title: Intracerebral hemorrhage associated with oral phenylephrine use: a case report and review of the literature.
abstract: BACKGROUND
  Prior reports have linked both ischemic and hemorrhagic stroke to use of sympathomimetic drugs including phenylephrine. The purpose of this study is to describe the first case, to our knowledge of intracerebral hemorrhage (ICH) after oral use of phenylephrine and to systematically review the literature on phenylephrine and acute stroke.
  
  
  METHODS
  A case report and review of the literature.
  
  
  RESULTS
  A 59-year-old female presented with thunderclap headache, right hemiparesis, aphasia, and left gaze deviation. Head computed tomography (CT) showed a left frontal ICH with intraventricular and subarachnoid extension. She had no significant past medical history. For the previous 30 days, the patient was taking multiple common cold remedies containing phenylephrine to treat sinusitis. CT and magnetic resonance angiography showed no causative vascular abnormality. Catheter cerebral angiography supported reversible cerebral vasoconstriction syndrome (RCVS). Phenylephrine was determined to be the most likely etiology for her hemorrhage. A review of the literature, found 7 cases describing phenylephrine use with acute stroke occurrence: female, 5 of 7 (71%); route of administration, nasal (n = 3), ophthalmic (n = 2), intravenous (n = 1), intracorporeal injection (n = 1). Stroke types were subarachnoid hemorrhage (n = 5), ICH (n = 4), and ischemic (n = 1). One case reported RCVS after phenylephrine use.
  
  
  CONCLUSIONS
  It is scientifically plausible that phenylephrine may cause strokes, consistent with the pharmacologic properties and adverse event profiles of similar amphetamine-like sympathomimetics. As RCVS has been well described in association with over-the-counter sympathomimetics, a likely, although not definitive, causal relationship between phenylephrine and ICH is proposed.
authors.affiliation: Department of Neurology and Stroke Center, SUNY Downstate Medical Center, Brooklyn, New York.
authors.forename: Brian E
authors.initials: BE
authors.lastname: Tark
authors.affiliation: Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Steven R
authors.initials: SR
authors.lastname: Messe
authors.affiliation: Department of Neurology and Stroke Center, SUNY Downstate Medical Center, Brooklyn, New York.
authors.forename: Clotilde
authors.initials: C
authors.lastname: Balucani
authors.affiliation: Department of Neurology and Stroke Center, SUNY Downstate Medical Center, Brooklyn, New York; Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York. Electronic address: steven.levine@downstate.edu.
authors.forename: Steven R
authors.initials: SR
authors.lastname: Levine
mesh_terms: D000281:Administration, Intranasal; D002533:Cerebral Angiography; D002561:Cerebrovascular Disorders / Q000139:chemically induced / Q000473:pathology; D005260:Female; D051270:Headache Disorders, Primary / Q000209:etiology; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced* / Q000473:pathology; D008875:Middle Aged; D010656:Phenylephrine / Q000008:administration & dosage / Q000009:adverse effects*; D020521:Stroke / Q000139:chemically induced / Q000209:etiology; D013566:Sympathomimetics / Q000008:administration & dosage / Q000009:adverse effects*; D020301:Vasospasm, Intracranial / Q000209:etiology
chemical_list: D013566:Sympathomimetics; D010656:Phenylephrine
keywords: Hemorrhagic stroke; phenylephrine; reversible cerebral vasoconstriction syndrome; sympathomimetics