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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1208853



Case Details

VAERS ID: 1208853 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-28
Onset:2021-02-26
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood creatinine, Computerised tomogram head, Death, Traumatic intracranial haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ACETYLSALICYLIC ACID; VALPROATE SODIUM; VALPROATE SODIUM; LITHIUM CARBONATE; LISINOPRIL; QUETIAPINE FUMARATE
Current Illness: Adiposis (WHO grade I (BMI 30.7 kg/m2)); Arterial hypertension; Bipolar affective disorder; Gonarthrosis
Preexisting Conditions: Medical History/Concurrent Conditions: Acute renal insufficiency (most likely pharmacological secondary to lithium overdose)
Allergies:
Diagnostic Lab Data: Test Date: 20210202; Test Name: Creatinine; Result Unstructured Data: high; Test Date: 20210226; Test Name: CT of neurocranium; Result Unstructured Data: cranial calvaria and posterior fossa, native and with i.v. contrast examination. RESULT: Large, space-occupying, acute subdural hematoma in the left hemisphere with consecutive midline shift. Subfalcine, uncal, and incipient transtentorial herniation. Extensive SAH [subarachnoid hemorrhage] emphasized in the left hemisphere and frontobasal contusion hemorrhages on the left. Signs of CSF congestion and consecutive brain stem compression. Suspected left hemispheric brain edema. Non-dislocated, semi-circumferential fracture with involvement of the frontal, parietal, and occipital bones on the right and the occipital and parietal bones on the left: Large, space-occupying, acute subdural hematoma in the left hemisphere with consecutive midline shift. Subfalcine, uncal, and incipient transtentorial herniation. Extensive SAH [subarachnoid hemorrhage] emphasized in the left hemisphere and frontobasal contusion hemorrhages on the left. Signs of CSF congestion and consecutive brain stem compression.
CDC Split Type: CHMODERNATX, INC.MOD20210

Write-up: Death NOS; Cerebral hemorrhage traumatic; This regulatory authority case was reported by an other health care professional (subsequently medically confirmed) and describes the occurrence of DEATH (Death NOS) and TRAUMATIC INTRACRANIAL HAEMORRHAGE (Cerebral hemorrhage traumatic) in a 76-year-old male patient who received mRNA-1273 (COVID-19 Vaccine Moderna) (batch no. 3000427) for COVID-19 vaccination. The patient''s past medical history included Acute renal insufficiency (most likely pharmacological secondary to lithium overdose) in January 2021, Arterial hypertension since an unknown date, Adiposis (grade I (BMI 30.7 kg/m2)) since an unknown date, Bipolar affective disorder since an unknown date and Gonarthrosis since an unknown date. Concomitant products included ACETYLSALICYLIC ACID, VALPROATE SODIUM, VALPROATE SODIUM, LITHIUM CARBONATE, LISINOPRIL and QUETIAPINE FUMARATE for an unknown indication. On 28-Jan-2021, the patient received first dose of mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 25-Feb-2021, received second dose of mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular) dosage was changed to 1 dosage form. On 26-Feb-2021, the patient experienced TRAUMATIC INTRACRANIAL HAEMORRHAGE (Cerebral hemorrhage traumatic) (seriousness criterion death). The patient died on 01-Mar-2021. The cause of death was not reported. It is unknown if an autopsy was performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 02-Feb-2021, Blood creatinine: 92 (High) high. On 26-Feb-2021, Computerised tomogram head: abnormal (abnormal) cranial calvaria and posterior fossa, native and with i.v. contrast examination. RESULT: Large, space-occupying, acute subdural hematoma in the left hemisphere with consecutive midline shift. Subfalcine, uncal, and incipient transtentorial herniation. Extensive SAH [subarachnoid hemorrhage] emphasized in the left hemisphere and frontobasal contusion hemorrhages on the left. Signs of CSF congestion and consecutive brain stem compression. Suspected left hemispheric brain edema. Non-dislocated, semi-circumferential fracture with involvement of the frontal, parietal, and occipital bones on the right and the occipital and parietal bones on the left: Large, space-occupying, acute subdural hematoma in the left hemisphere with consecutive midline shift. Subfalcine, uncal, and incipient transtentorial herniation. Extensive SAH [subarachnoid hemorrhage] emphasized in the left hemisphere and frontobasal contusion hemorrhages on the left. Signs of CSF congestion and consecutive brain stem compression.. For mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular), the reporter considered DEATH (Death NOS) and TRAUMATIC INTRACRANIAL HAEMORRHAGE (Cerebral hemorrhage traumatic) to be unlikely related. CT of neurocranium incl. cranial calvaria and posterior fossa, native and with i.v. contrast examination was performed RESULTS: Large, space-occupying, acute subdural hematoma in the left hemisphere with consecutive midline shift. Subfalcine, uncal, and incipient transtentorial herniation. Extensive SAH [subarachnoid hemorrhage] emphasized in the left hemisphere and frontobasal contusion hemorrhages on the left. Based on reporter''s causality and the patient''s advanced age along with multiple comorbidities, the event is assessed as unlikely related to mRNA-1273. Reporter did not allow further contact; Sender''s Comments: Based on reporter''s causality and the patient''s advanced age along with multiple comorbidities, the event is assessed as unlikely related to mRNA-1273.; Reported Cause(s) of Death: Unknown case of death


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