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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1755460

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Case Details

VAERS ID: 1755460 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-09-16
Onset:2021-09-16
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3005239 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cerebral haemorrhage, Cerebral ventricular rupture
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-20
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: JPMODERNATX, INC.MOD20213

Write-up: Cerebral haemorrhage; Cerebral ventricular rupture; This case was received via the Regulatory Authority (Reference number: JP-TAKEDA-2021TJP095727) on 24-Sep-2021 and was forwarded to Moderna on 27-Sep-2021. This case, initially reported to the Regulatory Authority by a clerical work, was received via the RA(Ref, v21128837). The patient''s underlying condition, cerebral arteriovenous malformation, was discussed with the interviewing physician, and the possibility of vaccination was discussed. On 16-Sep-2021, at 11:00, the patient received the 1st dose of this vaccine. Around 20:00, the patient had a headache and vomiting, so the patient''s family called for ambulance. At 20:50, the patient was taken to the hospital. The patients JCS3 was 300 on arrival. CT showed cerebral haemorrhage and cerebral ventricular rupture from cerebral arteriovenous malformation. On 20-Sep-2021, the patient was confirmed dead. The outcome of cerebral haemorrhage and cerebral ventricular rupture was reported as fatal. Follow-up investigation will be made. Company Comment: Although the events "cerebral haemorrhage" and "cerebral ventricular rupture" developed after the administration of COVID-19 vaccine mRNA (mRNA 1273), factors such as concurrent conditions and predisposing factors of the patient may have also had an influence.; Reporter''s Comments: Although the events "cerebral haemorrhage" and "cerebral ventricular rupture" developed after the administration of COVID-19 vaccine mRNA (mRNA 1273), factors such as concurrent conditions and predisposing factors of the patient may have also had an influence.; Sender''s Comments: This case concerns a 15-year-old, male patient with medical history of cerebral arteriovenous malformation, who experienced the unexpected serious adverse event of special interest of cerebral haemorrhage and unexpected serious adverse event of cerebral ventricular rupture . The events occurred approximately 9 hours after the first dose of Spikevax (Moderna COVID-19 vaccine) and had fatal outcome with death occurring 3 days after following day. The rechallenge was not applicable as the events occurred after the first dose. The event was considered related to the vaccine per the reporter''s assessment. The medical history of the patient of previous cerebral arteriovenous malformation remain as a significant confounder. The benefit-risk relationship of Spikevax (Moderna COVID-19 vaccine) is not affected by this report.; Reported Cause(s) of Death: Cerebral haemorrhage; Cerebral ventricular rupture


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