Effect of hyperoxia differs during ischemia and reperfusion.

Ephedrine-Induced Intracerebral Hemorrhage and Central Nervous System VasculitisTo the Editor: A 68-year-old right-handed man was admitted to the emergency room 2 hours after developing headache, dysphasia, and right hemiplegia.Computed tomography demonstrated a left temporoparietal hematoma with rupture into the lateral ventricle.On admission, his wife reported his use of an over-the-counter antiasthma pill containing theophylline 0.025 gm, ephedrine 0.01 gm, caffeine 0.015 gm, and theobromine 0.025 gm.He had taken this medication for 10 years, four to six tablets a day, and had used it 2 hours before the onset of ictus.His medical history consisted of chronic obstructive pulmonary disease for 40 years.Neurologic examination demonstrated nuchal rigidity, confusion, and hemiplegia on his right side.On the second hospital day, his level of consciousness deteriorated, and he showed an obvious dilatation of the left pupil.The hematoma was evacuated.Pathological examination demonstrated necrotizing angiitis of the small vessels with infiltration of polymorphonuclear leukocytes, especially prominent in the intima.Congo red stain was negative.Angiography showed irregularity at the siphon and diffuse segmental irregularity of the intracranial medium-sized and small arteries.The patient improved with prednisone.Ephedrine is a sympathomimetic agent and popular bronchodilator, similar to amphetamine and phenylpropanolamine in its effects. 1 A drug-induced vasculitis is often associated with intracranial hemorrhage, while vasculitides of the central nervous system (CNS) rarely produce this finding.2 The features, benign course, and histologic findings of drug-induced vasculitides are also similar to each other and unlike the fatal and evolving disease seen in polyarteritis of the CNS.The acute onset in our case is similar to another reported case of drug-induced vasculitis.3 This rapid onset of symptoms and the infiltration of polymorphonuclear leukocytes, particularly in the intima, seem more likely to be correlated with an immune complex-mediated process in its pathogenesis.4 While the pathogenesis of drug-induced vasculitis is still unknown, withdrawal and discontinuation of the offending agent is mandatory.Our case underscores that a patient with intracerebral hematoma and no obvious etiology should be evaluated for drug-induced vasculitis.