Middle Cerebral Artery Dissection after AstraZeneca COVID-19 Vaccination

A 51-year-old male with hypertension and hyperlipidemia presented with right hemiparesis 3 days after receiving the Oxford/AstraZeneca COVID-19 vaccine. Brain magnetic resonance imaging (MRI) with high-resolution vessel wall imaging (HR-VWI)[1] revealed dissection with 75% stenosis at the M1 segment of the left middle cerebral artery (MCA) [Figure 1a and b] and watershed infarcts at the left corona radiata. Aspirin was administered, but recurrent right hemiparesis and persistent MCA dissection [Figure 1c] remained at 6-month follow-up. Percutaneous angioplasty and stenting (PTAS) of the dissecting stenosis was performed [Figure 2a and b]. No recurrent stroke was observed at 22-month follow-up, and computed tomography angiography revealed a patent stent [Figure 2c]. COVID-19 vaccines have reportedly triggered cranial and coronary arterial dissection within 18 days postvaccination.[2-4] Owing to the different treatments available for arterial dissection, vasculitis, and thromboembolism, we suggest applying brain MRI with HR-VWI to elucidate the etiology of postvaccination stroke.[1] PTAS demonstrated favorable outcomes in the management of medically refractory postvaccination intracranial arterial dissection.Figure 1: Left middle cerebral artery (MCA) dissection and cerebral infarct. Magnetic resonance imaging with high-resolution vessel wall imaging on (a) sagittal T1-weighted imaging (T1WI) and (b) contrast-enhanced sagittal T1WI of the distal M1 segment of the left MCA showed eccentric luminal narrowing (arrowheads) with crescent-shaped hematoma formation (arrows), consistent with arterial dissection. (c) Time-of-flight magnetic resonance angiography showing 75% stenosis of the dissecting lesion.Figure 2: Dissecting stenosis of the MCA was treated via percutaneous angioplasty and stenting (PTAS). (a) Cerebral digital subtraction angiography demonstrated persistent dissection with 75% stenosis at the distal M1 of the left MCA (arrow). (b) PTAS of the dissecting stenosis at M1 of the left MCA was performed by angioplasty with a 2.5 mm × 8 mm Neurospeed® balloon catheter followed by deployment of a 3.5 mm × 20 mm Credo® stent. A control angiogram showed <30% residual stenosis (arrow). (c) Computed tomography angiography with a curved multiplanar reformatted image 22 months later, showing patency of the stent at the left MCA (arrow).Key point sentence Brain MRI with high-resolution vessel wall imaging (HR-VWI) should be performed in post-AstraZeneca COVID-19-vaccinated stroke patients to improve the diagnosis of arterial stenosis and provide the most appropriate treatment. Ethics statement This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and that due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Financial support and sponsorship This study received funding from Taipei Veterans General Hospital, Taiwan (V111B-032, V112B-007 [to CHW]; V111C-028, V112C-059, V112D67-002-MY3-2, V113C-182 [to FCC]), the Veterans General Hospitals and University System of Taiwan Joint Research Program (VGHUST 110-G1-5-2 [to FCC]), the Ministry of Science and Technology of Taiwan (NSTC 110-2314-B-075-005- and 111-2314-B-075-025-MY3 [to CHW] and 109-2314-B-075-036, 110-2314-B-075-032 and 112-2314-B-075-066 [to FCC]), the Yen Tjing Ling Medical Foundation, Taiwan (CI-111-2, CI-112-2 [to CHW]), Professor Tsuen CHANG’s Scholarship Program from the Medical Scholarship Foundation in Memory of Professor Albert Ly-Young Shen (to CHW), the Vivian W. Yen Neurological Foundation (to CHW and FCC) and the Yin Shu-Tien Foundation Taipei Veterans General Hospital-National Yang Ming Chiao Tung University Excellent Physician Scientists Cultivation Program (No. 112-V-B-039 [to CHW]). Conflicts of interest All authors declare no competing interests.