Sexual intercourse and cerebral aneurysmal rupture: potential mechanisms and precipitants

Early sexual activity lowers the incidence of intracranial aneurysm: a Mendelian randomization investigation

Objective

Investigate the potential correlation between the age of initial sexual contact, the lifetime accumulation of sexual partners, and the occurrence of intracranial aneurysm (IA) employing a two-sample Mendelian randomization approach.

Methods

This research aims to elucidate the causal relationship between intracranial aneurysm (IA) and sexual variables. Two distinct sexual variables, specifically the age had first sexual intercourse (n = 406,457) and the lifetime number of sexual partners (n = 378,882), were employed as representative parameters in a two-sample Mendelian randomization (MR) study. Outcome data from 23 cohorts, comprising 5,140 cases and 71,934 controls, were gathered through genome-wide association studies (GWAS). To bolster analytical rigor, five distinct methodologies were applied, encompassing MR-Egger technique, weighted median, inverse variance weighted, simple modeling, and weighted modeling.

Results

Our investigation unveiled a causal relationship between the age first had sexual intercourse and the occurrence of intracranial aneurysm (IA), employing the Inverse Variance Weighted (IVW) approach [Odds Ratio (OR): 0.609, p-value: 5.684E-04, 95% Confidence Interval (CI): 0.459-0.807]. This association was notably significant in the context of unruptured intracranial aneurysms (uIA) using the IVW approach (OR: 0.392, p-value: 6.414E-05, 95% CI: 0.248-0.621). Conversely, our findings did not reveal any discernible link between the lifetime number of sexual partners and the occurrence of IA (IA group: OR: 1.346, p-value: 0.415, 95% CI: 0.659-2.749; SAH group: OR: 1.042, p-value: 0.943, 95% CI: 0.338-3.209; uIA group: OR: 1.990, p-value: 0.273, 95% CI: 0.581-6.814).

Conclusion

The two-sample Mendelian Randomization (MR) study presented herein provides evidence supporting a correlation between the age of initial engagement in sexual activity and the occurrence of intracranial aneurysm (IA), with a noteworthy emphasis on unruptured intracranial aneurysms (uIA). Nevertheless, our investigation failed to establish a definitive association between IA and the cumulative lifetime number of sexual partners.

Role of microglia after subarachnoid hemorrhage

Subarachnoid hemorrhage is a devastating sequela of aneurysm rupture. Because it disproportionately affects younger patients, the population impact of hemorrhagic stroke from subarachnoid hemorrhage is substantial. Secondary brain injury is a significant contributor to morbidity after subarachnoid hemorrhage. Initial hemorrhage causes intracranial pressure elevations, disrupted cerebral perfusion pressure, global ischemia, and systemic dysfunction. These initial events are followed by two characterized timespans of secondary brain injury: the early brain injury period and the delayed cerebral ischemia period. The identification of varying microglial phenotypes across phases of secondary brain injury paired with the functions of microglia during each phase provides a basis for microglia serving a critical role in both promoting and attenuating subarachnoid hemorrhage-induced morbidity. The duality of microglial effects on outcomes following SAH is highlighted by the pleiotropic features of these cells. Here, we provide an overview of the key role of microglia in subarachnoid hemorrhage-induced secondary brain injury as both cytotoxic and restorative effectors. We first describe the ontogeny of microglial populations that respond to subarachnoid hemorrhage. We then correlate the phenotypic development of secondary brain injury after subarachnoid hemorrhage to microglial functions, synthesizing experimental data in this area.

Subarachnoid Haemorrhage Incidence Pattern Analysis with Circular Statistics

Knowledge about biological rhythms of diseases may not only help in understanding the pathophysiology of diseases but can also help health service policy makers and emergency department directors to allocate resources efficiently. Aneurysmal subarachnoid haemorrhage (SAH) has high rates of morbidity and mortality. The incidence of SAH has been attributed to patient-related factors such as characteristics of aneurysms, smoking, and hypertension. There are studies showing that the incidence of aneurysmal SAH appears to behave in periodic fashions over long time periods. However, there are inconsistencies in the literature regarding the impact of chronobiological factors such as circadian, seasonal, and lunar cycle factors on the occurrence of SAH. In this study, we focused on the analysis of a temporal pattern of SAH (infradian rhythms) with a novel approach using circular statistical methods. We aimed to see whether there is a circular pattern for the occurrence of SAH at all and if so, whether it can be related to known temporal patterns based on available literature. Our study did not support the notion that aneurysmal subarachnoid haemorrhages occur on any specific day in a cycle with specific lengths up to 365 days including specific weekdays, full moon, equinoxes, and solstices. Hence, we found no relationship between SAH incidence and timing. Study in larger populations using similar circular statistical methods is suggested.

Recurrent, Severe Coital Headaches Associated With Bilateral Carotid Artery Aneurysms and the Effect of Endovascular Treatment

Headaches are one of the most common chief complaints in the outpatient setting. Distinguishing between benign and life-threatening headaches can be difficult, particularly in the setting of a pre-existing history of headaches. Here, we present a 41-year-old female with a past medical history of migraines and uterine leiomyoma status post hysterectomy about nine months ago who presented to the clinic for severe coital headaches and worsening migraines starting eight months ago. Computer tomography angiogram (CTA) head and neck demonstrated bilateral para-ophthalmic internal carotid artery (ICA) aneurysms (right, 7.5, left 6 mm). A diagnostic cerebral angiogram (DSA) was subsequently done and confirmed the CTA findings. The patient underwent left and right flow-diverting stent placement two and four months later, respectively. One week after the right ICA stent placement, her headaches had improved to one to two times per week. At six months after the stent placement, she resumed her normal sex life and her migraines returned to baseline. Our case suggests that recurrent severe coital headaches are associated with bilateral carotid artery aneurysms. Thus, while assessing a patient with recurrent coital headaches, it is important to have a wide arsenal of differentials to rule out possibly catastrophic causes.

Aneurysmal subarachnoid hemorrhage occurring during sleep: Clinical characteristics and risk factors

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is known to be triggered by several specific human activities. Sleep, by contrast, has not been considered a triggering activity for aSAH, and clinical characteristics of patients who sustain aSAH during sleep have rarely been reported in the literature.

METHODS

This is a retrospective analysis on the data acquired through a multicenter aSAH registry. Between January 2019 and December 2021, a total of 732 aSAH patients had been registered into our database. After excluding 109 patients whose activities at aSAH onset had been unidentifiable, the remaining 623 aSAH patients were dichotomized to 59 patients who sustained aSAH during sleep (Sleep group) and 564 patients who sustained aSAH during daytime activities (Awake group). Two-group comparison of demographic variables and multivariate logistic regression analysis were performed to clarify their clinical characteristics and identify potential risk factors.

RESULTS

The Sleep group exhibited significantly higher frequencies of diabetes (15.5 % vs. 6.4 %, p = 0.01) and antiplatelet use (13.8 % vs. 4.6 %, p=0.004) than the Awake group. Furthermore, multivariate logistic regression analysis showed that diabetes (OR, 3.051; 95 % CI, 1.281-7.268; p = 0.012) and antiplatelet use (OR, 3.640; 95 % CI, 1.422-9.316; p = 0.007) were correlated with aSAH occurring during sleep. There were no significant inter-group differences in the patient outcomes evaluated at discharge.

CONCLUSION

The current results indicate that risk factors may exist for aSAH occurring during sleep. Further investigations on how comorbidities such as diabetes, antiplatelet use and sleep apnea affect human hemodynamic and hemostatic parameters during sleep is warranted to better understand those relationships.

Sudden death related to sexual activity: A multicenter study based on forensic autopsies (2010-2021)

INTRODUCTION AND OBJECTIVES

To investigate the epidemiological characteristics, clinic-pathological findings and recent use of substances of abuse and prescribed drugs in sexual activity-related sudden death (SArSD).

METHODS

Multicenter population-based study on forensic autopsies conducted in 27 provinces of Spain over 12 years (2010-2021).

RESULTS

Out of 18046 autopsied natural deaths, 64 cases (0.35 %) of SArSD were investigated (87 % males). Women were younger than males (50.5 ± 13.4 years vs 37.2 ± 14.2; p = 0.017). Sudden cardiac deaths (SCD) accounted for 87 % of cases. Ischemic heart disease was the predominant pathology (58 %), mainly affecting men ≥ 36 years of age. Cerebral haemorrhage (8 %) and asthma (5 %) were the leading non-cardiac causes. In young adults, SADS (36 %) and asthma (27 %) were the main causes The disease responsible of SCD was diagnosed in life in 7 subjects. In 64 % there were cardiovascular risk factors, mainly obesity. Toxicological analysis detected illicit drugs (23 %), mainly cocaine, medications for erectile dysfunction (9 %), and ethanol ≥ 0.5 g/L (8 %). Deaths occurred usually in the context of heterosexual intercourse and during or immediately after sexual activity. The most common location was at home (63 %). In 12 men the sexual partner was a sex worker.

CONCLUSIONS

SArSD has a low incidence in the general population affecting middle-aged males during intercourse with a heterosexual partner. It is of cardiovascular origin, mainly due to ischemic heart disease that frequently remained silent during life. There is a frequent association with obesity, use of cocaine (and, to a lesser extent, medications for erectile dysfunction) and performing unconventional sexual practices. Forensic investigation is useful for developing prevention strategies.

Etiologies and Mechanisms of Ischemic Stroke Associated with Sexual Intercourse: A Literature Review

BACKGROUND

Exposure to some special events, also called stroke triggers, can precipitate the onset of ischemic stroke (IS). Previous studies have presented preliminary hypotheses about sexual intercourse as a trigger of IS in predisposed individuals, but the mechanisms of IS associated with sexual intercourse are still not well defined. This literature review summarizes the etiologies and mechanisms of IS associated with sexual intercourse. Further studies on stroke triggers are warranted, and early recognition and appropriate preventive strategies directed against the short-term risks posed by stroke triggers may complement the long-term risk factor reduction approach.

METHODS

Articles were selected from PubMed (1946-2021) and Web of Science Core Collection (1990-2021) using the following search terms: ischemic stroke, ischaemic stroke, stroke, cerebral infarction, cerebral ischemia, cerebral embolism, embolism, sexual intercourse, sexual activity, intercourse, coitus, coition, and coital.

RESULTS

A total of 20 studies, which included 26 patients with IS associated with sexual intercourse, were included. This literature review found that IS associated with sexual intercourse is not rare but has not received enough attention, and paradoxical embolization and postcoital arterial dissection are common etiologies. Other etiologies include drug usage (such as sexual adjuvant drugs and illicit drugs), paroxysmal sympathetic hyperactivity, and reversible cerebral vasoconstriction syndrome.

DISCUSSION/CONCLUSION

Sexual intercourse should be considered an important trigger for IS. Clinicians should be aware that IS associated with sexual intercourse is not subjective but may be a warning sign of multiple etiologies and mechanisms.

Headache Associated with Sexual Activity-A Narrative Review of Literature

Headache associated with sexual activity (HAWSA) has accompanied humanity since ancient times. However, it is only since the 1970s that it has become the subject of more extensive and detailed scientific interest. The purpose of this review is to provide an overview of the development of the concept of HAWSA, its clinical presentation, etiopathogenesis, diagnosis and treatment especially from the research perspective of the last 20 years. Primary HAWSA is a benign condition, whose etiology is unknown; however, at the first occurrence of headache associated with sexual activity, it is necessary to exclude conditions that are usually immediately life-threatening. Migraine, hypnic headache or hemicrania continua have been reported to co-occur with HAWSA, but their common pathophysiologic basis is still unknown. Recent advances in the treatment of HAWSA include the introduction of topiramate, progesterone, and treatments such as greater occipital nerve injection, arterial embolization, and manual therapy. Whether these new therapeutic options will stand the test of time remains to be seen.

[Neurological complications of coitus: Review of literature]

INTRODUCTION

Sexual activity is composed of different phases (excitation, plateau, resolution). Each phase is associated with cardiovascular, respiratory, muscular and hormonal modification which can have an influence on the nervous system. This impact has been studied many times in literature, but no study has synthetized the complications related to coitus or orgasm.

METHOD

Systematic review of literature on neurological complications, except headache, of coitus based on Medline and Embase.

RESULTS

We screened 1424 articles and selected 46 for this review. 7 (15 %) were clinical or epidemiologic studies, 6 (13 %) were reviews of literature and 33 (72 %) were cases or series of cases reports. 12 articles (26 %) talked about strokes, 10 (22 %) about subarachnoid hemorrhage, 9 (20 %) about reversible cerebral vasoconstriction syndrome. We found 3 (7 %) articles for each of the following complication: intraparenchymal, hematoma and epilepsy. Autonomic hypereflexia was treated in 3 articles (7 %). Only 1 article was included concerning ictus, spinal cord injury, neuralgia and cataplexia. These events can be considered as rare as emergencies related to sexual activity represent only 0.1 % of all emergencies and among these, 12 % are neurological. 31 of the reported cases concerned vascular events (stroke or hemorrhage) and 18 (58 %) of these patients had a patent malformation (aneurism, intracardiac shunt, foramen ovale).

CONCLUSION

This is one of the first review of literature trying to synthetise the neurological complications of coitus. Many articles exist in literature. It is necessary to prevent the occurrence of these complications in a population already at risk of neurological events.

Influence of Triggering Events on the Occurrence of Spontaneous Intracranial Hemorrhage : Comparison of Non-Lesional Spontaneous Intraparenchymal Hemorrhage and Aneurysmal Subarachnoid Hemorrhage

Objective

Spontaneous intracranial hemorrhage is a life-threatening disease, and non-lesional spontaneous intraparenchymal hemorrhage (nIPH) and aneurysmal subarachnoid hemorrhage (aSAH) are the leading causes of spontaneous intracranial hemorrhage. Only a few studies have assessed the association between prior physical activity or triggering events and the occurrence of nIPH or aSAH. The purpose of this study is to investigate the role of specific physical activities and triggering events in the occurrence of nIPH and aSAH.

Methods

We retrospectively reviewed 824 consecutive patients with spontaneous intracranial hemorrhage between January 2010 and December 2018. Among the 824 patients, 132 patients were excluded due to insufficient clinical data and other etiologies of spontaneous intracranial hemorrhage. The medical records of 692 patients were reviewed, and the following parameters were assessed : age, sex, history of hypertension, smoking, history of stroke, use of antiplatelet or anticoagulation agents, season and time of onset, physical activities performed according to the metabolic equivalents, and triggering event at onset. Events that suddenly raised the blood pressure such as sudden postural changes, defecation or urination, sexual intercourse, unexpected emotional stress, sauna bath, and medical examination were defined as triggering events. These clinical data were compared between the nIPH and aSAH groups.

Results

Both nIPH and aSAH most commonly occurred during non-strenuous physical activity, and there was no significant difference between the two groups (p=0.524). Thirty-two patients (6.6%) in the nIPH group and 39 patients (8.1%) in the aSAH group experienced triggering events at onset, and there was a significant difference between the two groups (p=0.034). The most common triggering events were defecation or urination in both groups.

Conclusion

Specific physical activity dose no affect the incidence of nIPH and aSAH. The relationship between the occurrence of intracranial hemorrhage and triggering events is higher in aSAH than nIPH.

Subarachnoid haemorrhage: a sinister cause of transient loss of consciousness during oral sex

Transient loss of consciousness (TLOC) is a common presentation to the emergency department and has a multitude of causes from benign to potentially fatal. We describe the case of a young female presenting with TLOC during sexual activity that was subsequently diagnosed with subarachnoid haemorrhage. She had normal neurology and only moderate headache. She was subsequently transferred to a neurosurgical unit and underwent endovascular coiling of a small anterior communicating artery aneurysm. She was discharged 15 days later without sequelae.

Sudden and Unexpected Death During Sexual Activity, Due to a Glial Cyst of the Pineal Gland

Cysts of the pineal gland are benign lesions. Often asymptomatic, in the majority of cases they are discovered incidentally during brain magnetic resonance imaging or autopsy. Sporadically, however, they may cause such symptoms as chronic headache, loss of consciousness, corticospinal and sensory impairment, and, in some cases, even sudden death. A 45-year-old woman, in apparently good health, collapsed and died suddenly, after reaching orgasm while engaged in sexual intercourse. According to the circumstantial account of her relatives, the woman suffered from severe headaches, which were exacerbated by certain types of physical strain, such as sexual activity. Postmortem examination revealed no external injuries or internal diseases except for a cystic lesion of the pineal gland. Microscopically, the wall of the cyst consisted of a layer of glial tissue surrounded by an area of pineal elements. A complete forensic approach concluded that the cause of death was fatal cardiorespiratory failure resulting from midbrain compression due to a nonneoplastic pineal gland cyst, exacerbated by sexual activity. In this case, the intracranial pressure increase, secondary to Valsalva maneuver during climax, may further aggravate compression on the brainstem, thus concurring to determine the death.

Patterns and Rates of Supplementary Venous Drainage to the Internal Jugular Veins

BACKGROUND AND PURPOSE

Several studies have found supplemental venous drainage channels in addition to bilateral internal jugular veins for cerebral venous efflux. We performed this study to characterize the supplemental venous outflow patterns in a consecutive series of patients undergoing detailed cerebral angiography with venous phase imaging.

METHODS

The venographic phase of the arteriogram was reviewed to identify and classify supplemental cerebral venous drainage into anterior (cavernous venous sinus draining into pterygoid plexus and retromandibular vein) and posterior drainage pattern. The posterior drainage pattern was further divided into plexiform pattern (with sigmoid venous sinus draining into the paravertebral venous plexus), and solitary vein pattern (dominant single draining deep cervical vein) drainage. The posterior plexiform pattern was further divided into 2 groups: posterior plexiform with or without prominent solitary vein.

RESULTS

Supplemental venous drainage was seen ipsilateral to internal jugular vein in 76 (43.7%) of 174 venous drainages (87 patients) analyzed. The patterns were anterior (n = 23, 13.2%), posterior plexiform without prominent solitary vein (n = 40, 23%), posterior plexiform with prominent solitary vein (n = 62, 35.6%), and posterior solitary vein alone (n = 3, 1.7%); occipital emissary veins and/or transosseous veins were seen in 1 supplemental venous drainage. Concurrent ipsilateral anterior and posterior supplemental drainage was seen in 6 of 174 venous drainages analyzed.

CONCLUSIONS

We provide an assessment of patterns and rates of supplementary venous drainage to internal jugular veins to improve our understanding of anatomical and physiological aspects of cerebral venous drainage.

Diabetes may affect intracranial aneurysm stabilization in older patients: Analysis based on intraoperative findings

BACKGROUND

Only a small proportion of aneurysms progress to rupture. Previous studies have focused on predicting the rupture risk of intracranial aneurysms. Atherosclerotic aneurysm wall appears resistant to rupture. The purpose of this study was to evaluate clinical and morphological factors affecting atherosclerosis of an aneurysm and identify the parameters that predict aneurysm stabilization.

METHODS

We conducted a retrospective analysis of 253 consecutive patients with 291 unruptured aneurysms who underwent clipping surgery in a single institution between January 2012 and October 2013. Aneurysms were categorized based on intraoperative video findings and assessed morphologic and demographic data. Aneurysms which had the atherosclerotic wall without any super thin and transparent portion were defined as stabilized group and the others as a not-stabilized group.

RESULTS

Of the 207 aneurysms, 176 (85.0%) were assigned to the not-stabilized group and 31 (15.0%) to the stabilized group. The relative proportion of stabilized aneurysms increased significantly as the age increased (P < 0.001). Univariate logistic analysis showed that age ≥65 years (P < 0.001), hypertension (P = 0.012), diabetes (P = 0.007), and height ≥3 mm (P = 0.007) were correlated with stabilized aneurysms. Multivariate logistic analysis showed that age ≥65 years (P = 0.009) and hypertension (P = 0.041) were strongly correlated with stable aneurysms. In older patients (≥65 years of age), multivariate logistic regression revealed that only diabetes was associated with stabilized aneurysms (P = 0.027).

CONCLUSIONS

In patients ≥65 years of age, diabetes mellitus may highly predict the stabilized aneurysms. These results provide useful information in determining treatment and follow-up strategies, especially in older patients.

Sexual activity as a trigger for intracranial hemorrhage

BACKGROUND

Intracranial hemorrhage (ICH) has been reported in association with sexual activity. A case-series of patients with ICH following sexual activity is presented to further elucidate the role of the physiologic sexual response as a trigger of ICH.

METHOD

A retrospective review of the medical record was performed, identifying patients presenting with ICH temporally related to sexual activity. Clinical and radiographic data were collected and reported.

RESULTS

Sixteen patients presented with non-traumatic ICH temporally related to sexual activity. Eight (50 %) patients presented with aneurysmal subarachnoid hemorrhage, four (25 %) with angiogram-negative subarachnoid hemorrhage, two (12.5 %) with a ruptured arteriovenous malformation, and two (12.5 %) with an intracerebral basal ganglia hemorrhage. Overall average age was 49.9 (range, 28-74) years. Sexual activity involved male-female intercourse in 14 (87.5 %) patients and masturbation in 2 (12.5 %) patients.

CONCLUSIONS

Sexual-activity-related ICH is rare and includes various etiologies. The human sexual response in associated with dramatic increases in arterial blood pressure, which likely underlies the association.

Death after Sexual Intercourse

Sexuality is an essential aspect of quality of life. Nevertheless, sexual intercourse is physically challenging and leads to distinct changes in blood pressure, heart, and respiratory rate that may lead to vital complications. We present a case report of a 22-year-old female suffering from subarachnoid hemorrhage after sexual intercourse. The patient was immediately transported to hospital by emergency medical services and, after diagnosis, transferred to a tertiary hospital with neurosurgical expertise but died within 24 hours. After postcoital headaches, subarachnoid hemorrhage is the second most common cause of neurological complications of sexual intercourse and therefore patients admitted to an emergency department with headache after sexual intercourse should always be carefully evaluated by cerebral imaging.

Subarachnoid hemorrhage secondary to forceful sneeze

Subarachnoid hemorrhage (SAH) is a relatively less common but important neurological condition comprising 5% of all the cerebrovascular accidents. In most populations the reported incidence is 6-7 per 100,000 person-years and one-third of survivors become dependent. It is a serious but potentially treatable cause of neurological morbidity. Multiple authors have identified the most unusual novel associations and triggers of subarachnoid bleeds over the past decade. We herein report a rare case of subarachnoid hemorrhage leading to focal neurological deficit in a middle aged man secondary to forceful sneeze.

Stroke and sexual dysfunction - a narrative review

Sexual function is an essential part of quality of life in adults. However, sexual dysfunction (SD) in stroke survivors is a common but under-recognized complication after stroke. It is frequently neglected by patients and clinicians. The etiology of post-stroke SD, which is multifactorial includes anatomical, physical and psychological factors. Complete return of sexual function is an important target for functional recovery after stroke, so clinicians need to be aware of this issue and take a lead role in addressing this challenge in stroke survivors. Accurate diagnosis and prompt treatment of post-stroke SD should be routinely incorporated into comprehensive stroke rehabilitation. This narrative review article, outlines the anatomy and physiology of sexual function, discusses various factors contributing to post-stroke SD, and proposes directions for future research.

Compared to controls, patients with ruptured aneurysm and surgical intervention show increase in symptoms of depression and lower cognitive performance, but their objective sleep is not affected

OBJECTIVES

Patients with aneurysmal subarachnoid haemorrhage (aSAH) have impaired sleep and cognitive performance together with more difficulties in social and everyday life. Hypocortisolism has also been reported. However, a study assessing all dimensions between aSAH severity, objective and subjective sleep, cortisol secretion, cognitive performance and social and everyday life has not so far been performed. The aim of the present study was therefore two-fold: (1) to assess, in a sample of patients with aSAH, objective and subjective sleep, cognitive functioning, social skills and cortisol secretion concurrently, and (2) to compare patients on these variables with a control group.

METHODS

Twenty-one patients (17 females; mean age: 58.80 years) with ruptured aneurysm and surgical intervention and 21 (14 females; mean age: 58.90 years) age- and gender-matched controls took part in the study. Assessments covered objective sleep-EGG recordings, subjective sleep, salivary cortisol analysis, and psychological functioning including memory performance, mood, and emotion recognition.

RESULTS

Compared to healthy controls, patients had lower scores for verbal memory performance and emotion recognition; they also reported more marked depressive symptoms and complained of poor sleep. However, no differences were found for objective sleep or cortisol secretion. Subjective and objective sleep, cortisol secretion and psychological functioning were unrelated.

CONCLUSIONS

Findings indicate that patients with aSAH face psychological rather than physiological issues.

Radiological findings of sexual intercourse related emergency department admissions: a first overview

Objectives

Sexuality is an essential aspect of human function, well-being and quality of life. Many people have sex without complications. However, there are some people who need to seek emergency medical help for related health problems. The aim of this study was to present a first overview of patients who received a radiological examination related to sexual intercourse based emergency department admission.

Methods

Our centralized electronic patient record database was reviewed for patients who had been admitted to our emergency department with an emergency after sexual intercourse between 2000 and 2011. The database was scanned for the standardized key words ‘sexual intercourse’ or ‘coitus’ retrospectively. For all patients identified in the electronic patient record database the radiological examinations were searched for manually in our Radiology Information System, and reviewed by three independent radiologists.

Results

One hundred and twenty nine out of 445 (29,0%) patients received a radiological examination after immediate emergency department admission related to sexual intercourse. Fifty two out of 129 (40.3%) patients had positive radiological findings while 77 (59.7%) did not. Eighty point seven percent (n = 42) of the radiological findings were a sexual intercourse-associated pathology and 19.2% (n = 10) were considered to be incidental findings. Age and male sex positively correlated with radiological imaging workup (p<0.001, respectively p<0.037). The most common sexual intercourse-associated pathology was headache attributed to cerebrovascular insult (n = 21, 40.3%) followed by epididymitis (n = 7, 16.6%) and obstructive uropathy (n = 5, 11.6%). Of the patients with headache attributed to non-traumatic intracranial hemorrhage, subarachnoid hemorrhage (n = 14, 66.6%) was the most common, followed by intracerebral bleeding (n = 4, 19.0%) and one subdural hemorrhage.

Conclusions

Pathological findings are manifold. Cerebral imaging is the most common type of radiological imaging performed. Further prospective and standardized studies should be performed to better evaluate the significance of radiological imaging in this patient collective with the aim to gain better knowledge on what patients profit from what type of radiological imaging when presenting with a sexual intercourse related emergency.

Advances in Knowledge

The present study provides a first overview on radiological findings of sexual intercourse related emergency department admissions.

Perioperative variables contributing to the rupture of intracranial aneurysm: an update

Background. Perioperative aneurysm rupture (PAR) is one of the most dreaded complications of intracranial aneurysms, and approximately 80% of nontraumatic SAHs are related to such PAR aneurysms. The literature is currently scant and even controversial regarding the issues of various contributory factors on different phases of perioperative period. Thus this paper highlights the current understanding of various risk factors, variables, and outcomes in relation to PAR and try to summarize the current knowledge. Method. We have performed a PubMed search (1 January 1991–31 December 2012) using search terms including “cerebral aneurysm,” “intracranial aneurysm,” and “intraoperative/perioperative rupture.” Results. Various risk factors are summarized in relation to different phases of perioperative period and their relationship with outcome is also highlighted. There exist many well-known preoperative variables which are responsible for the highest percentage of PAR. The role of other variables in the intraoperative/postoperative period is not well known; however, these factors may have important contributory roles in aneurysm rupture. Preoperative variables mainly include natural course (age, gender, and familial history) as well as the pathophysiological factors (size, type, location, comorbidities, and procedure). Previously ruptured aneurysm is associated with rupture in all the phases of perioperative period. On the other hand intraoperative/postoperative variables usually depend upon anesthesia and surgery related factors. Intraoperative rupture during predissection phase is associated with poor outcome while intraoperative rupture at any step during embolization procedure imposes poor outcome. Conclusion. We have tried to create such an initial categorization but know that we cannot scale according to its clinical importance. Thorough understanding of various risk factors and other variables associated with PAR will assist in better clinical management as well as patient care in this group and will give insight into the development and prevention of such a catastrophic complication in these patients.

Impact of the moon on cerebral aneurysm rupture

BACKGROUND

Several external and internal risk factors for cerebral aneurysm rupture have been identified to date. Recently, it has been reported that moon phases correlate with the incidence of aneurysmal subarachnoid hemorrhage (SAH), however, another author found no such association. Therefore, the present study investigates the influence of the lunar cycle on the incidence of aneurysmal rupture, the initial clinical presentation, and the amount of subarachnoid blood.

METHODS

Lunar phase and the particular day of the lunar cycle were correlated to the date of aneurysm rupture, aneurysm location, initial clinical presentation, and amount of subarachnoid blood assessed from CT scans of all patients treated for basal SAH in our department from 2003 to 2010.

RESULTS

We found no correlation between incidence of aneurysmal SAH, location of the aneurysm, initial clinical presentation, or amount of subarachnoid blood and the lunar cycle.

CONCLUSIONS

The moon influences neither the incidence of aneurysmal SAH nor the grade of initial neurological deterioration or amount of subarachnoid blood.

High WSS or low WSS? Complex interactions of hemodynamics with intracranial aneurysm initiation, growth, and rupture: toward a unifying hypothesis

SUMMARY

Increasing detection of unruptured intracranial aneurysms, catastrophic outcomes from subarachnoid hemorrhage, and risks and cost of treatment necessitate defining objective predictive parameters of aneurysm rupture risk. Image-based computational fluid dynamics models have suggested associations between hemodynamics and intracranial aneurysm rupture, albeit with conflicting findings regarding wall shear stress. We propose that the "high-versus-low wall shear stress" controversy is a manifestation of the complexity of aneurysm pathophysiology, and both high and low wall shear stress can drive intracranial aneurysm growth and rupture. Low wall shear stress and high oscillatory shear index trigger an inflammatory-cell-mediated pathway, which could be associated with the growth and rupture of large, atherosclerotic aneurysm phenotypes, while high wall shear stress combined with a positive wall shear stress gradient trigger a mural-cell-mediated pathway, which could be associated with the growth and rupture of small or secondary bleb aneurysm phenotypes. This hypothesis correlates disparate intracranial aneurysm pathophysiology with the results of computational fluid dynamics in search of more reliable risk predictors.

Imaging in the evaluation of headache

When deciding to perform imaging for headache, it is important to consider many factors including the pretest probability, prevalence of diseases, sensitivity of imaging, and implications for treatment. For the first presentation of a headache or a change in headache pattern, if the characteristics do not perfectly fit a primary headache type, imaging may be indicated according to the ICHD-2 criteria to exclude a secondary cause before a primary headache is diagnosed. The value of negative imaging should not be underestimated in the cost-benefit analysis, which often only takes into account number needed to treat or likelihood of finding a significant treatable abnormality. One study has shown that some groups of patients are less likely to overuse other parts of the health care system after negative neuroimaging. Further studies with stronger methodologies, finer differentiation of acute and chronic headache presentations, more advanced imaging technology, among other factors, can improve decision making on when to use imaging and assess the impact of imaging on patient satisfaction and quality of life. In addition, functional MRI, MRS, and voxel-based morphometry MRI are only some of the neuroimaging techniques currently used in research to further understand the pathophysiology and mechanisms of headache. In conclusion, although most headaches are a primary headache disorder with a benign course, imaging is an important part of the diagnostic evaluation to exclude the presence of a secondary cause of headache that could cause fatal results or severe neurologic morbidity. In headache patients without focal neurologic examination abnormalities, the yield of neuroimaging for significant intracranial findings is generally low. However, specific subgroups of headache patients and headache presentations can have much higher rates of significant intracranial abnormalities.

Sexual activity-related emergency department admissions: eleven years of experience at a Swiss university hospital

PRINCIPALS

Most people enjoy sexual intercourse without complications, but a significant, if small, number need to seek emergency medical help for related health problems. The true incidence of these problems is not known. We therefore assessed all admissions to our emergency department (ED) in direct relation to sexual intercourse.

METHODS

All data were collected prospectively and entered into the ED's centralised electronic patient record database (Qualicare, Switzerland) and retrospectively analysed. The database was scanned for the standardised key words: 'sexual intercourse' (German 'Geschlechtsverkehr') or 'coitus' (German 'Koitus').

RESULTS

A total of 445 patients were available for further evaluation; 308 (69.0%) were male, 137 (31.0%) were female. The median age was 32 years (range 16-71) for male subjects and 30 years (range 16-70) for female subjects. Two men had cardiovascular emergencies. 46 (10.3%) of our patients suffered from trauma. Neurological emergencies occurred in 55 (12.4%) patients: the most frequent were headaches in 27 (49.0%), followed by subarachnoid haemorrhage (12, 22.0%) and transient global amnesia (11, 20.0%). 154 (97.0%) of the patients presenting with presumed infection actually had infections of the urogenital tract. The most common infection was urethritis (64, 41.0%), followed by cystitis (21, 13.0%) and epididymitis (19, 12.0%). A sexually transmitted disease (STD) was diagnosed in 43 (16.0%) of all patients presenting with a presumed infection. 118 (43.0%) of the patients with a possible infection requested testing for an STD because of unsafe sexual activity without underlying symptoms.

CONCLUSIONS

Sexual activity is mechanically dangerous, potentially infectious and stressful for the cardiovascular system. Because information on ED presentation related to sexual intercourse is scarce, more efforts should be undertaken to document all such complications to improve treatment and preventative strategies.

Sex after stroke: a content analysis of printable educational materials available online

BACKGROUND

Providing written educational materials to stroke survivors is a key recommendation in many international stroke guidelines. Yet, sexual concerns are generally overlooked in current stroke rehabilitation and the content of educational materials on sexual concerns has not been analyzed nor evaluated in published stroke research.

AIM

The aim of this study was to identify, describe, and analyze printable educational materials on sexual concerns that are available online and easily shared with stroke survivors.

METHOD

Google search engine was used to locate printable educational materials from the Internet using a search term strategy of 35 phrases that were piloted for accuracy. The content of eligible materials was analyzed using NVivo software to produce both enumerative and thematic data.

RESULTS

Nine educational materials from reputable organizations were included with an average length of seven pages and 1445 words (total 61 pages, 13 000 words). The content of the materials was similar and covered three main content areas: problems experienced after stroke: 30% coverage suggested solutions: 32% coverage, and reassurance: 9% coverage. Content describing potential problems reflected published research, but solutions and reassurance were general, nonspecific, and often not supported by evidence.

CONCLUSIONS

Educational materials on sex after stroke may be helpful for health professionals, stroke survivors, and their partners, yet some messages appear to discourage recovery. Educators, health professionals, and organizations can use this analysis to evaluate their own educational resources and create resources that better address the sexual concerns of stroke survivors and their partners.