8/13/2019 Ischaemic Stroke Provoked by Sexual Intercourse

1/2

8/13/2019 Ischaemic Stroke Provoked by Sexual Intercourse

2/2

clopidogrel 75 mg/day, without recurrences at two-year follow-up,

and propanolol (80 mg/day) with a consistent reduction in the fre-

quency of the cephalalgic attacks.

3. Discussion

Our report further suggests sexual activity as a possible trigger

of ischaemic stroke in predisposed individuals. Ischaemic stroke isa complex multifactorial disease and approximately 30% of strokes

are cryptogenic, especially in young adults. In the past 20 years, the

role of PFO as a risk factor for ischaemic stroke has been estab-

lished, particularly in young adults with cryptogenic stroke.7 PFO

amongst the general population is quite common, at 1530%. How-

ever, it has also been demonstrated that PFO, alone or together

with atrial septal abnormalities, is not associated with an increased

stroke risk in a multiethnic cohort.6

Becker et al.3 reported the occurrence of ischemic stroke during

sexual activity in four individuals with no known risk factors, rais-

ing concern that the presence of a PFO may increase the risk of

stroke during sexual intercourse. During the Valsalva manoeuvre

there is an increase in intrathoracic, central venous and right atrial

pressure; if the right pressure exceeds the left, a right-to-left shunt

may occur through the PFO. The physiologic changes during coital

activity, such as an increase in heart rate and blood pressure, are

likely similar to those seen during a Valsalva manoeuvre, and thus

could predispose individuals to paradoxical embolization.

Interestingly, since DVT has only rarely been documented in pa-

tients with PFO and cryptogenic stroke, emerging evidence sug-

gests that thrombophilias may play an important role in these

individuals.8 Although ischaemic stroke is thought to have a poly-

genic basis, identification of stroke susceptibility genes and quan-

tification of associated risks has been hampered by conflicting

results from underpowered case-control studies.9 Casas et al.10

performed a meta-analysis of all candidate gene association stud-

ies in ischaemic stroke, finding statistically significant associations

for factor V Leiden Arg506Gln (odds ratio [OR], 1.33; 95% confi-

dence interval [CI], 1.121.58), MTHFR C677T (OR, 1.24; 95% CI,

1.081.42), prothrombin G20210A (OR, 1.44; 95% CI, 1.111.86),

and ACE insertion/deletion (OR, 1.21; 95% CI, 1.081.35). However,

no single gene with major effect was identified; rather, common

variants in several genes, each exerting a modest effect, contribute

to the risk of stroke.

Moreover, we have recently described a family affected by car-

dioembolic ischaemic stroke suggesting a potential familial aggre-

gation (co-segregation) of cardiac interatrial abnormalities and

inherited prothrombotic disorders.11 Our Patient 1 presented with

a large PFO and genetic thrombophilic polymorphisms, which may

have been implicated in ischaemic stroke through a complex inter-

action. Indeed, based on the literature, it seems very unlikely that

genetic thrombophilia would cause an arterial ischaemic stroke in

the absence of other predisposing conditions.9 Although we do notdispute this view, we emphasize that experimental and clinical

data clearly indicate that these polymorphisms are implicated in

the mechanisms of blood coagulation, favoring a pro-thrombotic

state.9,10 Thus, the prevailing hypothesis is that this increased pro-

thrombotic propensity might favour an ischemic event in rare cir-

cumstances, such as in cases of probable paradoxical brain

embolism, as in our Patient 1.

The occurrence of acute stroke immediately after intercourse

has been also attributable to arterial dissection, intracerebral hem-

orrhage or subarachnoid hemorrhage. These common causes of se-

vere sexual headache with subsequent stroke have been ruled out

in Patient 2. Interestingly, hyperventilation is a typical feature of

human sexual response, and during hyperventilation cerebral

blood flow can be reduced by up to 50% of the baseline. Moreover,

cerebral artery narrowing shortly after orgasm has been recently

demonstrated in patients affected by sexual headache, supporting

the hypothesis that segmental vasospasm is involved in the

pathogenesis of this uncommon type of headache and its possible

complications, including cerebral ischaemia.12 However, this

pathomechanism could not be operant in our Patient 2, as she

suffered from a striatocapsular infarct, which is highly likely to

be embolic, even though still cryptogenic, since she tested negative

for potential sources of brain embolism, including on TCCD.

However, oral contraceptive use may have contributed in inducing

cerebral ischemia by affecting blood clotting.

Thus, sexual intercourse may be considered as an unusual, but

possible, trigger of cerebral ischemia, especially in young patients

presenting with cryptogenic stroke.

Nevertheless, it is important to underline that the only epidemi-

ologic study13 which examined the relation between frequency of

sexual intercourse and risk of ischemic stroke, failed to demon-

strate this correlation. This is reassuring for the public, who might

reasonably believe that sexual activities can cause stroke.

References

1. Koton S, Tanne D, Bornstein NM, et al. Triggering risk factors for ischemic

stroke: a case-crossover study. Neurology 2004;63:200610.2. Pandian JD, Perel R, Henderson RD, et al. Unusual triggers for stroke. J Clin

Neurosci2007;14:7867.3. Becker K, Skalabrin E, Hallam D, et al. Ischemic stroke during sexual

intercourse: a report of 4 cases in persons with patent foramen ovale. ArchNeurol2004;61:11146.

4. Velicu S, Biller J, Hacein-Bey L, et al. Paradoxical embolism to the central

nervous system after sexual intercourse in a young woman with a complex

atrial septal abnormality.J Stroke Cerebrovasc Dis 2008;17:3204.5. Lee SJ, Kim JS, Lee KS, et al. Coital transient ischaemic attacks. Eur J Neurol

2008;15:e1012.6. Di Tullio MR, Sacco RL, Sciacca RR, et al. Patent foramen ovale and the risk of

ischemic stroke in a multiethnic population.J Am Coll Cardiol2007;49:797802.7. Handke M, Harloff A, Bode C, et al. Patent foramen ovale and cryptogenic

stroke: a matter of age? Semin Thromb Hemost2009;35:50514.8. Pezzini A, Grassi M, Zotto ED, et al. Do common prothrombotic mutations

influence the risk of cerebral ischaemia in patients with patent foramen ovale?

Systematic review and meta-analysis.Thromb Haemost2009;101:8137.9. Matarin M, Singleton A, Hardy J, et al. The genetics of ischaemic stroke.J Intern

Med2010;267:13955.10. Casas JP, Hingorani AD, Bautista LE, et al. Meta-analysis of genetic studies in

ischemic stroke: thirty-two genes involving approximately 18,000 cases and

58,000 controls.Arch Neurol 2004;61:165261.11. Calabr RS, Gervasi G, Bramanti P. Can interaction between atrial septal

abnormalities and genetic prothrombotic polymorphisms play a role incryptogenic ischemic stroke? Description of a family. Neurol Sci2012;33:1179.

12. Yeh YC, Fuh JL, Chen SP, et al. Clinical features, imaging findings and outcomes

of headache associated with sexual activity. Cephalalgia2010;30:132935.13. Ben Shlomo Y, McCarron P, Frankel S, et al. Sexual intercourse and risk of

ischaemic stroke and coronary heart disease: the Caerphilly study. J EpidemiolCommunity Health2002;56:99102.

2 R.S. Calabr et al. / Journal of Clinical Neuroscience xxx (2013) xxxxxx

Please cite this article in press as: Calabr RS et al. Ischaemic stroke provoked by sexual intercourse. J Clin Neurosci (2013), http://dx.doi.org/10.1016/

j.jocn.2012.10.025

http://refhub.elsevier.com/S0967-5868(13)00021-0/h0005http://refhub.elsevier.com/S0967-5868(13)00021-0/h0005http://refhub.elsevier.com/S0967-5868(13)00021-0/h0005http://refhub.elsevier.com/S0967-5868(13)00021-0/h0005http://refhub.elsevier.com/S0967-5868(13)00021-0/h0005http://refhub.elsevier.com/S0967-5868(13)00021-0/h0005http://refhub.elsevier.com/S0967-5868(13)00021-0/h0010http://refhub.elsevier.com/S0967-5868(13)00021-0/h0010http://refhub.elsevier.com/S0967-5868(13)00021-0/h0010http://refhub.elsevier.com/S0967-5868(13)00021-0/h0010http://refhub.elsevier.com/S0967-5868(13)00021-0/h0010http://refhub.elsevier.com/S0967-5868(13)00021-0/h0010http://refhub.elsevier.com/S0967-5868(13)00021-0/h0010http://refhub.elsevier.com/S0967-5868(13)00021-0/h0015http://refhub.elsevier.com/S0967-5868(13)00021-0/h0015http://refhub.elsevier.com/S0967-5868(13)00021-0/h0015http://refhub.elsevier.com/S0967-5868(13)00021-0/h0015http://refhub.elsevier.com/S0967-5868(13)00021-0/h0015http://refhub.elsevier.com/S0967-5868(13)00021-0/h0015http://refhub.elsevier.com/S0967-5868(13)00021-0/h0015http://refhub.elsevier.com/S0967-5868(13)00021-0/h0015http://refhub.elsevier.com/S0967-5868(13)00021-0/h0020http://refhub.elsevier.com/S0967-5868(13)00021-0/h0020http://refhub.elsevier.com/S0967-5868(13)00021-0/h0020http://refhub.elsevier.com/S0967-5868(13)00021-0/h0020http://refhub.elsevier.com/S0967-5868(13)00021-0/h0020http://refhub.elsevier.com/S0967-5868(13)00021-0/h0020http://refhub.elsevier.com/S0967-5868(13)00021-0/h0020http://refhub.elsevier.com/S0967-5868(13)00021-0/h0020http://refhub.elsevier.com/S0967-5868(13)00021-0/h0025http://refhub.elsevier.com/S0967-5868(13)00021-0/h0025http://refhub.elsevier.com/S0967-5868(13)00021-0/h0025http://refhub.elsevier.com/S0967-5868(13)00021-0/h0025http://refhub.elsevier.com/S0967-5868(13)00021-0/h0025http://refhub.elsevier.com/S0967-5868(13)00021-0/h0030http://refhub.elsevier.com/S0967-5868(13)00021-0/h0030http://refhub.elsevier.com/S0967-5868(13)00021-0/h0030http://refhub.elsevier.com/S0967-5868(13)00021-0/h0030http://refhub.elsevier.com/S0967-5868(13)00021-0/h0030http://refhub.elsevier.com/S0967-5868(13)00021-0/h0030http://refhub.elsevier.com/S0967-5868(13)00021-0/h0030http://refhub.elsevier.com/S0967-5868(13)00021-0/h0035http://refhub.elsevier.com/S0967-5868(13)00021-0/h0035http://refhub.elsevier.com/S0967-5868(13)00021-0/h0035http://refhub.elsevier.com/S0967-5868(13)00021-0/h0035http://refhub.elsevier.com/S0967-5868(13)00021-0/h0035http://refhub.elsevier.com/S0967-5868(13)00021-0/h0035http://refhub.elsevier.com/S0967-5868(13)00021-0/h0040http://refhub.elsevier.com/S0967-5868(13)00021-0/h0040http://refhub.elsevier.com/S0967-5868(13)00021-0/h0040http://refhub.elsevier.com/S0967-5868(13)00021-0/h0040http://refhub.elsevier.com/S0967-5868(13)00021-0/h0040http://refhub.elsevier.com/S0967-5868(13)00021-0/h0040http://refhub.elsevier.com/S0967-5868(13)00021-0/h0040http://refhub.elsevier.com/S0967-5868(13)00021-0/h0045http://refhub.elsevier.com/S0967-5868(13)00021-0/h0045http://refhub.elsevier.com/S0967-5868(13)00021-0/h0045http://refhub.elsevier.com/S0967-5868(13)00021-0/h0045http://refhub.elsevier.com/S0967-5868(13)00021-0/h0045http://refhub.elsevier.com/S0967-5868(13)00021-0/h0045http://refhub.elsevier.com/S0967-5868(13)00021-0/h0050http://refhub.elsevier.com/S0967-5868(13)00021-0/h0050http://refhub.elsevier.com/S0967-5868(13)00021-0/h0050http://refhub.elsevier.com/S0967-5868(13)00021-0/h0050http://refhub.elsevier.com/S0967-5868(13)00021-0/h0050http://refhub.elsevier.com/S0967-5868(13)00021-0/h0050http://refhub.elsevier.com/S0967-5868(13)00021-0/h0050http://refhub.elsevier.com/S0967-5868(13)00021-0/h0055http://refhub.elsevier.com/S0967-5868(13)00021-0/h0055http://refhub.elsevier.com/S0967-5868(13)00021-0/h0055http://refhub.elsevier.com/S0967-5868(13)00021-0/h0055http://refhub.elsevier.com/S0967-5868(13)00021-0/h0055http://refhub.elsevier.com/S0967-5868(13)00021-0/h0055http://refhub.elsevier.com/S0967-5868(13)00021-0/h0055http://refhub.elsevier.com/S0967-5868(13)00021-0/h0060http://refhub.elsevier.com/S0967-5868(13)00021-0/h0060http://refhub.elsevier.com/S0967-5868(13)00021-0/h0060http://refhub.elsevier.com/S0967-5868(13)00021-0/h0060http://refhub.elsevier.com/S0967-5868(13)00021-0/h0060http://refhub.elsevier.com/S0967-5868(13)00021-0/h0060http://refhub.elsevier.com/S0967-5868(13)00021-0/h0065http://refhub.elsevier.com/S0967-5868(13)00021-0/h0065http://refhub.elsevier.com/S0967-5868(13)00021-0/h0065http://refhub.elsevier.com/S0967-5868(13)00021-0/h0065http://refhub.elsevier.com/S0967-5868(13)00021-0/h0065http://refhub.elsevier.com/S0967-5868(13)00021-0/h0065http://refhub.elsevier.com/S0967-5868(13)00021-0/h0065http://dx.doi.org/10.1016/j.jocn.2012.10.025http://dx.doi.org/10.1016/j.jocn.2012.10.025http://dx.doi.org/10.1016/j.jocn.2012.10.025http://dx.doi.org/10.1016/j.jocn.2012.10.025http://refhub.elsevier.com/S0967-5868(13)00021-0/h0065http://refhub.elsevier.com/S0967-5868(13)00021-0/h0065http://refhub.elsevier.com/S0967-5868(13)00021-0/h0065http://refhub.elsevier.com/S0967-5868(13)00021-0/h0060http://refhub.elsevier.com/S0967-5868(13)00021-0/h0060http://refhub.elsevier.com/S0967-5868(13)00021-0/h0055http://refhub.elsevier.com/S0967-5868(13)00021-0/h0055http://refhub.elsevier.com/S0967-5868(13)00021-0/h0055http://refhub.elsevier.com/S0967-5868(13)00021-0/h0055http://refhub.elsevier.com/S0967-5868(13)00021-0/h0050http://refhub.elsevier.com/S0967-5868(13)00021-0/h0050http://refhub.elsevier.com/S0967-5868(13)00021-0/h0050http://refhub.elsevier.com/S0967-5868(13)00021-0/h0045http://refhub.elsevier.com/S0967-5868(13)00021-0/h0045http://refhub.elsevier.com/S0967-5868(13)00021-0/h0040http://refhub.elsevier.com/S0967-5868(13)00021-0/h0040http://refhub.elsevier.com/S0967-5868(13)00021-0/h0040http://refhub.elsevier.com/S0967-5868(13)00021-0/h0035http://refhub.elsevier.com/S0967-5868(13)00021-0/h0035http://refhub.elsevier.com/S0967-5868(13)00021-0/h0030http://refhub.elsevier.com/S0967-5868(13)00021-0/h0030http://refhub.elsevier.com/S0967-5868(13)00021-0/h0025http://refhub.elsevier.com/S0967-5868(13)00021-0/h0025http://refhub.elsevier.com/S0967-5868(13)00021-0/h0020http://refhub.elsevier.com/S0967-5868(13)00021-0/h0020http://refhub.elsevier.com/S0967-5868(13)00021-0/h0020http://refhub.elsevier.com/S0967-5868(13)00021-0/h0015http://refhub.elsevier.com/S0967-5868(13)00021-0/h0015http://refhub.elsevier.com/S0967-5868(13)00021-0/h0015http://refhub.elsevier.com/S0967-5868(13)00021-0/h0010http://refhub.elsevier.com/S0967-5868(13)00021-0/h0010http://refhub.elsevier.com/S0967-5868(13)00021-0/h0005http://refhub.elsevier.com/S0967-5868(13)00021-0/h0005