Intracranial Hemorrhage and Cerebral Angiopathic Changes in a Suicidal Phenylpropanolamine Poisoning

Maertens, Paul; G, Lum; Jp, Williams; White, J. A.

doi:10.1097/00007611-198712000-00024

Cited by 17 publications

(4 citation statements)

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“…It is believed to arise from multifocal vasospasm which produces a picture of angiographic beading reminiscent of vasculitis. 8,14,15,23,24 These findings are nonspecific for cerebral arteritis and likely reflect segmental vasoconstriction rather than a drug-mediated immune vasculitis. 11 It may be that the arteries within the AVM are vulnerable to exogenous vasoconstrictors increasing the bleeding diathesis.…”

Section: Discussionmentioning

confidence: 99%

“…to ICH. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Recently, the Hemorrhagic Stroke Project, an elaborate case-control study, 17 concluded that PPA exposure from appetite suppressants, and to a lesser extent oral decongestants, significantly increased the risk for hemorrhagic stroke. The adjusted odds ratios (ORa) for the risk of ICH in women taking diet preparations or cough and cold remedies containing PPA was 16.58 and 1.54, respectively.…”

Section: Pseudoephedrine-induced Hemorrhage Associated With a Cerebramentioning

confidence: 99%

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Pseudoephedrine-induced Hemorrhage Associated with a Cerebral Vascular Malformation

Baker

Silva²,

Lam³

2005

Can. j. neurol. sci.

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248 Sympathomimetics (i.e., phenylpropanolamine (PPA), phenylephrine, ephedrine, and pseudoephedrine) found in overthe-counter decongestant and anorectic medications have been implicated in the causation of ischemic and hemorrhagic stroke. Particular interest has focussed on the increased risk of intracerebral hemorrhage (ICH) attributable to PPA ingestion. Since 1979, more than 30 published reports have linked PPA use ABSTRACT: Background: Sympathomimetic-related intracerebral hemorrhage is well-documented. Most cases are associated with phenylpropanolamine use. Case Report: We report a case of intracerebral hemorrhage occurring in a middle-aged man who suffered from chronic sinusitis and had been ingesting pseudoephedrine daily for one year. This patient was previously well with no known cardiovascular risk factors. Clinical examination revealed no evidence of vasculitis nor coagulopathy and initial neuroimaging (i.e., computed tomography, angiography, magnetic resonance imaging) demonstrated no features consistent with aneurysm, arteriovenous malformation (AVM), cavernoma, nor cerebral metastases. A follow-up cerebral angiogram demonstrated a small AVM arising off a branch of the pericallosal artery and a small arteriovenous fistula arising off the costal marginal branch. The AVM was embolized without incident, however, the AVF was not accessible. Conclusions: Sympathomimetics have long been associated with intracerebral hemorrhage. Since 1979, over 30 published case reports have documented the relationship between phenylpropanolamine and stroke. Only one report links phenylpropanolamine consumption to an intracerebral hemorrhage in a patient with an AVM. There is a paucity of literature etiologically inculpating other ephedra alkaloids in the causation of intracerebral hemorrhage. This is a case of pseudoephedrine-induced intracerebral hemorrhage in a patient with an underlying vascular malformation. RÉSUMÉ: Hémorragie induite par la pseudoéphédrine au niveau d'une malformation vasculaire cérébraleIntroduction: L'hémorragie intracérébrale (HIC) en relation avec les substances sympathomimétiques est bien connue. La plupart des cas sont associés à la phénylpropanolamine. Cas clinique: Il s'agit d'un cas de HIC chez un homme d'âge moyen atteint de sinusite chronique qui faisait usage de pseudoéphédrine quotidiennement depuis un an. Ce patient était en bonne santé, sans facteur de risque cardiovasculaire connu. L'examen clinique n'a montré aucun signe de vasculite ou de coagulopathie. À la neuroimagerie (CT, angiographie, RMN), aucune image compatible avec un anévrisme, une malformation artérioveineuse (MAV), un angiome caverneux ou des métastases cérébrales n'a été décelée. Au cours du suivi, une angiographie cérébrale a montré la présence d'une petite MAV issue d'une branche de l'artère péricalleuse ainsi qu'une petite fistule artérioveineuse (FAV) issue d'une branche de l'artère callosomarginale. La MAV a été traitée par embolisation sans incident. Cependant, la FAV n'était pas accessible. Conclusions: Le lie...

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Section: Discussionmentioning

confidence: 99%

Section: Pseudoephedrine-induced Hemorrhage Associated With a Cerebramentioning

confidence: 99%

Pseudoephedrine-induced Hemorrhage Associated with a Cerebral Vascular Malformation

Baker

Silva²,

Lam³

2005

Can. j. neurol. sci.

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“…We found 39 cases reported in the literature: 31 associated with the use of PPA 2-10,19 -21,25-40 ; 4 with pseudoephedrine, ephedrine, and ephedra alkaloid derivatives 16,[41][42][43] ; 2 with phentermine 44,45 ; and 2 with sympathomimetics used by the nasal route (oxymetazoline and fenoxazoline). 46,47 PPA use is associated largely with the occurrence of intracranial hemorrhage 21,26,27 and only occasionally with development of an ischemic stroke. 7,25 Only 1 of the 16 patients in our series had an ischemic stroke, and only 2 cases are described in 31 previous reports.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, some patients have taken an overdose as a deliberate suicide attempt. 8,26 Conversely, it should be noted that some cerebrovascular events are associated with a single low dose of PPA, probably in an idiosyncratic manner. 3,8,9,31,[33][34][35][36][37]39 The interval between the use of the sympathomimetic and stroke onset was variable, in most cases Յ6 hours (60% to 70%), but in 25% to 35% the interval lasted Ͻ1 hour.…”

Section: Discussionmentioning

confidence: 99%

Editorial Comment—Over-the-Counter Cold Remedies and Stroke

Brust

2003

Stroke

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Background and Purpose-Phenylpropanolamine (PPA) and pseudoephedrine are sympathomimetics contained in over-the-counter cold preparations. A case-control study linked PPA use with hemorrhagic stroke in women. Twenty-two patients with stroke associated with use of these drugs are described. Methods-In a consecutive stroke registry since 1988, 22 patients had stroke associated with over-the-counter sympathomimetics. Sympathomimetic dosage and type, time interval until stroke onset, and neuroimaging findings are described. Results-Ten male and 12 female patients were included. Intracerebral hemorrhage occurred in 17 patients, subarachnoid hemorrhage in 4, and ischemic stroke in 1. Stroke was associated with PPA use in 16 patients (dose 75 to 675 mg), with pseudoephedrine in 4 (dose 60 to 300 mg), and with others administered by the nasal route in 2 (oxymetazoline and phenylephrine). Stroke occurred after a single dose in 17 patients and after daily use during several days in 5. The interval between drug exposure and clinical onset varied from 30 minutes to 24 hours. Stroke occurred after recommended doses of PPA (50 to 75 mg) in 32% and pseudoephedrine (60 mg) in 50% of patients. Eight patients had acute hypertension at stroke onset. Cerebral angiography was normal in 8 cases and showed diffuse vasospasm or beading in 10 patients. Conclusions-Stroke related to over-the-counter sympathomimetics was associated with acute hypertension and/or vasospasm or angiitis mechanisms, most related to the use of PPA; however, stroke also occurred with the use of other sympathomimetics, particularly pseudoephedrine. Although stroke complications occurred when doses were used that were higher than recommended doses, apparently there is also a stroke risk when these agents are taken properly.

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