Vertebral Artery Dissection with Acute Ischemic Stroke after COVID-19 Vaccination: Three Case Reports
Article information
Abstract
SARS-CoV-2 is a global pandemic with high mortality and prevalence. Although the disease severity has weakened, it remains a significant global health burden as an endemic disease. Several reports have explored the relationship between intracranial artery dissection and SARS-CoV-2 infection; however, an association with SARS-CoV-2 vaccination has not been established. Here, we describe three cases of vertebral arterial dissection with acute ischemic stroke after SARS-CoV-2 vaccination. This report aimed to raise the clinical awareness of this potential adverse effect, which may facilitate earlier diagnosis and intervention.
SARS-CoV-2 infection is a global pandemic with high mortality rates and continues to impose substantial social and healthcare burdens worldwide.1 Several SARS-CoV-2 vaccines have been approved by the World Health Organization. Neurological complications, including headache, Guillain-Barre syndrome, transverse myelitis, and autoimmune encephalitis, have been reported following SARS-CoV-2 vaccination2-5; however, a direct causal relationship remains unclear. Although cervicocerebral and carotid artery dissections have been reported after SARS-CoV-2 infection,6 cases involving intracranial artery dissection and SARS-CoV-2 vaccines are rare. Herein, we report three cases of vertebral artery dissection after the administration of the BNT162b2 SARS-CoV-2 vaccine (Pfizer/BioNTech Commission vaccine).
CASE
1. Case 1
A 52-year-old male with a history of hypertension presented with dizziness, ptosis in the right eye, and hypesthesia of the right side of the face and left extremities 4 weeks after the 2nd Pfizer SARS-CoV-2 vaccination. He had received the 1st vaccination 4 months earlier and experienced persistent headaches. Brain imaging revealed an acute infarction in the right medulla and dissection of the right vertebral artery (Fig. 1A–C). Apart from a mild increase in D-dimer levels (68 ng/mL), laboratory findings, including protein C/S, Fibrinogen, rheumatic antibody, and angiotensin-converting enzyme levels, were within normal limits. The patient was prescribed antiplatelet agents and statins, which resulted in gradual improvement in symptoms.
DWI, MRA, and MPR results of the three patients. An acute ischemic lesion is observed in the right medulla of patients 1 (A) and 2 (D). Segmental stenosis (B, arrow) with intramural hematoma (C, arrow) was noted in patient 1. Pear-and-string sign (E, arrow) with a double-luminal sign (F, arrow) was noted in patient 2. Acute ischemic lesions in the cerebellum (G) and focal luminal narrowing (H, arrow) with a double luminal sign (I, arrow) was observed in patient 3. DWI, diffusion-weighted imaging; MRA, magnetic resonance angiography; MPR, multiplanar reformation.
2. Case 2
A 46-year-old male with no known medical history developed a headache shortly after his second Pfizer vaccination. Twenty days later, the patient presented with dysarthria, right facial, and left limb hypesthesia. The laboratory test results were normal. Brain magnetic resonance imaging (MRI) with angiography revealed an acute right medullary infarction and a pearl-and-string sign with a double lumen in the right vertebral artery, indicative of dissection (Fig. 1D–F).7 The patient reported persistent headaches, and his symptoms improved after the administration of antiplatelet and analgesic agents.
3. Case 3
A 53-year-old-male with no known comorbidities collapsed 1 week after receiving the first dose of the Pfizer vaccine. The patient exhibited dysdiadochokinesia, and his serum glucose level was elevated at 435 mg/dL. However, no laboratory evidence of thrombosis or connective tissue disorders was observed. Brain MRI revealed a right cerebellar infarction with right vertebral artery dissection, confirmed by the double-luminal sign (Fig. 1G–I). The patient was treated with antiplatelet agents, statins, and antidiabetic drugs. The patient’s symptoms gradually improved.
DISCUSSION
Here, we describe three cases of vertebral artery dissection leading to acute ischemic stroke that occurred within 4 weeks of SARS-CoV-2 vaccination. None of the patients had a history of trauma, connective tissue disease, congenital hypercoagulability, or an infectious disease.
However, the association between SARS-CoV-2 vaccination and arterial dissection remains unclear. This may have occurred simultaneously. However, there is growing evidence that messenger RNA (mRNA) vaccines, such as the BNT162b2 SARS-CoV-2 vaccine, are associated with endothelial dysfunction.8 An increase in inflammatory biomarkers, such as Metallic Metalloproteinase-9 and Interleukin-6, has been demonstrated after BNT162b2 mRNA SARS-CoV-2 vaccination, which may cause damage to the tunica intima and result in intramural hematoma.8,9 Furthermore, the SARS-CoV-2 spike protein, which is the target of major SARS-CoV-2 vaccines, has been shown to trigger endothelial damage by activating the inflammatory cascade after binding to the ACE2 receptor and may independently induce autophagy in endothelial cell.10 Although speculative, these mechanisms may explain the association between vaccination and arterial dissections.
Coronavirus disease 2019 remains as a global threat, and vaccination remains essential for disease mitigation. However, cerebral artery dissection should be considered a potential, albeit rare, complication. Given the scarcity of reported cases,9 a concerted effort is needed to collect global cases and determine the mechanisms of the cerebrovascular side effects that may occur after vaccination.
Notes
Ethics Statement
This study was approved by the Institutional Review Board of Hanyang University Guri Hospital (IRB No. 2021-12-034) and written informed consent was obtained from the all patients.
Availability of Data and Material
All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.
Author Contributions
Ji Hyun Kim and Hong Keun Yoo reviewed the literature and wrote the manuscript. Young Joo Lee, Kyu Yong Lee, Seong Ho Koh, Seong Ho Park , Hojin Choi and Hyuk Sung Kwon were involved in planning and supervised the manuscript.
Acknowledgments
This research was supported by a grant from the research fund of Hanyang University (HY-202200000000845).
Sources of Funding
This study received no specific grant from any funding agency.
Conflicts of Interest
The authors declare that they have no conflict of interest.