Cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia in middle-income countries

Anita van de Munckhof, Afshin Borhani-Haghighi, Sanjith Aaron, Katarzyna Krzywicka, Mayte Sánchez van Kammen, Charlotte Cordonnier, Timothy J. Kleinig, Thalia S. Field, Sven Poli, Robin Lemmens, Adrian Scutelnic, Erik Lindgren, Jiangang Duan, Yıldız Arslan, Eric C.M. van Gorp, Johanna A. Kremer Hovinga, Albrecht Günther, Katarina Jood, Turgut Tatlisumak, Jukka PutaalaMirjam R. Heldner, Marcel Arnold, Diana Aguiar de Sousa, Mohammad Wasay, Antonio Arauz, Adriana Bastos Conforto, José M. Ferro, Jonathan M. Coutinho

Research output: Contribution to journalArticlepeer-review

1 Citation (Scopus)


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.

Original languageEnglish
Pages (from-to)1112-1120
Number of pages9
JournalInternational Journal of Stroke
Issue number9
Publication statusPublished - Oct 2023


  • COVID-19
  • CVST
  • VITT
  • global health
  • thrombosis
  • vaccination


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