Age: 76.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Heart rate, Heart rate irregular, Infarction, Investigation, Magnetic resonance imaging
Clinical narrative: Stroke; Caller reported that one of the CT scans that he got showed a brain bleed/he had a small bleed in the cerebellum.; Caller reported that the minor infarct on his first CT scan performed after his stroke; Irregular heartbeat; Lost balance; Dizzy; This is spontaneous report from a contactable consumer (patient). A 76-year-old male patient received bnt162b2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, Lot Number: EP7534), second dose via an unspecified route of administration, administered in Arm Left on 17Mar2021 08:30 (at 76 years old), single dose for covid-19 immunisation. Medical history included ongoing Low thyroid, Possible atrial fibrillation,  there was a question of whether he had atrial fibrillation in years past but it was never determined with certainty whether the caller actually had atrial fibrillation. He went to see a cardiologist years ago for the possible atrial fibrillation but the tests came back negative; Knees were so painful. Every time his family went overseas, he got tetanus, typhoid, diphtheria, and other vaccines. The vaccines were all done in military facilities.  He received these vaccines somewhere between the ages of 0 and 15 years old. Patient's tetanus and diphtheria booster in 2007 caused a sore arm. The shingles vaccine in 2012 caused a sore arm. The Prevnar-23 vaccine in 2013 or 2014 caused a sore arm. He was adopted so he doesn't know his family history. He heard anecdotal evidence that his mother suffered a stroke and died at 61 but that his father lived apparently well into his 90's.The patient had his first dose of bnt162b2 for COVID-19 immunisation on 23Feb2021, left arm, lot number: EN6200. Concomitant medications included levothyroxine; vitamin c [ascorbic acid]; chondroitin sulfate sodium, glucosamine hydrochloride; colecalciferol (VITAMIN D3); aspirin [acetylsalicylic acid].  Patient experienced 15 hours after he received his second dose of the Covid-19 vaccine on 17Mar2021, he had a stroke.Stroke occurred at 11:30 PM on 17Mar2021. He was admitted on 18Mar2021 as the stroke occurred so late on 17Mar2021. He was discharged late in the afternoon on 22Mar2021. He has vastly improved. He is not 100% recovered but that he has made great strides and great improvements. He was in great shape before the stroke on 17Mar2021. For a guy his age, he has the vitals of a 19 year old.    he was walking 2 to 3 miles or biking for 30-45 minutes daily, lifting weights three times a week, and doing yoga before the stroke. He was in good shape and that he thinks that may have had a part in bringing him back quickly from the stroke.   we are only a month in post-stroke, and that he is not 100% but he is very close, probably 90% back.He was started on Atorvastatin and Clopidogrel after his stroke. He takes the vitamins as a prophylactic for overall health. The glucosamine and chondroitin seems to have helped his knee pain immensely. He has been wearing a heart monitor since his stroke on 17Mar2021. He noted an irregular heartbeat once when he woke up about a week ago. The irregular heartbeat occurred maybe on 15Apr2021. There was just one episode of irregular heartbeat. All of his stroke assessments kept improving and getting better while he was hospitalized after his stroke on 17Mar2021.The hospital was performing CT scans and MRIs practically daily while in the hospital.One of the CT scans that he got showed a brain bleed. He thinks the CT scan that showed a brain bleed was after tPA, tissue plasminogen activator, had been administered. The repeat CT scans and MRIs were because the medical staff wanted to ensure that there was no further damage or bleed after the tissue plasminogen activator was administered.One CT scan showed that he had a small bleed in the cerebellum. The bleed in his cerebellum was probably because of the tissue plasminogen activator that was administered but it doesn't seem to have any lasting effects.Caller queried for product details of tissue plasminogen activator but he was unable to provide as it was administered in the hospital.His balance is back, he is riding a bike again, he is going for walks, and he does not feel dizzy.His balance returned probably about 2 weeks ago.On 17Mar2021, he was so dizzy that he couldn't raise himself up in bed.   the dizziness was slow to resolve and probably resolved in the last week.The minor infarct on his first CT scan performed after his stroke on 17Mar2021 may have occurred previously.The hospital staff performed a CT scan after the patient arrived at the hospital following his 17Mar2021 stroke.Hospital staff administered the tissue plasminogen activator after the first CT scan and that another CT scan was performed 12 hours later after tissue plasminogen activator administration. The CT after the tissue plasminogen activator administration showed the small bleed in his cerebellum. He has had video visits with occupational therapy, physical therapy, his neurologist, and he had one scheduled for a speech therapist but she didn't want to talk to him.His therapists and physician say that he is ok and there is no reason for them to see the caller again. He had one follow up with his occupational therapist and the therapist told the caller that she didn't see any reason to see the caller again. The outcome of the event Stroke was recovering; Cerebellar bleeding, infarction was unknown, other events was recovered.