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Dietary Supplements and Stroke
MEDICAL IMAGES RUNNING HEAD
Dietary Supplements and Stroke ELIZABETH S. MCDONALD, MD, PHD, AND JOHN I. LANE, MD Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minn
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n the past, phenylpropanolamine (dl-norephedrine, an ephedrine alkaloid) was a common ingredient in appetite suppressants and cough and cold medicines. It has been associated with hypertension1 and is an independent risk factor for hemorrhagic stroke in women.2 Dietary supplements with ephedra alkaloids are also associated with cardiovascular and central nervous system adverse events.3 A 36-year-old woman presented to the emergency department with headache, dizziness, nausea, vomiting, and abdominal discomfort. She was diagnosed with a migraine and was discharged with a prescription for promethazine. She later returned still complaining of headache and was referred to an outpatient clinic without emergency department evaluation. She was admitted from this clinic to the hospital for rehydration. On admission, noncontrast computed tomography of the head showed infarction of the posterior two thirds of the medial aspect of the right cerebellar hemisphere with adjacent localized mass effect. The next day, an acute stroke was confirmed on magnetic resonance imaging: fluid-attenuated inversion recovery axial images revealed increased signal in the right posterior inferior cerebellar artery (PICA) territory (A), and diffusion-weighted axial images showed increased signal consistent with restricted diffusion, which is indicative of acute ischemia (B). Cerebral angiography showed occlusion of the right PICA (C) and bilateral vertebral artery dissections (D). An extensive thrombophilia work-up revealed no evidence of a coagulation disorder. The patient had no risk factors for or family history of stroke. A urine drug screen confirmed the presence of ephedrine and phenylpropanolamine. After these findings were discussed, the patient’s husband brought in a bottle of the patient’s “diet and energy pills,” which listed ephedrine group alkaloids as one of the ingredients. Ephedrine alkaloid ingestion with resulting hypertension and subsequent vertebral artery dissection may be the mechanism of massive stroke in this otherwise healthy young woman. It is important to consider dietary supplement ingestion when evaluating young patients with unexpected stroke or myocardial infarction. 1. Cantu C, Arauz A, Murillo-Bonilla LM, Lopez M, Barinagarrementeria F. Stroke associated with sympathomimetics contained in over-the-counter cough and cold drugs. Stroke. 2003;34:1667-1672. 2. Kernan WN, Viscoli CM, Brass LM, et al. Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med. 2000;343:1826-1832.
Mayo Clin Proc.
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D 3. Haller CA, Benowitz NL. Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. N Engl J Med. 2000;343:1833-1838. © 2005 Mayo Foundation for Medical Education and Research
March 2005;80(3):315 •
www.mayoclinicproceedings.com
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Dietary Supplements and Stroke ELIZABETH S. MCDONALD, MD, PHD, AND JOHN I. LANE, MD Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minn
I
n the past, phenylpropanolamine (dl-norephedrine, an ephedrine alkaloid) was a common ingredient in appetite suppressants and cough and cold medicines. It has been associated with hypertension1 and is an independent risk factor for hemorrhagic stroke in women.2 Dietary supplements with ephedra alkaloids are also associated with cardiovascular and central nervous system adverse events.3 A 36-year-old woman presented to the emergency department with headache, dizziness, nausea, vomiting, and abdominal discomfort. She was diagnosed with a migraine and was discharged with a prescription for promethazine. She later returned still complaining of headache and was referred to an outpatient clinic without emergency department evaluation. She was admitted from this clinic to the hospital for rehydration. On admission, noncontrast computed tomography of the head showed infarction of the posterior two thirds of the medial aspect of the right cerebellar hemisphere with adjacent localized mass effect. The next day, an acute stroke was confirmed on magnetic resonance imaging: fluid-attenuated inversion recovery axial images revealed increased signal in the right posterior inferior cerebellar artery (PICA) territory (A), and diffusion-weighted axial images showed increased signal consistent with restricted diffusion, which is indicative of acute ischemia (B). Cerebral angiography showed occlusion of the right PICA (C) and bilateral vertebral artery dissections (D). An extensive thrombophilia work-up revealed no evidence of a coagulation disorder. The patient had no risk factors for or family history of stroke. A urine drug screen confirmed the presence of ephedrine and phenylpropanolamine. After these findings were discussed, the patient’s husband brought in a bottle of the patient’s “diet and energy pills,” which listed ephedrine group alkaloids as one of the ingredients. Ephedrine alkaloid ingestion with resulting hypertension and subsequent vertebral artery dissection may be the mechanism of massive stroke in this otherwise healthy young woman. It is important to consider dietary supplement ingestion when evaluating young patients with unexpected stroke or myocardial infarction. 1. Cantu C, Arauz A, Murillo-Bonilla LM, Lopez M, Barinagarrementeria F. Stroke associated with sympathomimetics contained in over-the-counter cough and cold drugs. Stroke. 2003;34:1667-1672. 2. Kernan WN, Viscoli CM, Brass LM, et al. Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med. 2000;343:1826-1832.
Mayo Clin Proc.
•
A
B
C
D 3. Haller CA, Benowitz NL. Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. N Engl J Med. 2000;343:1833-1838. © 2005 Mayo Foundation for Medical Education and Research
March 2005;80(3):315 •
www.mayoclinicproceedings.com
315