Pseudoephedrine-induced Hemorrhage Associated with a Cerebral Vascular Malformation

Abstract

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...

Chronic rhinosinusitis increased the risk of stroke: A 5‐year follow‐up study

“…Furthermore, sleep difficulties and snoring are common among many CRS patients,19 and have been suggested to elevate the risk of stroke and cardiovascular disease 20, 21. Finally, it also is possible that some management of CRS may increase the risk of stroke such as decongestant22 and glucocorticoids23 use, as well as endoscopic sinus surgery 24…”

Don't Get Cut on Occam's Razor!

“…The article Pseudoephedrine-induced hemorrhage associated with a cerebral vascular malformation by Baker et al in this issue of the Journal forces one to consider several issues in addition to the ones they raise: 1 1. Occam's Law of Parsimony, later called Occam's razor, states that one should not look for multiple causes when a single one provides a suitable explanation.…”

“…In the case by Baker et al an arteriovenous malformation AND a hypertensive response to pseudoephedrine were responsible for the intracerebral hemorrhage. 1 The exaggerated pharmacological response, in turn, may relate to a hereditary predisposition, invoking a third potential contributor.…”

“…In the case reported by Baker et al, the hemorrhage occurred in the centrum semiovale in a 50 year old man. 1 This site would be atypical for a hypertensive hemorrhage, even if it were druginduced. Most hypertensive hemorrhages occur in the "vascular centrencephalon" (the thalamus, lentiform nuclei, middle pons and cerebellum) where end-arteries bear the brunt of severe hypertension.…”

“…The authors were exemplary in demonstrating this principle. 1 3. Disasters cry out for preventive measures.…”