Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
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Journal of Cancer Research and Treatment
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Label_Title

Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

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I am looking forward to hearing from you.

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David Rain
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Science and Education Publishing (http://www.sciepub.com)

Moyamoya Angiopathy Presenting with Cerebrovascular Stroke post-COVID-19 Vaccination

Mohammed Aboelnaga*, Mahfoud El. Bashari, Amani Alzaabi, Hesham Eissa

Zayed Military Hospital, Abu Dhabi, United Arab Emirates, Neurology Department

Abstract: Despite being uncommon, thrombotic complications from COVID-19 vaccinations that cause cerebrovascular events have been extensively studied. Moyamoya angiopathy (MMA) is a progressive intracranial vasculopathy that is responsible for causing recurrent strokes. This report analyzes a case of cerebrovascular stroke post-COVID-19 vaccination (inactivated-Sinovac) in a middle-aged Asian female. The patient was administered two doses of Sinovac, followed by one dose of the Pfizer vaccine, which led to the diagnosis of Moyamoya disease. The report aims to study MMA in a patient exhibiting exacerbated symptoms post-vaccination, thereby forming a basis for research regarding the safety of COVID-19 vaccinations in patients with pre-existing intracranial vasculopathy. Although such a correlation may not necessarily imply causality, caution must be exercised till future robust observations are obtained, especially considering the possibility of a shared inﬂammatory pathophysiological foundation between MMA and COVID-19 vaccinations.

Keywords: moya moya, vaccination, stroke, COVID-19, angiopathy

Received October 28, 2023; Revised November 30, 2023; Accepted December 06, 2023

Citation: Mohammed Aboelnaga, Mahfoud El. Bashari, Amani Alzaabi, Hesham Eissa, Moyamoya Angiopathy Presenting with Cerebrovascular Stroke post-COVID-19 Vaccination. American Journal of Medical Case Reports, 11 (12). 169-171. January 2023. doi:10.12691/ajmcr-11-12-1

1. Introduction

An increased incidence of thrombotic events, including stroke, has been reported in patients with coronavirus disease (COVID-19), although the characteristics and outcomes of the patients who experienced strokes are not adequately known. There has been evidence of a higher incidence of thrombotic events, including stroke, in COVID-19 patients; however, there is insufficient information available regarding the patient characteristics and outcomes of patients who experienced strokes.

Since the beginning of the epidemic, there have been numerous reports about the potential for stroke and cerebrovascular disease to exacerbate SARS-CoV-2 infection. Scientists, regulators, and governments worldwide have worked together to speed up the development of multiple SARS-CoV-2 vaccines. [1].

One of the most important developments and breakthroughs in the fight against the pandemic was the creation of vaccines against SARS-CoV-2. However, as our knowledge of the side effects of vaccines continues to expand, many cerebrovascular events in close temporal association with vaccinations are being reported.

Moyamoya angiopathy (MMA) is an uncommon, chronic condition that is characterized by the progressive narrowing of the intracranial portion of the internal carotid artery (ICA), or proximal anterior cerebral artery (ACA), and/or middle cerebral artery (MCA). At the base of the brain, it is accompanied by the formation of aberrant collateral vessels, which usually resemble a "puff of smoke." [2]. It has been suggested that an inﬂammatory state initiates and enhances the changes that MMA exerts on the cytokine pathways [3].

MMA is a type of vasculitis brought on by immune-mediated vascular injury and inﬂammatory response through anti - and pro-inflammatory mediators. Anti-inflammatory mediators - such as IL-4, IL-10, IL-13, IFN-α, and TGF-β - lead to acute aggravation of MMA by affecting vascular reactivity and auto-regulation. Meanwhile, pro-inﬂammatory mediators - such as IFN-β, IFN-γ, TNF-α, IL-1, and IL-6 - inﬂuence the initiation, often causing severe and sudden progression of MMA. Pro-inflammatory mediators activate the RNF-dependent signal transducing pathway. Therefore, in genetically predisposed patients, any acute systemic inflammatory response will likely result in intimal vascular smooth muscle cell hyperplasia, which narrows the lumen and causes neovascularization by rapidly increasing endothelial cells. In a study by Das et al., 64.3% of MMA patients with COVID-19 infection had worsening neurological symptoms. [4].

We herein report the case of a middle-aged female patient who suffered from acute ischemic stroke; she was later diagnosed with MMA. We observed neurological symptoms occurring in close temporal association with the Pfizer vaccine preceded by the Sinovac vaccination.

2. Case Presentation

The patient was a 43-year-old Pakistani female with a past medical history of HTN. She presented to our neurology clinic in June 2022 for further workup and evaluation, having visited a hospital two days prior for the sudden onset of left facial deviation with speech difficulty and a tingling sensation in the left arm. The symptoms continued for a few minutes and then subsided completely (transient ischemic attack).

Additionally, the patient history suggested a sudden onset of speech difficulty three months prior to visiting our hospital that continued for a few days. In March 2022, before developing these symptoms, the patient received a third dose of the COVID-19 vaccination (Pfizer). Additionally, she received the first two doses of the Sinovac vaccine on May 30, 2021, and July 1, 2021, respectively. An MRI of her brain was conducted, and the patient was diagnosed with acute ischemic stroke, for which she was evaluated and treated.

3. Physical Examination

The neurological examination was normal, and no focal neurological deficits were found.

4. Investigations

We evaluated the case extensively for secondary causes. The complete blood count – including platelet count, erythrocyte sedimentation rate (ESR), serum electrolytes, blood sugar, and lipid profile – was normal, as was the C-reactive protein level. Anti-nuclear antibody (ANA) and vasculitis screen were negative, including anti-phospholipid antibodies, p-ANCA, c-ANCA, and lupus anticoagulant. Thyroid function tests and coagulation profile were normal, and screening for hyper-coagulable state was negative. Chest X-ray, electrocardiogram, and echocardiography were also normal. Carotid Doppler ultrasound showed no significant stenosis. The work-up revealed no potential source for thrombo-embolism.

Follow-up revealed that the patient was stable on medications with no neurological problems at that time.

Figure 1A and 1B. Magnetic resonance imaging (MRI) of the brain revealed diffusion-weighted image (DWI) hypointense signal in the high right frontal region with corresponding changes in apparent diffusion coefficient (ADC) as chronic infarction.

Figure 2A and 2B. Magnetic resonance angiography (MRA) revealed irregularities in the small bilateral cavernous part of the internal carotid artery in both calibers. It also showed a narrowing proximal left middle cerebral artery with collateral vessel formation suggestive of Moyamoya angiopathy.

Figure 3A and 3B. Magnetic resonance angiography (MRA) revealed irregularities in the small bilateral cavernous part of the internal carotid artery in both calibers. It also showed a narrowing proximal left middle cerebral artery with collateral vessel formation suggestive of Moyamoya angiopathy.

5. Discussion

An estimated 1.4% of COVID-19 cases suffered from strokes. Thus, COVID-19 infection has been observed to be a risk factor for stroke. The major mechanisms implicated are hypercoagulability, vasculitis, and cardiomyopathy. Compared to COVID-19 infection, the adverse cerebrovascular effects seen with COVID-19 vaccinations are much less. Among the several reported cases of vaccine-associated cerebrovascular events, cerebral venous sinus thrombosis appears to occur more frequently than arterial stroke [4].

Though arterial stroke following COVID-19 vaccination has been documented, it is rare. However, it may not be so uncommon in cases that are genetically predisposed to or have pre-existing vasculopathy. MMA has been intensively studied in terms of inﬂammatory pathophysiology in genetically predisposed patients, thereby leading to progressive vaso-occlusive disease. According to a few documented reports, COVID-19 infection enhances MAA symptoms. Thus, based on the inﬂammatory etiopathogenesis of MAA, it can be extrapolated that COVID-19 vaccinations can similarly have an effect on the symptoms associated with MMA. These case reports form the basis for further research on the complex interplay of COVID-19 vaccinations and neurological destabilization in patients having vasculopathy of inﬂammatory pathophysiology [5].

As proposed earlier, the aberrant inﬂammatory pathway activation due to vaccines can probably inﬂuence these down-signaling pathways, thus leading to similar aggravation of Moyamoya symptoms.

Previous studies have noted the occurrence of strokes following varicella and inﬂuenza vaccination, and it was anticipated that, like their natural infections, these vaccines, too, can lead to intracranial angiopathy resulting in narrowing and occlusion of vessels and resultant ischemic stroke [5].

A similar mechanism could be involved in other vaccines, causing a hypercoagulable state leading to thromboembolism. Therefore, more data is needed to establish the precise correlation between COVID-19 vaccinations and cerebrovascular events.

6. Conclusion

Currently, there is no proven association between cerebrovascular accidents and COVID-19 vaccinations. Furthermore, the available data has limitations like under-reporting, diﬀerential reporting, and non-reported or undiagnosed concomitant COVID-19 infection. These factors preclude establishing a cause-eﬀect relationship. Therefore, additional research in the form of controlled studies is required to establish an accurate relationship between COVID-19 vaccinations and cerebrovascular accidents.

References

[1]   | Alammar, M.A. (2021). Ischemic stroke after AstraZeneca (COVID-19) vaccination. Saudi Med. J. [online], 42(10), pp. 1136-1139. Available from: 10.15537/smj.2021.42.10.20210326.
[2]   | Das, S., Dubey, S., Acharya, M., Chatterjee, S., Lahiri, D., Das, G., Ray, B.K., and Kraemer, M. (2019). Thalassemia and Moyamoya syndrome: unfurling an intriguing association. J Neurol. [online], 266(11), pp. 2838-2847. Available from: https://pubmed.ncbi.nlm.nih.gov/31422456/.
[3]   | Garg, R.K., and Paliwal, V.K. (2021). Spectrum of neurological complications following COVID-19 vaccination. Neurol. Sci. [online], 43(1), pp. 3-40.
[4]   | Michele, M.D., Kahan, J., Berto, I., Schiavo, O.G., Iacobucci, M., Toni, D., and Merkler, A.E. (2022). Cerebrovascular complications of COVID-19 and COVID-19 vaccination. Circulation Research [online], 130, pp. 1187-1203.
[5]   | Das S, Kanti Ray B, Pandit A, Dutta A, Bhat S, Bhattacharyya D, Prava Chakraborty A, Agrawal R, Dubey S. Covid-19 vaccine (covishield) heralding Moyamoya angiopathy. Neuroimmunology Reports. 2022; 2: 100100.