Nivedita Jha, M.D., Steven Lippmann, M.D.

Many people with COVID-19 infections evidence constitutional and/or respiratory concerns. Neurological, gastrointestinal, and/or cardiovascular presentations are less common. Stroke occurrences among people with COVID-19 illness include ischemic events, intracerebral hemorrhage, and cerebral venous thromboses (1).

COVID-19 disproportionately affects certain groups (2). Patients with serious COVID-19 disease evidence an elevated incidence of stroke; increased cytokine activity and inflammatory responses are observed. Stroke etiologies are multifactorial. Risk factors include hypertension, diabetes, sickle cell disease, and/or other cardiovascular pathology. COVID-19 infections induce a systemic inflammatory response with plaque instability. Intense cytokine activity, elevated D-dimer, and/or inflammatory markers are documented (3). Other contributing factors causing a cardio-embolic stroke could include an infection-induced prothrombotic state, a vasculopathy caused by neuro-invasion by the virus, and/or cardiac injury resulting from the infection (4).

COVID-19 vaccinations are the major measures to diminish the devastating impact of this virus on the brain. Over 3.82 billion doses of vaccine have been administered in 180 countries to date (5). In the USA, 341 million doses have been administered (6). The vaccine is highly effective in preventing severe illnesses that result in hospitalization and/or death (5).

There are serious concerns about COVID-19 vaccine side effects. A sore arm, fever, flu-like symptoms, headaches, chills, tiredness, sore throat, and fatigue are reported (7).  People also worry about an increased risk of blood clots and stroke following vaccination, vaccine safety overall, and the effect on anticoagulant medication. This has resulted in apprehension and hesitancy of our receiving this vaccine. A prior stroke might make a new cerebrovascular accident more likely (2).

Coagulopathies are documented after receiving these vaccinations (8). Cerebral venous sinus thromboses, thrombosis-thrombocytopenia syndromes, and thrombocytopenias are reported 2-4 weeks after some persons were administered coronavirus vaccines. A possible mechanism is a vaccine-induced immune thrombotic thrombocytopenia, like with heparin-induced thrombocytopenias, that evidence IgG PF-4 antibodies (9). Medical intervention teams are alert to neurological presentations since early treatment mitigates disability and mortality.

The infrequency of stroke and severe thrombocytopenia after COVID-19 vaccination outweigh the risks of a vaccination (9). To diminish vaccine hesitancy and maximise immunization compliance understanding opposition and identifying targets for behavior change might improve vaccination rates. Fear of the vaccine might decline with education and/or with rising rates of infection. Understanding the perspectives of people about vaccine fears will hopefully counter this pandemic (2).

References

1. Avula A, Nalleballe K, Narula N, et al. COVID-19 presenting as stroke. Brain Behav Immun. 2020;87:115–119.
2. Turner G, Heron N, Crow J, et al. Stroke and TIA Survivors’ Perceptions of The COVID-19 Vaccine: Cross Sectional Survey. In Review; June 8, 2021. https://www.researchsquare.com/article/rs-543899/v1.  Accessed July 12, 2021.
3. Guo T, Fan Y, Chen M, et al. Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):811-818.
4. Sarzi-Puttini P, Giorgi V, Sirotti S, et al. COVID-19, cytokines and immunosuppression: what can we learn from severe acute respiratory syndrome? Clin Exp Rheumatol. 2020;38(2): three 337–342.
5. More Than 3.82 Billion Shots Given: Covid-19 Tracker. Bloomberg.com. https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution. Accessed July 12, 2021
6. COVID-19 Vaccine Tracker: How Many People Have Been Vaccinated In The U.S.? : Shots – Health News : NPR.https://www.npr.org/sections/health-shots/2021/01/28/960901166/how-is-the-covid-19-vaccination-campaign-going-in-your-state. Accessed July 12, 2021
7. Possible Side Effects After Getting a COVID-19 Vaccine |CDC. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html. Accessed July 12, 2021
8. Scully M, Singh D, Lown R, et al. Pathologic Antibodies to Platelet Factor 4 after ChAdOx1 nCoV-19 Vaccination. N Engl J Med. 2021;384(23): 2202–2211.
9. Mehta PR, Mangion AS, Benger M, et al. Cerebral venous sinus thrombosis and thrombocytopenia after COVID-19 vaccination – A report of two UK cases. Brain Behav Immun. 2021;95:514–517.