Webinar Series on COVID-19 vaccine: Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research (ICR), NIH Speaker: Dr. Ong Tien Lee, neurologist in Sungai Buloh Hospital, Ministry of Health Malaysia.

1. Possible neurological
complications following
COVID-19 Vaccines
Dr Ong Tien Lee
Neurology Unit
Hospital Sg Buloh

2. Disclaimers
•This slide was prepared for the Webinar Series on
COVID-19 session on 3rd March 2021, by Dr. Ong
Tien Lee, Neurology Unit, Hospital Sungai Buloh,
Malaysia.
•This is intended to share within healthcare
professionals, not for public.
•Kindly acknowledge “Clinical Updates in COVID-19
http://www.nih.gov.my/covid-19” should you plan to
share the information obtained from this slide with
your colleagues.
Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research, NIH

3. Content/Outline
•Common neurological manifestations
•Uncommon neurological manifestations
Both condition may first present at primary care setting

4. Common neurological side effect
for all vaccine
Headache
•Short-lived: 24 to 48 hours & > after second dose of
vaccination
•CDC recommends against use of NSAIDS or acetaminophen
as prophylaxis prior to vaccination

5. •If headache develop after vax, use of NSAIDs or
acetaminophen not contraindicated and would be
considered first-line treatment (Gelfand AA, 2021)
•Migraine may flare
•Patients may dev visual aura for the first time after
immunization
•Usually last 3 to 5 days
•Those on triptan/ GCRP/ gepants/ ditans may
continue with treatment (Martin V)

6. •Observational study monitoring post-vaccination A/E in 491
patients with stable autoimmune inflammatory rheumatic diseases
[RA, Sjogren, etc]
•6 patients develop first episode HZ
• ? Possible reactivation HZ might occur following covid19
(Pfizer) vax

7. Uncommon neurological
complications
•Concern about neurological
complications from COVID 19 vaccine
escalated in end of 2020 when transverse
myelitis was reported in 3 patients during
AstraZeneca vax trial
•Transverse myelitis:
inflammation of the spinal cord
Lower limb weakness, bowel & bladder
dysfunction, sensory level

8. • In 12174 recipients 🡪 1 TM occurred 14 days after the second
dose (37 year old woman)
• 2 additional cases were considered unlikely related to the
vaccine
• 1 had pre-existing MS (10 d after 1st
dose)
• 1 control group, 68 days after vaccination
? co incidental or association

9. • 7 cases out of 37,000 mRNA vax recipients dev Bell’s palsy:
4 Pfizer, 3 Moderna (6 occurred after 2nd dose)
• FDA: observed frequency of Bell’s palsy is consistent with
expected background rate in general population
• Imbalance in incidence of bell’s following vaccination compared
to placebo arm: Pfizer: 0 in placebo, 4 cases in vaccine group
• Post marketing: 2 cases reported

10. Feb 2021
• Data from mRNA vax clinical trials: no participants
developed GBS
• 82 year old female presented with generalised body aches,
paraesthesia & difficulty walking 2 weeks after her first dose
of Pfizer COVID vaccine.
Neurological Complications of COVID-19: Guillain-
Barre Syndrome Following Pfizer COVID-19 Vaccine

11. •Estimated risk GBS in the world: 1 - 2 cases per
100,000 people/yr (Babazadeh et al)
•Lifetime individual risk of acquiring GBS 1:1000
(P.Lunn et al)
•Within 1 B people, 17000 cases of sporadic GBS per
annum 🡪 Approx 1962 in any 6 week period
•If vaccinate 4 B person in 1 year, 68k cases of GBS
would be expected to occur naturally within this time
(Michael P. Lunn, 2021)
•Of these, 13K would occur in 10 week window
following double dose vax
•Therefore inevitable these sporadic cases will appear
temporarily associate with COVID-19 vaccine

12. •Multiple other vaccines (hep B, polio, tetanus,
meningococcus, rabies,) previously alleged to be
associated with GBS (Mc Neil 2019, Chen et al, 2020)
•No causative links have been conclusively proven
despite these individuals reports being widely quoted
(Michael P. Lunn, 2021)
•CDC stated that the independent Advisory Committee
on Immunization Practices do not include a history of
GBS as a precaution to vaccination with other
vaccines

14. Vaccine & ADEM acute
disseminated encephalomyelitis
•Associated with several vaccines:
rabies, smallpox, MMR, etc
•For most vaccine: incidence rate
0.1 to 0.2 per 100,000 vaccinated
individuals
•only 5% of cases of ADEM are
preceded by vaccination within 1
month prior to symptoms onset.
(W.Huynh, 2008)
•1 case report of ADEM (inactivated
covid 19 vaccine, vero cells)

15. Acute ischemic stroke &
COVID-19 vaccine
•Pfizer phase 3 trial; 38,000 participants randomised 1:1 to
vaccine or placebo, median of 2 months f/up after dose 2
•None died of CNS related complication
•Only one participant in older placebo group had
haemorrhagic stroke 15 days after dose 2 & died the
following day
•Phase 1&2 sinovac trial: no serious A/E reported

16. HPT after covid vax?
• Case series: 9 patients: 7 females, 2 males: stage III
HPT within mins of vax (8 symptomatic)
• 8: prior history of arterial HPT & most on anti-HPT
meds (? many/dose)
• 8 Pfizer, 1 moderna (just introduced)
• No pre-vaccination BP values

17. • Suggests a fraction of HPT pts may react
with symptomatically significant increases in
both syst/ diastolic BP
•More data needed
•Pre vaccination control of BP
•? need post vaccination monitoring/
symptom screening for elderlies with history
of HPT or significant prior CV risk factor

18. Cerebral venous sinus
thrombosis (CVST)
•uncommon: 0.22 – 1.57 per 100,000
•0.5 to 1% of all strokes (CVST in general, CVST with
thrombocytopenia is very rare) (Fesler,2011)
•Median age: 37 years
•Female: male ratio of 3:1
•(Ferro JM 2001, Coutinho JM, 2012, Devasagayam S, 2016)
•Risk factors: OCP, pregnancy & postpartum, malignancy,
infection (saposnik G, 2011)

19. CVST S&S
More common presentations
•Raised ICP (headache, vomiting, papilloedema, visual problem)
•Focal deficits/ seizures
•Encephalopathy
Uncommon presentations
•Subarachnoid hemorrhage
•Cavernous sinus syndrome

20. Additional characteristics of patients
with CVST and thrombocytopenia
after Janssen COVID-19 vax
• Current estrogen/ progesterone use (1)
• Obese (3)
• HPT (1)
• Hypothyroidism (1)
• Asthma (1)
Source: CDC

21. Source: CDC

22. Location of CVST
Source: CDC

23. Vaccine induced immune
thrombotic thrombocytopenia
•11 patients in Germany & Austria: 9 had CVST
• Median age: 36 (22- 49). Onset (d5 to d16),
•5 patients in Norway

24. Norway

25. Final message
Common side effect usually short
lived and self limiting
Important to be aware of
uncommon or rare neurological
condition following covid 19
vaccination & report AEFI