Hemorrhagic Stroke in a Patient Recently Started on Mixed Amphetamine Salts

“Mr. B” was a 53-year-old, right-handed Caucasian man who, at the time of his initial psychiatric evaluation, reported a life-long pattern of symptoms consistent with DSM-IV-TR criteria for ADHD, inattentive subtype (2), which significantly interfered with his functioning. The patient's symptoms had never been identified or treated before. He had a history of head and neck squamous cell carcinoma postsurgery and radiation (13 years prior) as well as hyperlipidemia, gastroesophageal reflux disease, and hypothyroidism. After obtaining his consent, a treatment trial of mixed amphetamine salts was initiated at 5 mg daily by mouth and titrated to 15 mg b.i.d. by mouth over 4 months, resulting in significant clinical improvement. The treatment was well tolerated, without signifi-cant increase in blood pressure or anxiety and with only mild suppression of appetite.

Two and one-half months after the last dose increase, the patient presented in the emergency room with a progressively worsening posterior headache with left-face numbness and tingling and complains of diplopia. His blood pressure at the time was 164/103; his heart rate was 88 beats per minute; and his temperature was 97.5°F. He was awake, alert, and oriented but soon became more somnolent. Noncontrast head computed tomography revealed a right posterior paramedian midbrain hematoma with cerebral aqueduct effacement and mild ventriculomegaly. There was no evidence of hypertension on transthoracic echocardiogram and no arteriovenous malformations, cavernous malformations, or aneurysms on magnetic resonance imaging of the brain and arteries.