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Neurological Manifestations Following COVID-19 Vaccines: A Review
With ten vaccines approved by the World Health Organization (WHO) and nearly 48% of people fully vaccinated worldwide, we have observed several individual case studies of neurological manifestations post-COVID-19 vaccination. Various pathogenic mechanisms have been described, and severe complications, such as acute disseminated encephalomyelitis (ADEM) and stroke, have been reported in the Vaccine Adverse Event Reporting System (VAERS) and the Medicines and Healthcare products Regulatory Agency (MHRA).
Objectives:
Through this systematic review, we aim to discern the central (CNS) and peripheral nervous system (PNS) manifestations associated with the seven most commonly available COVID-19 vaccines. We detailed their clinical presentation, neuroimaging features, treatment, and outcomes, to help guide practitioners in the management of these adverse events.
Methods:
A thorough literature search of Google Scholar and PubMed was conducted from 1 December 2020 until 10 October 2021, including all case reports of neurological side effects with the following COVID-19 vaccines: Pfizer-BioNTech, Moderna, J&J/Janssen, AstraZeneca, Sinovac-CoronaVac, Sputnik V, and COVAXIN. The search and data analysis were performed by two independent reviewers according to prespecified inclusion and exclusion criteria using PRISMA.
Results:
The most common CNS manifestation was cerebral venous sinus thrombosis (CVST) (14.47%), found in females (64%) younger than 50 years (71%) after the first AstraZeneca dose (93%). The remaining included CNS demyelinating disorders (TM, ADEM, MS, NMOSD) (9.30%), encephalopathy/encephalitis (3.10%), and others (4.13%). The most common PNS manifestation was Guillain–Barré syndrome (GBS) (14.67%) found in males (71%) older than 50 years (79%), followed by Bell’s palsy (5.24%) and others (2.10%), comprising of small fiber neuropathy and phantosmia. Most of these occurred with the AstraZeneca (28.55%), Pfizer-BioNTech (9.18%), and Moderna (8.16%) vaccines. Nine (64%) out of the 14 patients with CVST died. However, most cases overall (42 out of 51) were non-fatal (82%). The most frequent neuroimaging findings were ischemic stroke including lacunar infarct, CVST (14, 35.8%) associated with hemorrhagic stroke/ICH, SAH (13, 33.3%), encephalopathy (4, 10.2%), and enhancement of the cauda equina nerve roots (4, 10.2 %) seen with GBS.
Conclusions:
Several post-marketing CNS and PNS adverse events have occurred following the COVID-19 vaccination, including CVST, GBS, and TM. A high level of vigilance with early identification and treatment categorically leads to better outcomes. Further studies with non-vaccinated controls might help understand the pathophysiologic mechanisms of these neurological manifestations associated with the COVID-19 vaccination.