541675
research-article2014
CPJXXX10.1177/0009922814541675Clinical PediatricsSamanta
Brief Report
Reversible Cerebral Vasoconstriction Syndrome: Another Health Hazard of Energy Drinks?
Clinical Pediatrics 2015, Vol. 54(2) 186–187 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814541675 cpj.sagepub.com
Debopam Samanta, MD1 Introduction Reversible cerebral vasoconstriction syndrome (RCVS) includes a diverse group of diseases characterized by reversible narrowing of the cerebral arteries. Patients present with thunderclap headache with or without neurologic deficit. RCVS can be idiopathic but in most cases association with vasoactive agents (sympathomimetic drugs or drugs that modulate dopamine or serotonin system) is present.1 Energy drinks are very popular in the young generation for its stimulant effect. Binge drinking is not uncommon in sports enthusiasts and in students or young professionals, especially before major examination or prior to an event when they try to stay awake longer. We report a pediatric case of RCVS presenting after binge drinking of one type of energy drink. Vigorous search for precipitating secondary factor is highly rewarding as sometimes discontinuation of the offending agent is the only treatment required and very effective to prevent further episodes.
Case Report A 16-year-old previously healthy teenager was transferred to our hospital from an outside hospital where he had presented with complaints of thunderclap headache, vomiting, left leg numbness, and gait difficulty. He was tachycardic but his blood pressure was within the normal range. Higher mental function, cranial nerve examination, and motor strength were normal. Deep tendon reflexes were brisker in the left knee and ankle. Sensory deficit was noted in the left lower extremity to light touch, pinprick, and temperature. Proprioception was very much impaired in the left lower extremity up to ankle. Babinski sign was positive on the left side. Computed tomography scan of the head was negative for subarachnoid hemorrhage. Magnetic resonance imaging scan of the (MRI) brain revealed numerous cortical and subcortical foci of abnormally restricted diffusion (Figure 1). Diffuse luminal irregularity with intermittent narrowing of distal branches of the anterior, middle, and posterior cerebral arteries were evident in the MR angiography (Figure 2). He denied using any drugs except acetaminophen. Specific enquiry about cocaine, Ecstasy, cannabis,
bromocriptine, nasal decongestants, diet pills, stimulant drugs, and selective serotonin reuptake inhibitor were made and was negative. Urine drug screen, echocardiogram, blood and cerebrospinal fluid metabolic panel, hypercoagulability panel, inflammatory and infectious workup were noncontributory. With extensive questioning, history of binge drinking of an energy drink (four 8-ounce cans) several hours prior to his onset of his symptoms was found. The caffeine content of that drink was approximately 10 mg/ oz.2 The patient received oral analgesic and antiemetic for symptomatic management. He was discharged after initiation of verapamil and was advised for strict avoidance of the energy drink and caffeine. Serial follow-up for more than 2 years showed compliance in avoiding vasoactive agents with no recurrence of symptoms. MR angiography after 6 months of initial presentation showed reversal of vascular abnormality.
Discussion The energy drink market is growing significantly in recent years with resurgence of fitness consciousness.3 There have been reports of sudden death, tachycardia, and psychiatric problems after consumption of energy drinks.4 Caffeine and related compounds are the primary psychoactive ingredients of energy drinks. Caffeine, antagonist of adenosine and presynaptic α1 receptor, causes increase catecholamine release to produce the vasoactive effect.5 Phosphodiesterase inhibition may produce an additional effect. Caffeine is primarily metabolized by the cytochrome P450 (CYP) oxidase system in the liver. The clearance and plasma half-life of caffeine vary considerably from person to person and potentially make an individual susceptible to the toxic effect of caffeine in lower doses. In addition, the hepatic enzyme system responsible for caffeine metabolism can become 1
University of Arkansas for Medical Sciences, Little Rock, AR, USA
Corresponding Author: Debopam Samanta, 2010 Rebsamen Park Road, Apt #301, Little Rock, AR 72202, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at Purdue University on June 4, 2015
187
Samanta
Figure 1. DWI MRI shows cortical and subcortical foci of abnormally restricted diffusion.
saturated at high levels, resulting in a marked increase in serum concentration with small additional doses. Energy drinks may also contain herbal constituents (ginkgo biloba leaf extract, Siberian ginseng root extract, etc) with significant sympathomimetic properties. Worrall et al published a report of cerebral vasculopathy and stroke after single consumption of an herbal energy drink.6 The temporal link between heavy energy drink consumption and the occurrence of stroke and cerebral vasculopathy in this young patient without any other vascular risk factors indicates vasospasm from the sympathomimetic constituents of the energy drink. The patient did not have a serum caffeine level but clinical utility of caffeine levels is limited anyway. Because energy drink use is widespread, it could represent a casual event, but in this particular patient symptoms started very closely after binge drinking of this agent and symptoms did not reappear in more than 2 years of follow-up. His continuous clinical and radiological improvement and absence of any other known aggravating factors of RCVS also suggests association of vasospasm with this drink. Cerebral infarction developing from vasoconstriction can produce permanent neurologic deficit though vasoconstriction is reversible with the withdrawal of the offending agent. Treatment of RCVS includes discontinuation of the offending agent with or without calcium channel blocker depending on the clinical situation.7 In view of widespread use of the drink, careful enquiry of consumption of energy drink is warranted in young patients presenting with thunderclap headache, focal deficit, and evidence of cerebral ischemia or vasoconstriction. Reporting of adverse reaction of drink should be warranted to mitigate possible risk of public health.
Figure 2. MR angiography reveals diffuse luminal irregularity with intermittent narrowing of distal branches of the anterior, middle, and posterior cerebral arteries.
Acknowledgments The study was done at the University of Virginia Medical Center, Virginia. Dr Erin Willis proofread the draft for nonintellectual content.
Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author received no financial support for the research, authorship, and/or publication of this article.
References 1. Chen SP, Fuh JL, Wang SJ. Reversible cerebral vasoconstriction syndrome: current and future perspectives. Expert Rev Neurother. 2011;11:1265-1276. 2. Caffeineinformer. http://www.caffeineinformer.com/ caffeine-content/red-bull. Accessed May 23, 2014. 3. Babu K, Church R, Lewander W. Energy drinks: the new eye opener for adolescents. Clin Pediatr Emerg Med. 2008;9:35-42. 4. Higgins JP, Tuttle TD, Higgins CL. Energy beverages: content and safety. Mayo Clin Proc. 2010;85:1033-1041. 5. Benowitz NL. Clinical pharmacology of caffeine. Annu Rev Med. 1990;41:277-288. 6. Worrall BB, Phillips CD, Henderson KK. Herbal energy drinks, phenylpropanoid compounds, and cerebral vasculopathy. Neurology. 2005;65:1137-1138. 7. Chen SP, Fuh JL, Wang SJ. Reversible cerebral vasoconstriction syndrome: an under-recognized clinical emergency. Ther Adv Neurol Disord. 2010;3:161-171.
Downloaded from cpj.sagepub.com at Purdue University on June 4, 2015
research-article2014
CPJXXX10.1177/0009922814541675Clinical PediatricsSamanta
Brief Report
Reversible Cerebral Vasoconstriction Syndrome: Another Health Hazard of Energy Drinks?
Clinical Pediatrics 2015, Vol. 54(2) 186–187 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814541675 cpj.sagepub.com
Debopam Samanta, MD1 Introduction Reversible cerebral vasoconstriction syndrome (RCVS) includes a diverse group of diseases characterized by reversible narrowing of the cerebral arteries. Patients present with thunderclap headache with or without neurologic deficit. RCVS can be idiopathic but in most cases association with vasoactive agents (sympathomimetic drugs or drugs that modulate dopamine or serotonin system) is present.1 Energy drinks are very popular in the young generation for its stimulant effect. Binge drinking is not uncommon in sports enthusiasts and in students or young professionals, especially before major examination or prior to an event when they try to stay awake longer. We report a pediatric case of RCVS presenting after binge drinking of one type of energy drink. Vigorous search for precipitating secondary factor is highly rewarding as sometimes discontinuation of the offending agent is the only treatment required and very effective to prevent further episodes.
Case Report A 16-year-old previously healthy teenager was transferred to our hospital from an outside hospital where he had presented with complaints of thunderclap headache, vomiting, left leg numbness, and gait difficulty. He was tachycardic but his blood pressure was within the normal range. Higher mental function, cranial nerve examination, and motor strength were normal. Deep tendon reflexes were brisker in the left knee and ankle. Sensory deficit was noted in the left lower extremity to light touch, pinprick, and temperature. Proprioception was very much impaired in the left lower extremity up to ankle. Babinski sign was positive on the left side. Computed tomography scan of the head was negative for subarachnoid hemorrhage. Magnetic resonance imaging scan of the (MRI) brain revealed numerous cortical and subcortical foci of abnormally restricted diffusion (Figure 1). Diffuse luminal irregularity with intermittent narrowing of distal branches of the anterior, middle, and posterior cerebral arteries were evident in the MR angiography (Figure 2). He denied using any drugs except acetaminophen. Specific enquiry about cocaine, Ecstasy, cannabis,
bromocriptine, nasal decongestants, diet pills, stimulant drugs, and selective serotonin reuptake inhibitor were made and was negative. Urine drug screen, echocardiogram, blood and cerebrospinal fluid metabolic panel, hypercoagulability panel, inflammatory and infectious workup were noncontributory. With extensive questioning, history of binge drinking of an energy drink (four 8-ounce cans) several hours prior to his onset of his symptoms was found. The caffeine content of that drink was approximately 10 mg/ oz.2 The patient received oral analgesic and antiemetic for symptomatic management. He was discharged after initiation of verapamil and was advised for strict avoidance of the energy drink and caffeine. Serial follow-up for more than 2 years showed compliance in avoiding vasoactive agents with no recurrence of symptoms. MR angiography after 6 months of initial presentation showed reversal of vascular abnormality.
Discussion The energy drink market is growing significantly in recent years with resurgence of fitness consciousness.3 There have been reports of sudden death, tachycardia, and psychiatric problems after consumption of energy drinks.4 Caffeine and related compounds are the primary psychoactive ingredients of energy drinks. Caffeine, antagonist of adenosine and presynaptic α1 receptor, causes increase catecholamine release to produce the vasoactive effect.5 Phosphodiesterase inhibition may produce an additional effect. Caffeine is primarily metabolized by the cytochrome P450 (CYP) oxidase system in the liver. The clearance and plasma half-life of caffeine vary considerably from person to person and potentially make an individual susceptible to the toxic effect of caffeine in lower doses. In addition, the hepatic enzyme system responsible for caffeine metabolism can become 1
University of Arkansas for Medical Sciences, Little Rock, AR, USA
Corresponding Author: Debopam Samanta, 2010 Rebsamen Park Road, Apt #301, Little Rock, AR 72202, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at Purdue University on June 4, 2015
187
Samanta
Figure 1. DWI MRI shows cortical and subcortical foci of abnormally restricted diffusion.
saturated at high levels, resulting in a marked increase in serum concentration with small additional doses. Energy drinks may also contain herbal constituents (ginkgo biloba leaf extract, Siberian ginseng root extract, etc) with significant sympathomimetic properties. Worrall et al published a report of cerebral vasculopathy and stroke after single consumption of an herbal energy drink.6 The temporal link between heavy energy drink consumption and the occurrence of stroke and cerebral vasculopathy in this young patient without any other vascular risk factors indicates vasospasm from the sympathomimetic constituents of the energy drink. The patient did not have a serum caffeine level but clinical utility of caffeine levels is limited anyway. Because energy drink use is widespread, it could represent a casual event, but in this particular patient symptoms started very closely after binge drinking of this agent and symptoms did not reappear in more than 2 years of follow-up. His continuous clinical and radiological improvement and absence of any other known aggravating factors of RCVS also suggests association of vasospasm with this drink. Cerebral infarction developing from vasoconstriction can produce permanent neurologic deficit though vasoconstriction is reversible with the withdrawal of the offending agent. Treatment of RCVS includes discontinuation of the offending agent with or without calcium channel blocker depending on the clinical situation.7 In view of widespread use of the drink, careful enquiry of consumption of energy drink is warranted in young patients presenting with thunderclap headache, focal deficit, and evidence of cerebral ischemia or vasoconstriction. Reporting of adverse reaction of drink should be warranted to mitigate possible risk of public health.
Figure 2. MR angiography reveals diffuse luminal irregularity with intermittent narrowing of distal branches of the anterior, middle, and posterior cerebral arteries.
Acknowledgments The study was done at the University of Virginia Medical Center, Virginia. Dr Erin Willis proofread the draft for nonintellectual content.
Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author received no financial support for the research, authorship, and/or publication of this article.
References 1. Chen SP, Fuh JL, Wang SJ. Reversible cerebral vasoconstriction syndrome: current and future perspectives. Expert Rev Neurother. 2011;11:1265-1276. 2. Caffeineinformer. http://www.caffeineinformer.com/ caffeine-content/red-bull. Accessed May 23, 2014. 3. Babu K, Church R, Lewander W. Energy drinks: the new eye opener for adolescents. Clin Pediatr Emerg Med. 2008;9:35-42. 4. Higgins JP, Tuttle TD, Higgins CL. Energy beverages: content and safety. Mayo Clin Proc. 2010;85:1033-1041. 5. Benowitz NL. Clinical pharmacology of caffeine. Annu Rev Med. 1990;41:277-288. 6. Worrall BB, Phillips CD, Henderson KK. Herbal energy drinks, phenylpropanoid compounds, and cerebral vasculopathy. Neurology. 2005;65:1137-1138. 7. Chen SP, Fuh JL, Wang SJ. Reversible cerebral vasoconstriction syndrome: an under-recognized clinical emergency. Ther Adv Neurol Disord. 2010;3:161-171.
Downloaded from cpj.sagepub.com at Purdue University on June 4, 2015
