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Fatal Post COVID mRNA-Vaccine Associated Cerebral Ischemia Keywords: COVID-19; Moderna vaccine; cerebral edema; neurology; stroke. McMillan N, Rosenberg HJ, Anderson MP, Pal P, Stephenson K, Fehnel CR. Fatal Post COVID mRNA-Vaccine Associated Cerebral Ischemia. Neurohospitalist. 2023 Apr;13(2):156-158. doi: Epub 2022 Dec 5. PMID: 37064937; PMCID: PMC10091442. Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA. Background Venous thromboses have been linked to several COVID-19 vaccines Here we describe a case of post-Moderna COVID-19 vaccination arterial infarct, with vaccine-associated diffuse cortical edema, that was complicated by refractory intracranial hypertension. Case summary 24 hrs after receiving her first dose of the Moderna COVID-19 vaccine, a 30-year-old female developed severe headache. Three weeks later she was admitted with subacute headache and confusion. Imaging initially showed scattered cortical thrombosis with an elevated opening pressure on lumbar puncture. An external ventricular drain was placed, but she continued to have elevated intracranial pressure. Ultimately, she required a hemicraniectomy, but intractable cerebral edema resulted in her death. Pathology was consistent with thrombosis and associated inflammatory response. Conclusion Though correlational, her medical team surmised that the mRNA vaccine may have contributed to this presentation. The side effects of COVID-19 infection and vaccination are still incompletely understood. Though complications are rare, clinicians should be aware of presentations like this one. More information Had prior asymptomatic COVID-19 infection three months earlier 24-hours after first dose of the mRNA COVID-19 vaccine (Moderna). Developed severe, atypical throbbing bi-frontal headache Headaches were atypical (no prior headaches) Three weeks after vaccination Developed blurred vision and confusion Bifrontal headache with photophobia Lumbar puncture revealed lymphocytosis Broad spectrum antimicrobial coverage was started. Her mental status acutely worsened later that evening New left hemiparesis. Elevated D-dimer CSF cultures and PCR testing returned negative Intracranial pressure remained refractory to maximal medical management, including deep sedation, paralysis and hypothermia, prompting a right decompressive hemicraniectomy. The patient expired from refractory cerebral edema. Brain autopsy showed infiltrates of CD8 and CD4-positive T-cells, in association with intravascular thrombi Fungal and bacterial stains were negative. Discussion Diffuse endothelial damage and vessel wall inflammation, suggested an underlying pro-thrombotic state and T cell inflammatory response. The arterial infarct in this case is likely related to a pro-thrombotic state Due to the large volume of infarction, the patient was not started on anticoagulation after extensive discussion of the risks vs potential benefit. In summary, administration of COVID-19 vaccine was considered a possible cause of the extensive multifocal arterial thromboses with associated inflammatory response and elevated intracranial pressure given the temporal association. The mechanism for initial elevation in intracranial pressure is not known but may relate to cerebral autoregulatory changes in the setting of cortical microvascular thrombosis. Suspected Unexpected Serious Adverse Reaction (SUSAR) such as this would have put a pause on the entire study and an investigation into why this happened and a call for risk mitigation measures to prevent the same complication from happening to more subjects.
