Cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia in middle-income countries
Authors: van de Munckhof Anita , Borhani-Haghighi Afshin , Aaron Sanjith , Krzywicka Katarzyna , van Kammen Mayte Sánchez , Cordonnier Charlotte , Kleinig Timothy J , Field Thalia S , Poli Sven , Lemmens Robin , Scutelnic Adrian , Lindgren Erik , Duan Jiangang , Arslan Yıldız , van Gorp Eric CM , Kremer Hovinga Johanna A , Günther Albrecht , Jood Katarina , Tatlisumak Turgut , Putaala Jukka , Heldner Mirjam R , Arnold Marcel , de Sousa Diana Aguiar , Wasay Mohammad , Arauz Antonio , Conforto Adriana Bastos , Ferro José M , Coutinho Jonathan M , Mbroh Joshua , Ciccone Alfonso , Wittstock Matthias , Zimmermann Julian , Bode Felix J , Skjelland Mona , Dizonno Vanessa , Devroye Annemie , Hiltunen Sini , Petruzzellis Marco , Bakchoul Tamam , Levi Marcel , Middeldorp Saskia , Sharma Aarti R , Ghoreishi Abdoreza , Elkady Ahmed , Negro Alberto , Gutschalk Alexander , Buture Alina , Cervera Alvaro , Paiva Nunes Ana , Romina Montané Baños Ana , Tiede Andreas , Tuladhar Anil M , Mengel Annerose , Medina Antonio , Aujayeb Avinash , Ramasamy Balakrishnan , Casolla Barbara , Spratt Neil , Ziaadini Bentolhoda , Varkey Maramattom Boby , Buck Brian , Garcia-Esperon Carlos , Vayne Caroline , Jacobi Christian , Pfrepper Christian , Bal Deepti , Sergio Zimatore Domenico , Michalski Dominik , Blacquiere Dylan , Johansson Elias , Cuadrado-Godia Elisa , Sadeghi-Hokmabadi Elyar , Carrera Emmanuel , Maistre Emmanuel De , Saxhaug Kristoffersen Espen , Hooshmandi Etrat , Bonneville Fabrice , Vuillier Fabrice , Giammello Fabrizio , D’Onofrio Florindo , Tsivgoulis Georgios , Gulli Giosue , Katzberg Hans , Sibon Igor , Baharoglu Irem , Masjuan Jaime , Fernandes João , Pelz Johann , Octavio López Esparza Jorge , Schouten Judith , Ng Karl , Derex Laurent , Puy Laurent , Poorsaadat Leila , Valler Lenise , Januzi de Almeida Rocha Letícia , Murillo-Bonilla Luis , Kellermair Lukas , Morin Martin Mar , Sofia Cotelli Maria , Hernandez Perez Maria , Zedde Marialuisa , Carvalho Dias Mariana , Carvalho Marta , Ghiasian Masoud , Umaiorubahan Meenakshisundaram , Roozbeh Mehrdad , Romoli Michele , Miranda Miguel , Wronski Miriam , Saadatnia Mohammad , Bandettini di Poggio Monica , Almasi-Dooghaee Mostafa , Hoseininejad Mir Nahid , Ichaporia Nasli R , Kumar Paramasivan Naveen , Raposo Nicolas , Fadakar Nima , Kruyt Nyika , Detante Olivier , Sharma Pankaj , Candelaresi Paolo , Scoppettuolo Pasquale , Reiner Peggy , Sylaja PN , Kumar Karunakaran Ravi , Vieira Ricardo , Kern Rolf , Goh Rudy , Erat Sreedharan Sapna , Murphy Seán , Timsit Serge , Coutts Shelagh , Sharma Shyam S , Schoenenberger Silvia , Nagel Simon , Kaul Subhash , Karapanayiotides Theodoros , Gattringer Thomas , Mathew Thomas , Bartsch Thorsten , Palma Vincenzo , Mirzaasgari Zahra , Zamani Zohreh , Mirahmadizadeh Alireza , Gutierrez-Romero Alonso , Iván Valdes-Ferrer Ivan , Elizabeth Ceballos-Liceaga Santa , Maria Santibañez-Copado Ana 
Published: June 2023

Background: Adenovirus-based COVID-19 vaccines are extensively used in low- and middle-income countries (LMICs). Remarkably, cases of cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) have rarely been reported from LMICs. Aims: We studied the frequency, manifestations, treatment, and outcomes of CVST-VITT in LMICs. Methods: We report data from an international registry on CVST after COVID-19 vaccination. VITT was classified according to the Pavord criteria. We compared CVST-VITT cases from LMICs to cases from high-income countries (HICs). Results: Until August 2022, 228 CVST cases were reported, of which 63 were from LMICs (all middle-income countries [MICs]: Brazil, China, India, Iran, Mexico, Pakistan, Turkey). Of these 63, 32 (51%) met the VITT criteria, compared to 103 of 165 (62%) from HICs. Only 5 of the 32 (16%) CVST-VITT cases from MICs had definite VITT, mostly because anti-platelet factor 4 antibodies were often not tested. The median age was 26 (interquartile range [IQR] 20–37) versus 47 (IQR 32–58) years, and the proportion of women was 25 of 32 (78%) versus 77 of 103 (75%) in MICs versus HICs, respectively. Patients from MICs were diagnosed later than patients from HICs (1/32 [3%] vs. 65/103 [63%] diagnosed before May 2021). Clinical manifestations, including intracranial hemorrhage, were largely similar as was intravenous immunoglobulin use. In-hospital mortality was lower in MICs (7/31 [23%, 95% confidence interval (CI) 11–40]) than in HICs (44/102 [43%, 95% CI 34–53], p = 0.039). Conclusions: The number of CVST-VITT cases reported from LMICs was small despite the widespread use of adenoviral vaccines. Clinical manifestations and treatment of CVST-VITT cases were largely similar in MICs and HICs, while mortality was lower in patients from MICs.