Malignant cerebral infarction after ChAdOx1 nCov-19 vaccination: a catastrophic variant of vaccine-induced immune thrombotic thrombocytopenia

Nat Commun. 2021 Aug 2;12(1):4663. doi: 10.1038/s41467-021-25010-x.


Vaccine-induced thrombotic thrombocytopenia with cerebral venous thrombosis is a syndrome recently described in young adults within two weeks from the first dose of the ChAdOx1 nCoV-19 vaccine. Here we report two cases of malignant middle cerebral artery (MCA) infarct and thrombocytopenia 9-10 days following ChAdOx1 nCoV-19 vaccination. The two cases arrived in our facility around the same time but from different geographical areas, potentially excluding epidemiological links; meanwhile, no abnormality was found in the respective vaccine batches. Patient 1 was a 57-year-old woman who underwent decompressive craniectomy despite two prior, successful mechanical thrombectomies. Patient 2 was a 55-year-old woman who developed a fatal bilateral malignant MCA infarct. Both patients manifested pulmonary and portal vein thrombosis and high level of antibodies to platelet factor 4-polyanion complexes. None of the patients had ever received heparin in the past before stroke onset. Our observations of rare arterial thrombosis may contribute to assessment of possible adverse effects associated with COVID-19 vaccination.

Publication types

  • Case Reports

MeSH terms

  • Autoantibodies / blood
  • Autoantibodies / immunology
  • COVID-19 / immunology*
  • COVID-19 / virology
  • COVID-19 Vaccines / administration & dosage
  • COVID-19 Vaccines / adverse effects*
  • COVID-19 Vaccines / immunology
  • Cerebral Infarction / chemically induced*
  • Cerebral Infarction / diagnostic imaging
  • ChAdOx1 nCoV-19
  • Computed Tomography Angiography / methods
  • Female
  • Humans
  • Magnetic Resonance Imaging / methods
  • Middle Aged
  • Platelet Factor 4 / immunology
  • Purpura, Thrombocytopenic, Idiopathic / chemically induced*
  • Purpura, Thrombocytopenic, Idiopathic / diagnostic imaging
  • SARS-CoV-2 / immunology*
  • SARS-CoV-2 / physiology
  • Thrombosis / chemically induced*
  • Thrombosis / diagnostic imaging
  • Tomography, X-Ray Computed / methods
  • Vaccination / adverse effects
  • Venous Thrombosis / chemically induced
  • Venous Thrombosis / diagnostic imaging


  • Autoantibodies
  • COVID-19 Vaccines
  • Platelet Factor 4
  • ChAdOx1 nCoV-19