A stroke is a terrible neurologic event.  I heard in neurology training years ago that some in England call a “stroke” a “shock” which says something about the suddenness of the event and the later emotional toil that comes with a stroke.

Many persons use energy drinks for that extra “high” that comes from drinking them, providing just the needed energy to stay awake and do that job or finish that long drive or see the end of that great movie.

The problem is that what is in all energy drinks is not known and energy drinks are not USP (United States Pharmacopeia) or FDA (Federal Drug Administration) approved.  The purpose of these organizations is to protect persons from harmful products.  Energy drinks are all considered to be “supplements” and for these products, “let the buyer beware.”

Energy drinks may contain caffeine, or amphetamine like products such as pseudoephedrine, and phenylalanine.

See my article discussing pseudoephedrine on my website , “Sinus, Allergy, or Migraine headache?” at www.doctormigraine.com. Please click here to read.

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This is an article by Britt Talley Daniel MD, retired member of the American Academy of Neurology, the American Headache Society, migraine textbook author, podcaster, YouTube video producer, and blogger.

There is no doubt that energy drinks can cause sudden surges in blood pressure to high levels causing hemorrhagic strokes in the brain.  The elevated blood pressure ruptures small brain arteries, causing bleeding directly into the brain.

Incidence of Stroke

Strokes in the brain kill 140,000 Americans each year which is 1 out of every 20 deaths. Stroke attacks someone in the United States every 40 seconds.  Every year, more than 795,000 people in the United States have a stroke.

Risk factors of Stroke

Strokes can happen again, or repeat in susceptible persons, those with overweight, atherosclerosis, hypertension, diabetes, heart disease, or elevated cholesterol.  Previous strokes occur in 185,000 strokes or in 1 of every 4 persons.

About 87% of all strokes are ischemic strokes, in which blood flow to the brain is blocked either by a small blood or cholesterol clot, called an embolus or from a completely closed neck or cerebral artery, called a thrombosis.

Stroke is a leading cause of serious long-term disability and often has a major effect on personal mobility.

Hypertension is the main natural cause of cerebral hemorrhage (CH).

Treating hypertension has reduced the incidence of CH significantly.  However, the combination of energy drinks causing surges of increased blood pressure combined with a person who has hypertension is a bad medical situation.

Intracerebral hemorrhage has an increased mortality over ischemic stroke.

Strokes related to hypertension and bleeding into the brain itself cause more mortality than ischemic strokes.  A literature review of increased mortality from intracerebral hemorrhage is found in the following article:

Christian Weimar and Julian Kleine-Borgmann wrote in Review Curr Pharm Des 2017;23(15):2193-2196 on Epidemiology, Prognosis and Prevention of Non-Traumatic Intracerebral Hemorrhage

Abstract

Background: Spontaneous non-traumatic intracerebral hemorrhage (ICH) has a worse prognosis than ischemic stroke. The purpose of this review was to update the reader on epidemiology, prognosis, and secondary prevention strategies of CH.

Methods: We performed a selected review from the literature including recent original articles and meta-analyses.

Results: ICH has an overall incidence of 24.6 per 100.000 patient years, which is considerably higher in Asian populations. Despite some progress in acute interventions and a great increase in clinical studies over the last decade, mortality of ICH remains high. In addition, survivors remain at increased risk of recurrent hemorrhagic as well as ischemic stroke.

Conclusion: Knowledge on risk factors and prevention strategies can greatly decrease the incidence of ICH and improve prognosis of ICH survivors.

Read my webpage article about “Caffeine is a Drug” at www.doctormigraine.com. Please click here to read.

Case of Hemorrhagic stroke from an energy drink.

Anand Venkatraman, Ayaz Khawaja, and Angela Shapshak gave a presentation at the 2017 AAN Annual Meeting Science Program  Published on Feb 21, 2017 on Hemorrhagic stroke following consumption of energy drink (P3.271)

Investigators at the University of Alabama at Birmingham have presented the first case study of a patient experiencing a hemorrhagic stroke — a brain bleed — following consumption of an energy drink.

In an article in press in the American Journal of Emergency Medicine, the UAB physicians detail the case of a 57-year-old man who developed an intracranial hemorrhage within 15 minutes of drinking a popular energy drink.

The patient presented at a local emergency department and was transferred to the stroke unit at UAB with symptoms of sensory changes (tingling and numbness) in the right arm and leg, along with ataxia (shaky gait and movement).  A CT scan revealed a small hemorrhage near the left thalamus.

“The man reported that his symptoms began about 15 minutes after drinking an energy drink, the first time he had consumed this particular product, as he was about to do yardwork,” said Anand Venkatraman, M.D., a fourth-year resident in the Department of Neurology at UAB and the lead author of the study.

Venkatraman says the drink contains a high level of caffeine, along with a variety of other ingredients, many of which are associated with increases in blood pressure.

“This particular drink contains several supplements for which we have little understanding of their potential interactions with each other or with caffeine,” Venkatraman said. “One is structurally similar to amphetamines, and several are known to stimulate the sympathetic nervous system.”

The sympathetic nervous system regulates what is known as the “flight or fight” response.  When faced with an urgent, potentially dangerous situation, the body gears up to either take extraordinary action (fight) or run away (flight).

“The body begins to marshal all of its resources to respond to the situation at hand — boosting strength and alertness, for example — in part by raising blood pressure to increase blood flow,” Venkatraman said.  “For a patient who may be at risk for vascular disease, this increase in blood pressure could be potentially dangerous, as a rise in blood pressure can affect an already weakened blood vessel to the point that it ruptures.”

Ingredients in the drinks that are suspected to influence the sympathetic nervous system include β-phenylethylamine hydrochloride, yohimbine and green tea extract. 

“These ingredients are supplements and, as such, are not regulated by the government to the same degree that medications are,” Venkatraman said.  “We don’t have good information on dosing for some of these supplements.  We don’t know how much is too much, for example, especially in populations with varying degrees of risk.”

Another issue is serving size.  The manufacturer’s label says the bottle contains two servings, but the patient reported that he drank the full 8 oz. bottle at one time, a behavior that Venkatraman believes is common.

“The warning here is that we do not fully understand how some of these ingredients interact with other compounds,”  Venkatraman said. “Nor do we have enough information on maximum dosages, especially for individuals with underlying health issues.  Consumers need to be aware of the ingredients in the drinks if they choose to use them, and check with their physician if they have questions.  They should also follow the manufacturer’s recommendations.”

 In this case, the patient had a history of elevated blood pressure and was at increased risk for vascular disease.  Several months after the incident, the patient reported that he still had some residual effects from the incident.

“I am not anti-energy drink,” Venkatraman said.  “In fact, I use them myself on occasion.  But I strongly urge consumers to read the label and be informed.  Don’t take unnecessary risks with your health.  There is potential for a serious outcome.”

Contributing authors to the study are Angela Shapshak, M.D., associate professor of neurology, and Ayaz Khawaja, M.D., now a fellow in neurology at Harvard Medical School.

Subarachnoid hemorrhage from Caffeinated Energy Drink

Grant, R.A., et al, wrote in Review Interv Neuroradiol. 2016 Dec; 22(6):674-678 on Aneurysmal Subarachnoid Hemorrhage and Severe, Catheter-Induced Vasospasm Associated With Excessive Consumption of a Caffeinated Energy Drink

Abstract

Excessive consumption of over-the-counter stimulants is associated with coronary vasospasm, thrombotic complications, and sudden cardiac death. Their effects on cerebrovascular physiology are not yet described in the neurointerventional literature. Patients are increasingly exposed to high levels of these vasoactive substances in the form of caffeinated energy drinks and specialty coffees. We report a case of aneurysmal subarachnoid hemorrhage (SAH) and severe, catheter-induced vasospasm during attempted endovascular repair of a ruptured anterior communicating artery (AComA) aneurysm in the setting of excessive energy drink consumption. We review the literature and alert clinicians to this potentially serious complication.

Hemorrhagic stroke after consumption of an energy drink.

Herbal energy drinks, phenylpropanoid compounds, and cerebral vasculopathy.

Worrall BB, et al, wrote in Neurology. 2005 Oct 11;65(7):1137-8 on Herbal energy drinks, phenylpropanoid compounds, and cerebral vasculopathy

We report a 21-year old man with cerebral vasculopathy and concurrent ischemic and hemorrhagic strokes shortly after his first exposure to an “energy drink” containing numerous sympathomimetic herbal compounds.

Several hours after drinking 250 mL of the energy drink XS Cranberry–Grape Blast, the patient had onset of profound headache and hemiataxia while on a hike with friends.  His medical history included type I diabetes, asthma, and remote syncope.  He denied exposure to over-the-counter stimulants, cold preparations, diet aids, or illicit drugs.

On examination, he had photophobia and marked hemiataxia.  His imaging revealed an acute brainstem infarction and bilateral subarachnoid hemorrhage on the cerebral convexities (figure). CSF analysis confirmed subarachnoid blood without elevation of white blood cells or protein. Cerebral angiography revealed multifocal areas of narrowing and dilatation in distal long segments of the middle and posterior cerebral arteries without evidence of aneurysm (see the figure).  An extensive evaluation for systemic inflammatory vasculitis or hypercoagulable state and a screen for drugs of abuse were both negative.

Figure. (A) Diffusion-weighted MR image demonstrating the acute infarct in the upper right pons. (B) Fluid-attenuated inversion recovery MR image showing subarachnoid blood at the convexity. (C) Digital subtraction angiogram right vertebral injection demonstrating areas of narrowing and dilation of distal vessels. (D) Close-up of the area inside the white box in (C). The black-and-white arrowheads indicate the areas of narrowing and dilatation in a posterior cerebral artery branch.

The manufacturer's Web site (http://www.xsgear.com/store/faqs.asp#Available%20Drinks) indicates that this energy drink contains an “adaptogenic” mixture of herbal compounds: Eleutherococcus (Acanthopanax) senticosus (Siberian ginseng), Schisandra (Wu Wie Zi or Chinese magnolia vine), Astragalus (Huang Qi or milk-vetch root), Reishi (a mushroom), and several other Panaxes (various ginseng species).

The manufacturer states that “adaptogenic herbs aid the body in managing stress” (http://www.xsgear.com/store/faqs.asp#Available%20Drinks). The patient routinely drank another energy drink (Red Bull Sugar Free) that does not contain these compounds (http://www.redbullusa.com/extras/ingredients.jsp). Both drinks contain carbonated water, caffeine, taurine, citric acid, acesulfame k (sweetener), and B vitamins (B3, B5, B6, B12).

Three constituents of the adaptogenic blend in this energy drink, Eleutherococcus senticosus, Schisandra, and Panax species, are sympathomimetic, and all contain phenylpropanoid lignans among other potentially vasoactive compounds.1–3

The Food and Drug Administration requested withdrawal of phenylpropanolamine from all prescription and over-the-counter drugs as of November 2000 based largely on evidence of cerebrovascular risk (http://www.fda.gov/cder/drug/infopage/ppa/default.htm).

Exposure to herbal sympathomimetic substances including ephedra and ginseng is a risk factor for cerebral vasculopathy, subarachnoid hemorrhage, and ischemic stroke.  The terms “vasculitis” and “vasospasm” are both used in the literature to describe the angiographic findings, although the more generic term “vasculopathy” is more appropriate.

This case highlights the potential relationship between pharmacologically active and widely available "herbal supplements" and cerebral vasculopathy, although we cannot unequivocally prove a connection. The patient's diabetes, a known vascular risk factor, may have also altered his susceptibility to the vasoactive moieties.

Physicians and other health care providers should include a detailed history of exposure to herbal preparations including those found in popular soft drinks. Mechanisms for reporting adverse reactions to these products when used as a dietary supplement are evolving; current options include use of the Food and Drug Administration MedWatch Program.

Only through aggressive reporting and critical scrutiny will we be able to determine if legitimate public health risks exist from herbal compounds in “energy drinks” and other sources.

References

1. Hikino H, Kiso Y, Taguchi H, Ikeya Y. Antihepatotoxic actions of lignoids from Schizandra chinensis fruits. Planta Med 1984;50:213–218.PubMedGoogle Scholar

2.Kang JS, Linh PT, Cai XF, Kim HS, Lee JJ, Kim YH. Quantitative determination of eleutheroside B and E from Acanthopanax species by high performance liquid chromatography. Arch Pharmacol Res 2001;24:407–411.PubMedGoogle Scholar

3.Steinmann GG, Esperester A, Joller P. Immunopharmacological in vitro effects of Eleutherococcus senticosus extracts. Arzneimittelforschung 2001;51:76–83.PubMedGoogle Scholar

4. Chen C, Biller J, Willing SJ, Lopez AM. Ischemic stroke after using over the counter products containing ephedra. J Neurol Sci 2004;217:55–60.CrossRefPubMedGoogle Scholar

5.Ryu SJ, Chien YY. Ginseng-associated cerebral arteritis. Neurology 1995;45:829–830.Abstract/FREE Full TextGoogle Scholar

How do energy drinks cause the bleeding?

Anyone who has ever blown up a rubber balloon until it pops has an idea of the situation.  The increasing air pressure by breath blowing into the balloon stretches the rubber of the balloon as the size of the balloon grows, until finally the filament of the rubber gives way and the balloon pops and then collapses as the air pressure is released.

Chemicals that cause increased blood pressure in cerebral arteries react in a similar fashion.  The pressure in the artery increases, the vessel wall stretches and finally it rents, depositing fresh blood into the substance of the brain—a hemorrhagic stroke.

Because of the nature of the vasculature of the human brain, the rupture is commonly deep in the middle of the brain in the thalamus which is supplied on both sides of the brain by what are called the lenticulostriate arteries.  This are tiny arteries supplying the middle of the brain which are usually the first to blow in this scenario.

In general are energy drinks dangerous?

The answer to this question seems obvious by studying the case presentations in this article.  Energy drinks can cause accelerated blood pressure that then stretches, ruptures an artery, and causes bleeding into the brain.

All energy drinks are also “supplements” which are not controlled by the FDA, although in the news through the years the FDA has threatened to take over the supplement industry and regulate it.  Consider that caffeine, first mainly in Coca Cola, was regulated by the FDA early in the nineteenth century. 

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All the best.

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Britt Talley Daniel MD