背景:脑静脉血栓形成(CVT),在COVID大流行之前,很少代表所有笔划的0.5,经MRI或CT静脉造影诊断1-,3COVID-19患者与普通人群相比,患CVT的风险是未受影响人群的30-60倍,多达三分之一的严重COVID患者可能有血栓并发症4-8目前,疫苗是预防严重COVID-19的最佳方法。2021年2月,CVT和疫苗诱导的免疫性血栓性血小板减少症(VITT)的报告与腺病毒载体疫苗有关,包括牛津-阿斯利康疫苗(AZD1222(ChAdOx1))和强生COVID-19疫苗(JNJ-78436735(Ad26。COV2·S)),被注意到,在美国,Johnson和Johnson疫苗的发病率为1/583,000。11,12本研究回顾性分析了2018年至2021年东部医学中心的CVT和横截面静脉造影,并介绍了CVT的影像学示例以及从免疫反应中学到的知识。
方法:IRB批准后,我们对2018年1月1日至2021年4月30日在一个单一卫生系统中的横断面CTV和MRV进行了回顾性回顾.指示,疫苗状态,患者年龄,性别,阳性发现发生率在每年的3月和4月期间进行了具体评估.使用泊松回归的多变量调整趋势分析估计静脉造影频率和多变量逻辑回归比较性别,年龄,适应症和疫苗接种状态。
结论:从2018年1月1日至2021年4月30日,(图。1),总共获得了n=2206的患者和急诊室横截面静脉造影图,有322个CTV和1884个MRV。在2018年,2019年,2020年,横截面静脉造影的总数分别为568、657、660,而2021年前四个月的横截面静脉造影为321。2018年、2019年、2020年,CTV的总数分别为51、86、97,MRV的总数分别为517、571、563,而2021年前四个月的总数为88个CTV和233个MRV。March,2018年4月、2019年、2020年,CTV分别为6、17、11,相比2021年前4个月的59个CTV,占93个CTV总数的63%,各自的MRV分别为79、97、52,而2021年前四个月为143MRV,占371MRV总数的39%。三月,2020年4月在大流行期间,东海岸医疗中心的横断面影像减少了,作为维持病人通气的优先事项,高水平的护理和限制疾病的传播。2021年3月/4月,VITT和CVT的报告可能导致CTV和MRV增加,比以前增加39.65%[1.20-1.63](P<0.001)。三月,2021年4月获得的202个静脉照片,158(78.2。%)是未接种疫苗的患者,CVT为16正(10.1%),44人接种了疫苗(21.7%),8专门订购疫苗作为临床适应症,2为CVT(4.5%),(赔率比=0.52[0.12-2.38],p=0.200)。
结论:COVID大流行前的CTV,是罕见的,负责所有中风的0.5次,在东海岸大流行开始时,由于保持通气,整体横截面成像量下降,高水平的护理和限制疾病传播,尽管COVID-19患者的CVT风险是普通人群的30-60倍,疫苗接种是目前缓解严重疾病的最佳选择。2021年初,腺病毒载体COVID疫苗引起CTV和VITT的报道,导致横截面静脉造影增加39.65%,然而,在这项研究中,2021年未接种疫苗的患者CVT发病率较高(10.1%),与接种疫苗的患者相比(4.5%)。临床医生应该意识到,VITTCVT可能在接种疫苗后5-30天出现头痛,血栓形成最好在CTV或MRV诊断。如果存在血栓形成并伴有血小板减少症,血小板<150×109,D-二聚体升高>4000FEU,抗PF4ELISA检测阳性,诊断明确13.VITTCVT类似于自发性自身免疫性肝素诱导的血小板减少症(HIT),据推测,血小板因子4(PF4)与疫苗腺病毒载体结合形成一种新型抗原,抗PF4记忆B细胞和抗PF4(VITT)抗体14-17.
BACKGROUND: Cerebral Venous Thrombosis (CVT), prior to the COVID pandemic, was rare representing 0.5 of all strokes, with the diagnosis made by MRI or CT venography.1-,3 COVID-19 patients compared to general populations have a 30-60 times greater risk of CVT compared to non-affected populations, and up to a third of severe COVID patients may have thrombotic complications.4-8 Currently, vaccines are the best way to prevent severe COVID-19. In February 2021, reports of CVT and Vaccine-induced immune thrombotic thrombocytopenia (VITT) related to adenovirus viral vector vaccines including the Oxford-AstraZeneca vaccine (AZD1222 (ChAdOx1)) and Johnson & Johnson COVID-19 vaccine (JNJ-78436735 (Ad26.COV2·S)), were noted, with a 1/583,000 incidence from Johnson and Johnson vaccine in the United States.11, 12 This study retrospectively analyzed CVT and cross-sectional venography at an Eastern Medical Center from 2018 to 2021, and presents radiographic examples of CVT and what is learned from the immune response.
METHODS: After IRB approval, a retrospective
review of cross-sectional CTV and MRVs from January 1st 2018 to April 30th 2021, at a single health system was performed. Indications, vaccine status, patient age, sex, and positive finding incidence were specifically assessed during March and April for each year. A multivariable-adjusted trends analysis using Poisson regression estimated venogram frequencies and multivariable logistic regression compared sex, age, indications and vaccination status.
CONCLUSIONS: From January 1, 2018 to April 30, 2021, (Fig. 1), a total of n = 2206 in patient and emergency room cross-sectional venograms were obtained, with 322 CTVs and 1884 MRVs. In 2018, 2019, 2020, respective totals of cross-sectional venograms were 568, 657, 660, compared to 321 cross-sectional venograms in the first four months of 2021. CTV in 2018, 2019, 2020, respective totals were 51, 86, 97, MRV totals were 517, 571, 563, compared to the 2021 first four month totals of 88 CTVs and 233 MRVs. March, April 2018, 2019, 2020, CTVs respectively were 6, 17, 11, compared to the 2021 first four months of 59 CTVs, comprising 63% of the total 93 CTVs, respective MRVs were 79, 97, 52, compared to 143 MRVs in the first four months of 2021 for 39% of the total 371 MRVs. In March, April 2020 during the pandemic onset, cross-sectional imaging at the East Coast Medical Center decreased, as priorities were on maintaining patient ventilation, high level of care and limiting spread of disease. In March/April 2021, reports of VITT and CVT likely contributed to increased CTVs and MRVs, of 39.65% [1.20-1.63] increase (P < 0.001) from prior. In March, April 2021 of 202 venograms obtained, 158 (78.2.%) were unvaccinated patients, 16 positive for CVT (10.1%), 44 were on vaccinated patients (21.7%), 8 specifically ordered with vaccination as a clinical indication, 2 positive for CVT (4.5%), (odds ratio = 0.52 [0.12-2.38], p = 0.200).
CONCLUSIONS: CTV prior to the COVID pandemic, was rare, responsible for 0.5 of all strokes, at the onset of the pandemic in the East Coast, overall cross-sectional imaging volumes declined due to maintaining ventilation, high levels of care and limiting disease spread, although COVID-19 patients have a 30-60 times greater risk of CVT compared to the general population, and vaccination is currently the best option to mitigate severe disease. In early 2021, reports of adenoviral vector COVID vaccines causing CTV and VITT, led to at 39.65% increase in cross-sectional venography, however, in this study unvaccinated patients in 2021 had higher incidence of CVT (10.1%), compared to the vaccinated patients (4.5%). Clinicians should be aware that VITT CVT may present with a headache 5-30 days post-vaccination with thrombosis best diagnosed on CTV or MRV. If thrombosis is present with thrombocytopenia, platelets <150 × 109, elevated D-Dimer >4000 FEU, and positive anti-PF4 ELISA assay, the diagnosis is definitive.13 VITT CVT resembles spontaneous autoimmune heparin induced thrombocytopenia (HIT), and is postulated to occur from platelet factor 4 (PF4) binding to vaccine adenoviral vectors forming a novel antigen, anti-PF4 memory B-cells and anti-PF4 (VITT) antibodies.14-17.