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VAERS Report 2157252

Case Report Section

Vaer Report Details

Age: 63 years old

Gender: Male

State: Outside US

Patient Died?
Yes
Vaccine information

Name: COVID19 (COVID19 (MODERNA))

Type: Coronavirus 2019 vaccine

Manufacturer: MODERNA

Lot: 030g21a


Date report was received
2022-03-04
Date form completed
Date Vaccinated
2022-01-10
Date of Onset
2
Number of days (onset date – vaccination date)
2
Adverse Event Description

from 12.01 headache, high blood pressure. 24.01 seizure. hospitalization brain hemorrhage, aneurysm.; from 12.01 headache, high blood pressure. 24.01 seizure. hospitalization brain hemorrhage, aneurysm.; this case was received via regulatory authority (reference number: it-minisal02-841384) on 25-feb-2022 and was forwarded to moderna on 25-feb-2022. this regulatory authority case was reported by a consumer and describes the occurrence of cerebral haemorrhage (from 12.01 headache, high blood pressure. 24.01 seizure. hospitalization brain hemorrhage, aneurysm.) and aneurysm (from 12.01 headache, high blood pressure. 24.01 seizure. hospitalization brain hemorrhage, aneurysm.) in a 63-year-old male patient who received mrna-1273 (spikevax) (batch no. 030g21a) for covid-19 vaccination. no medical history information was reported. on 10-jan-2022, the patient received dose of mrna-1273 (spikevax) (intramuscular) 1 dosage form. on 12-jan-2022, the patient experienced cerebral haemorrhage (from 12.01 headache, high blood pressure. 24.01 seizure. hospitalization brain hemorrhage, aneurysm.) (seriousness criterion death) and aneurysm (from 12.01 headache, high blood pressure. 24.01 seizure. hospitalization brain hemorrhage, aneurysm.) (seriousness criterion death). the patient died on 12-jan-2022. it is unknown if an autopsy was performed. no concomitant drug details were reported. no treatment details were reported. company comment: this regulatory authority case concerns a 63 year old male with no medical history reported, who experienced the seroius ( fatal ) , unexpected. event of cerebral hemorrhage and serious ( fatal ) , unexpected event of aneurysm which occurred two days post vaccination with an unknown dose number of mrna-1273 vaccine. the patient died two days post vaccination and it is unknown if an autopsy was done. the cause of death was not reported. other details surrounding the events were not reported. the benefit -risk relationship of mrna -1273 ( moderna covid 19 vaccine) is not affected by this report.; reporter's comments: information requests.; sender's comments: this regulatory authority case concerns a 63 year old male with no medical history reported, who experienced the seroius ( fatal ) , unexpected. event of cerebral hemorrhage and serious ( fatal ) , unexpected event of aneurysm which occurred two days post vaccination with an unknown dose number of mrna-1273 vaccine. the patient died two days post vaccination and it is unknown if an autopsy was done. the cause of death was not reported. other details surrounding the events were not reported. the benefit -risk relationship of mrna -1273 ( moderna covid 19 vaccine) is not affected by this report

Lab Data
na
List of symptoms
aneurysm cerebral haemorrhage
Patient Died?
Yes
Date Died
2022-01-12
Birth defect
false
Vaccine Administered By:
Unknown
Vaccine Purchased By:
Unknown
Patient visit ER?
No
Patient Hospitalized?
No
Stay in hospital
No
Days in hospital
Unspecified
Permanent disability?
No
Allergies:
na
Current Illness
na