramen ovale (PFO), which was confirmed transesophageal echocardiography. The previous history was only positive for sepsis at 3 years of age. Clinical neurologic exam only revealed discrete ataxia on the left lower leg. Blood tests were non-informative. Serum interleukin-6 was 3.2 pg/mL (n, 0–7 pg/mL). The APC resistance was mildly increased. There was no indication for deep venous thrombosis. Cerebral MRI 19 days after the stroke confirmed the previously detected ischaemic lesion in the right cerebellar hemisphere with a tendency of regression in size. Time-of-flight-angiography did not show occlusion, stenosis, or atherosclerosis of intracerebral arteries. The patient was discharged symptom-free after 6 days with the recommendation to regularly take acetylsalicylic acid. She is currently scheduled for PFO closure with a device.
The presented patient is interesting for juvenile, ischaemic stroke 4 days after vaccination with a vector-based SARS-CoV-2 vaccine in the presence of a PFO. An argument against a Valsalva manoeuvre during sexual intercourse and transmigration of thrombi from the right to the left cardiac chambers is that the patient previously had sexual intercourse several times without ever experiencing a cerebrovascular event. A further argument against paradoxical embolism is the absence of a deep venous thrombosis. Considering that a PFO was truly present, it is nonetheless conceivable that subclinical deep venous thrombosis had occurred and that these thrombi were asymptomatic in the leg but passed to the left atrium and resulted in the cerebellar stroke. An argument in favour of the PFO hypothesis is that venous thrombosis has been previously reported as a complication of vaccination with vector-based SARS-CoV-2 vaccines. However, since there were no indications for deep venous thrombosis, paradoxical embolism was regarded as rather unlikely. Putative neurological side effects of SARS-CoV-2 vaccines so far reported include transverse myelitis, facial palsy, dizziness, headache, pain, muscle spasms, myalgia, and paresthesias. More rarely reported were tremor, diplopia, tinnitus, dysphonia, seizures, and occasionally stroke, Guillain-Barré syndrome, and acute disseminated encephalomyelitis (ADEM). However, establishing any causal link between vaccination and any of these neurologic abnormalities is challenging.
In conclusion, this case shows that juvenile, ischaemic stroke may occur shortly after vaccination with a vector-based SARS-CoV-2 vaccine in a patient with the risk factors smoking and PFO. Whether stroke and vaccination were causally related or not remains speculative.
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Informed consent was obtained.
Ethics committee approval
The study was approved by the institutional review board.
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Conflicts of interest
There are no conflicts of interest.
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