According to a case report published in the National Library of Medicine, a 41-year-old Moroccan woman died from a fatal intracerebral hemorrhage (ICH) 18 days after receiving the ChAdOx1 nCoV-19 COVID-19 vaccine, with medical evaluations showing normal platelet counts and no coagulation abnormalities. The event highlights rare neurological complications following viral vector vaccination outside the typical parameters of vaccine-induced immune thrombotic thrombocytopenia.
Patient Presentation and Clinical Timeline
The patient, a 41-year-old mother of three with no prior cardiovascular risk factors, was admitted to the hospital with an afebrile altered level of consciousness exactly 15 days after receiving her dose of the ChAdOx1 nCoV-19 vaccine, according to the case report. Upon admission, her Glasgow Coma Scale score registered at 3 out of 15, and her blood pressure was recorded at 130/80 mmHg with no history of trauma or anticoagulant use.
Eight days post-vaccination—one week prior to her hospital admission—she developed a persistent headache accompanied by ocular pain and photophobia that failed to respond to paracetamol. A subsequent brain computed tomography (CT) scan revealed a deep capsulolenticular intraparenchymal hemorrhage extending into the brainstem. The scan also showed extensive intraventricular hemorrhage, diffuse cerebral edema, and subfalcine herniation.
Laboratory Findings and VITT Exclusion
Hematological evaluations upon admission showed a normal platelet count of 342,000 per microliter, placing her well within the normal reference range of 150,000 to 400,000 per microliter. Additional lab results indicated a hemoglobin level of 12.5 grams per deciliter and normal liver and renal function test parameters. These standard parameters meant the clinical picture did not support a diagnosis of vaccine-induced immune thrombotic thrombocytopenia (VITT), which typically features low platelets and elevated D-dimer levels.
Did you know? VITT typically occurs between five and 30 days after receiving a ChAdOx1 vaccination, frequently involving cerebral venous sinus thrombosis accompanied by thrombocytopenia and anti-platelet factor 4 antibodies.
The treating clinicians noted a limitation in their diagnostic workup: anti-platelet factor 4 (anti-PF4) antibody testing could not be performed due to local unavailability and financial constraints preventing an external lab transfer. Despite this missing assay, the normal platelet count and standard coagulation parameters made VITT unlikely.
Comparative Analysis with Prior Cases
Isolated hemorrhagic strokes occurring without thrombocytopenia remain exceedingly rare following viral vector immunizations. The Moroccan case shares striking similarities with a previously documented patient evaluated by de Mélo Silva and colleagues, who reported a 57-year-old woman experiencing a large frontal intracerebral hematoma five days after her first dose of the ChAdOx1 nCoV-19 vaccine.
| Variable | Current Case | de Mélo Silva et al. (2021) |
|---|---|---|
| Age and Sex | 41-year-old woman | 57-year-old woman |
| Vaccine Type | ChAdOx1 nCoV-19 | ChAdOx1 nCoV-19 |
| Time to Onset | 8–15 days | 5 days |
| Platelet Count | Normal (342,000/μL) | Normal |
| Outcome | Fatal (death on day 2 of admission) | Survived with neurological deficit |
While the de Mélo Silva patient survived with neurological deficits and showed no thrombosis on angiography, the 41-year-old patient managed in intensive care deteriorated rapidly and died two days after admission. Using the Naranjo Scale, authors of the Moroccan case assigned a score of 4, indicating a possible association between the vaccine and the hemorrhage.
Hospital Management and Pharmacovigilance
Medical staff in the intensive care unit managed the patient by positioning her in a semi-recumbent posture and providing mechanical ventilation supported by sedation with propofol and midazolam, according to the case report. Fluid and electrolyte replacements were administered alongside mannitol to reduce intracranial pressure and valproate for antiepileptic prophylaxis.
Despite intensive interventions, the patient succumbed to her injuries 18 days after receiving the vaccine. In line with national protocols, the case was formally reported to the National Pharmacovigilance Center via the post-vaccination adverse event surveillance program.
Frequently Asked Questions
What is intracerebral hemorrhage?
Intracerebral hemorrhage is a severe stroke subtype where bleeding occurs directly into the brain tissue, accounting for 10% to 20% of all global stroke incidents.
How does VITT differ from standard post-vaccination bleeding?
Vaccine-induced immune thrombotic thrombocytopenia typically involves low platelet counts, elevated D-dimers, and thrombosis at unusual sites like cerebral venous sinuses, whereas isolated ICH cases present with normal clotting parameters.
Was a causal link established in this case report?
No definitive causal relationship can be established. The Naranjo Scale score of 4 points only to a possible association, and researchers emphasize that further studies are required to explore alternative mechanisms such as endothelial dysfunction or inflammation-mediated vascular injury.
To stay updated on medical case reports, neurological research, and global health pharmacovigilance data, subscribe to our newsletter or explore our archive of recent clinical studies.