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JNNP:ChAdOx1-nCoV-19疫苗诱导的以缺血性中风为表现的免疫性血栓性血小板减少症

2021-06-18 MedSci原创 MedSci原创

编码SARS-CoV-2.1-4棘突糖蛋白的ChAdOx1 nCoV-19(牛津-阿斯利康)重组腺病毒载体疫苗之后,最近报道了一种疫苗诱导的免疫性血栓性血小板减少症(VITT)综合征。先前描述的患者发

编码SARS-CoV-2.1-4棘突糖蛋白的ChAdOx1 nCoV-19(牛津-阿斯利康)重组腺病毒载体疫苗之后,最近报道了一种疫苗诱导的免疫血栓性血小板减少症(VITT)综合征。先前描述的患者发生血栓,主要影响脑静脉窦等,但VITT伴动脉血栓形成的特征尚未被描述。在此,本文报告三位以缺血性中风为表现的VITT患者。

患者1,35岁亚洲女性,在接受ChAdOx1-nCoV-19疫苗后数天,伴有发作性右颞部和眶周头痛 。五天后,她醒来时左脸、胳膊和腿无力、昏昏欲睡。非对比CT和CT血管造影(CTA)显示右侧大脑中动脉(MCA)远端M1段闭塞,伴有广泛缺血和出血性转化。随后的影像显示右门静脉血栓形成。血小板计数是64 x 109/L(参考范围150 –400 x 109/升);D-二聚体在11岁时升高 220 µg/L(参考范围0-550);抗PF4抗体HPIA-IgG检测阳性率为76.1%。患者接受了紧急半开颅减压术。静脉注射免疫球蛋白和血浆置换后血小板计数增加。她接受中剂量磺达肝癸钠抗凝治疗。14天后,她的意识水平突然下降;CT头颅显示左侧大脑中动脉梗死广泛出血性改变,伴有肿块效应,经去骨瓣减压术后出现脑疝。脑干死亡随后被证实。

Figure 1

患者磁共振显影

患者2是一名37岁的白人女性,在接种ChAdOx1 nCoV-19疫苗12天后出现弥漫性头痛、左视野丧失、意识混乱和左臂无力。CTA显示双侧颈内动脉闭塞和左横窦血栓形成;磁共振弥散加权成像显示双侧急性脑梗死呈交界性分布。随后的影像学检查证实左横窦和乙状窦、左颈静脉、右肝静脉和双髂静脉有肺栓塞和血栓形成。血小板计数为9×109/L;D-二聚体在34 000 µ克/升;抗PF4抗体检测阳性率为99.7%。静脉注射免疫球蛋白、两次甲基强的松龙和血浆置换治疗后血小板计数增加;患者随后接受磺达肝癸钠治疗,临床症状有所改善。

患者3,43岁亚洲男性,在接种ChAdOx1 nCoV-19疫苗21天后出现语言障碍。CT和磁共振(MR)显示急性左额叶和岛叶梗死与左大脑中动脉前皮质区相对应,梗死内有少量出血性转化。MR和CT静脉造影均未见脑静脉窦血栓形成。血小板计数为48 x 109/升;D-二聚体在24岁时升高 000 µ克/升;抗PF4抗体检测呈阳性。他接受了血小板输注、静脉注射免疫球蛋白和磺达肝癸钠治疗,临床上保持稳定。

研究结果显示,除了静脉血栓形成外,VITT的神经症状还包括动脉闭塞。接受ChAdOx1-nCoV-19疫苗后出现缺血性中风的年轻患者应立即通过实验室检查(包括血小板计数、D-二聚体、纤维蛋白原和抗PF4抗体)评估VITT,并评估是否同时存在静脉血栓;他们应该由一个多学科团队(血液学、神经学、中风、神经外科和神经放射学)管理,以便快速获得治疗,包括静脉注射免疫球蛋白、甲基强的松龙、血浆置换和非肝素抗凝剂,例如磺达肝癸钠、阿加曲班或直接口服抗凝剂。 

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    2021-06-18 guging

    中风是俗称,应该称为缺血性卒中吧

    0

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