Many strokes attributed to ephedrine have actually been caused by the ingestion of ephedrine enantiomers, pseudoephedrine (82-85), phenylpropanolamine (86-93), and even methylephedrine (77). Two cases of ischemic stroke have been reported (94,95), but in neither case was their any toxicological testing to confirm the use of ephedrine. A decade-old report described the autopsy findings in three individuals with intracerebral hemorrhage and positive toxicology testing for ephedrine; however, one had hypertensive cerbrovasular disease and the other had a demonstrable ruptured aneurysm (96). Intracerebral hemorrhage has also been described in suicide and attempted suicide victims who took overdoses of pseudoephedrine (97,98). There is also a report describing a patient who developed described arteritis following the intravenous administration of ephedrine during a surgical procedure (99). On the other hand, a large study to assess risk factors for stroke in young people (age 20-49) over a 1-year period was carried out in Poland, a country where ephedra-based products are widely used. Nearly one-half the cases of stroke were associated with preexisting hypertension, another 15% had hyperlipi-demia, and 6% were diabetic (100). None of the individuals were ephedrine users.
Sometimes, especially in Japan and the Philippines, ephedrine is taken specifically as a psychostimulant. In Japan, BRON, the OTC cough medication containing methylephedrine, dihydrocodeine, caffeine, and chlorpheniramine, is very widely abused, and transient psychosis commonly results (76-78). Reports of ephedrine-related psychosis following prolonged, heavy use are fairly common (101-105). In general, psychosis is only seen in ephedrine users ingesting more than 1000 mg/day, and it resolves rapidly once the drug is withdrawn (106). Ephedrine psychosis closely resembles psychosis induced by amphetamines: paranoia with delusions of persecution and auditory and visual hallucinations, even though consciousness remains unclouded. Typically, patients with ephedrine psychosis will have ingested more than 1000 mg/day. Recovery is rapid after the drug is withdrawn (103). The ephedrine content per serving of most food supplements is on the order of 10-20 mg, making it extremely unlikely that, in recommended doses, use of any of the products would lead to neurological symptoms.
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