CVST is a serious pathology with high mortality if misdiagnosed, but its correct and rapid diagnosis offers the opportunity for early treatment. Here’s what to know about symptoms of blood clots if you received the vaccine. Like other rare but serious cases of headache, the consequences of missed diagnosis are severe. This came after a "rigorous" scientific review by the agency of report cases and data from hospital admissions and GP records. You are then in a position where the treatment for the index condition is anticoagulation, but the patient has intracranial bleeding. Cerebral venous sinus thrombosis (CVST) is a rare condition. This is a relatively unknown condition, with a very limited evidence base. Bringing together all the yellow card reports and known cases, the MHRA describe the risk of serious harm with the vaccine of around 1:250,000. Meanwhile, the MHRA said it had found no evidence of either the AstraZeneca or Pfizer-BioNTech vaccine causing blood clots in veins - a condition called venous thromboembolism. A key factor here is ensuring that we don’t put people into the investigation pathway unless they need investigation for VITT, else you might end up doing a lot of FBCs. Sinus vein thrombosis (CVST) describes the formation of a blood clot in the cerebral vein of the brain. As an example, subarachnoid haemorrhage is actually very rare – 6:100,000 according to some authors (7). Cerebral venous sinus thrombosis (CVST), cerebral venous and sinus thrombosis or cerebral venous thrombosis (CVT), is the presence of a blood clot in the dural venous sinuses (which drain blood from the brain), the cerebral veins, or both. Officials have not drawn a causal link between the vaccine and the cases, stating they are still rare, but some people may be more at risk than others. She included a reminder that the most common side-effects are still mild flu-like symptoms, such as a headache, chills and fever. I would suggest being your usual glorious selves and taking a thorough history (including recent vaccination), performing a thorough examination (checking for pupura and signs of VTE in particular) and bearing this condition in mind throughout. If you have CVST, respond quickly to symptoms like headaches, blurry vision, fainting, losing control of a part of your body, and seizures. Symptoms and signs arise from a combination of thrombosis of cerebral veins and increased intracranial pressure. The most common and sometimes only symptom of CVST is headache (80-90% of patients), while visual symptoms, stroke symptoms, seizures and depressed level of consciousness … There appears to be a specific syndrome caused by vaccination (AstraZeneca in particular) which presents at 5-28 days and is characterised by thrombocytopenia and unusual site thrombosis. Based on a work at https://litfl.com/, Cite this article as: Dan Horner, "Post-vaccine headache in the Emergency Department: what you need to know. Specific HITT antibody assays can be sent as well to help clarify the diagnosis, but they do not come back quickly…. Headache is the most frequent symptom of cerebral venous sinus thrombosis (CVST). I am sure you all saw the recent MHRA press release and guidance, discussing the issue of a possible link between the AstraZeneca COVID19 vaccine and a rare type of thrombotic condition of Vaccine induced thrombocytopenic thrombosis (VITT). And if we really think there is a significant risk of VITT/CVST based on this preliminary assessment, then we should pursue definitive investigations and seek expert help. HITT tends to present about 5-10 days after starting heparin compounds, and presents with worsening thrombosis and thrombocytopenia. effective analgaesia, reassurance and appropriate disposition (8,9). So before we roll our sleeves up and get stuck into the uncertainty, let’s take a look at a similar condition to see if we can learn anything that may help. Although in Vaccine Induced Thrombosis and Thrombocytopenia Cerebral Vein Thrombosis is the commonest type, abdominal thrombosis (esp portal vein) and some arterial thrombosis also occur. He is chair of the national exemplar centre Thrombosis Committee and Regional lead for Injuries and Emergencies on the NIHR Clinical Research Network. BMJ 2014;349:g7566, 3 – Dentali et al. 2 This may result from venous sinus stenosis or thrombosis, causing venous hypertension proximal to the obstruction. Emergency medicine (EM) physicians should be aware of various clinical presentations as … There have been several anecdotal cases reported of unusual site thrombosis following vaccination in otherwise healthy adults. The announcement to report such symptoms follows fears the … As a result, MHRA chief executive Dr June Raine said people should continue to attend their scheduled vaccination appointments as normal. Both HITT and VITT can present with unusual site thrombosis. Inspiration. Rick Body. Treating cavernous sinus thrombosis Think about a platelet count and considered clinical examination in a patient with post vaccine symptoms and a consistent history. Blimey, what a day. The European Medicines Agency has been carrying out a case-by-case evaluation of clotting incidents, but has said there is "no indication" of a causal link and that it is "safe and effective". However, the evidence is not perfect and there are real downsides to indiscriminate use of this test, as we all know. Current evidence suggests a clear link between COVID-19 and thromboembolic events. "Further work with expert haematologists is under way to further understand the nature of these cases and whether there is a causal association with any of the vaccines," said Professor Sir Munir Pirmohamed, the chair of the Commission on Human Medicines, the government's independent advisory group. For me, that means when I have a patient who is GCS 15 with no focal neurology and no other indication to image, but there are some concerns in the history or specific risk factors that make me consider the diagnosis. The low platelet count is key. BET 1: Does a normal D-dimer rule out cerebral venous sinus thrombosis (CVST)? We should evaluate risk based on historical and clinical features. Emergency physicians are generally excellent at thinking about and looking for needles, in our continually growing haystack. Platelet transfusions should be avoided if at all possible. It is tricky to diagnose, as it can present with isolated headache only. 2015; 15: 118. Recurrent headaches almost took away a teenager’s life An MRI investigation revealed cerebral venous sinus thrombosis (CVST). Use your noggins and order further tests only when necessary, following this initial assessment. We should inform this risk assessment judiciously, with ancillary tests like a platelet count, fibrinogen, d-dimer when indicated. If a patient is presenting shortly after vaccination (4 to 28 days) with significant symptoms, a platelet count would be a useful place to start regarding investigations. The Royal College of Emergency Medicine, in association with the Society for Acute Medicine and Royal College of Physicians, have released a guideline as linked below. The opportunity costs would likely be far greater than any benefits. Symptoms leading to the diagnosis include unusually bad forgetfulness (I would be driving 1 mile from my house & have no idea where I was), difficulty focusing on things (cerebrally, not visually), and increased frequency of headaches/ migraines, which I have had for years. Like always, the vast majority of headaches attending the ED will be primary headache disorders and need nothing more than diagnosis, effective analgaesia, reassurance and appropriate disposition (8,9). And I am not saying that everyone with a post vaccination headache should get a MRV/CTV. The risks for CVST include irregular menstruation, pregnancy, trauma, surgery, postpartum state, and hormonal changes in young women, and the patients often suffer non-specific headache. Thrombocytopenia describes when a person has a lowered number of platelets, which are cells that help the blood to clot. SMACC Dublin Workshop. Dr Daniel Horner BA MBBS MD PgCert MRCP (UK) FRCEM FFICM is an editorial board member on the St Emlyn’s blog and podcast. The U.S. Centers for … Getting Your Chest Pain Evaluation Right. Cerebral venous sinus thrombosis (CVST) is an uncommon cause of postpartum headache. He is a consultant in Emergency Medicine and Intensive Care at Salford Royal NHS Foundation Trust. #SMACCGold. The insinuation being either that the risk of these conditions presenting to ED is so very low, that no tests other than a definitive one would be useful, or that the risk is just so low we should not investigate at all. SMACCGold Workshop. The most common presenting symptom is a non-descriptive headache, but presentation varies with underlying etiology. As above, unusual site thrombosis can refer to clots in a variety of locations. Firstly, it is very rare, as above. 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