Letters to the Editor
Monoamine Oxidase Inhibitors and Subarachnoid Hemorrhage
Dear Editor:
Hypertensive crisis with monoamine oxidase inhibitor (MAOI) use has been reported in the literature and carries an overall risk of less than 1% (1). The reported reactions were triggered by diet noncompliance or by the use of concomitant medications. Specific agents responsible for these crises include tricyclic antidepressants (TCAs), meperidine, levodopa, and hay fever and cold remedies (2–4). However, spontaneous hypertensive reactions have also been described (1). Here, we present the first case of a subarachnoid hemorrhage (SAH) observed over the last 35 years that was likely caused by a hypertensive crisis secondary to MAOI use (5).
Case Report
A man, aged 52 years, with a long-standing history of treatment-refractory atypical depression presented to hospital complaining of a severe headache. The patient’s medical history did not suggest any risk factors for SAH. Five weeks prior to admission, he had begun taking oral tranylcypromine with a dosage escalating to 20 mg daily. One week after starting this medication, he complained of the “worst headache of [his] life” after consuming a meal of chicken teriyaki that included a half-tablespoon of soy sauce. When he presented at a local emergency room, his blood pressure was elevated to a systolic pressure of 210 mmHg. A noncontrast CT scan was performed. The scan revealed 2 small, hyperdense foci in the left frontal lobe and left lateral occipital lobe, with surrounding edema, consistent with an SAH. There was no evidence of hydrocephalus. His GCS score was found to be 13 to 14, and we were consulted in regard to delirium. The patient was unable to follow commands and, interestingly, had evidence of perseveration. Routine investigations were normal. A cerebral angiogram showed no evidence of aneurysm or vascular malformation and only showed vasospastic changes along branches of the left middle cerebral artery. An investigation for vasculitis was also negative.
His delirium was left untreated so that his level of consciousness could be accurately followed. The tranylcypromine and a neuroleptic for the treatment of delirium were withheld owing to concerns on the part of the neurosurgery service. The delirium resolved, and he was discharged after 17 days.
On follow-up, the patient opted for no further treatment with medication and was offered a trial of interpersonal therapy. He relied upon Tylenol 3 to manage his headache symptoms, which dissipated over time.
Discussion
Multiple factors led to the conclusion that this SAH was triggered by MAOI use. The patient’s consumption of soy sauce, a recent increase in tranylcypromine dosage, ingestion of tranylcypromine close to mealtime, and a medical history devoid of SAH risk factors all suggest that MAOI use was a precipitating factor. Further, negative angiography and a laboratory workup helped rule out other possible causes. It is interesting to note that the patient’s outpatient psychiatrist considered treating his depression with a TCA, which has been cited to precipitate SAH in some patients (4). MAOI agents can be effective antidepressants, but as this case highlights, physicians and patients should be aware of their propensity to cause SAH.
References
1. Lavin MR, Mendelowitz A, Kronig MH. Spontaneous hypertensive reactions with monoamine oxidase inhibitors. Biol Psychiatry 1993:34:146–51.
2. Laurence DR. Hypertension from cold remedies. BMJ 1969;1:189–90.
3. Acute hypertension after monoamine oxidase inhibitors and the ingestion of cheese. German Medical Monthly 1965;10:337–8.
4. Gardner DM, Shulman KI, Walker SE, Tailor SA. The making of a user-friendly MAOI diet. J Clin Psychiatry 1996;57:99–104.
5. De Villiers JC. Intracranial hemorrhage in patients treated with monoamineoxidase inhibitors. Br J Psychiatry 1967;112:109–18.
PS Kundhal, BA; S Sockalingam, BA, BSc, MD;
N Krishnadev, BSc; R Demarchi, BSc;
S Bhalerao, BSc, BA, PgD, MD, FRCPC
Toronto, Ontario
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