Sexual intercourse and cerebral aneurysmal rupture: potential mechanisms and precipitants

A review

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Aneurysmal subarachnoid hemorrhage (SAH) is a significant cause of death in young and middle-aged individuals and causes tremendous morbidity in affected patients. Despite the identification of various risk factors, the series of events leading to the formation, growth, and rupture of intracranial aneurysms is poorly understood. Cerebral aneurysm rupture has been associated with sexual intercourse and other forms of physical exercise. In fact, multiple case series reported that coitus was the immediate preceding activity in 3.8–14.5% of patients suffering from aneurysmal SAH. This may be related to the large elevations in mean arterial blood pressure that occur in both males and females during sexual intercourse (130–175 and 125–160 mm Hg, respectively). While coitus and physical exercise share important physiological similarities, each may differentially affect the probability that a preformed aneurysm will rupture. In this literature review and synthesis, the authors analyze the physiological human response to sexual intercourse in an effort to delineate those factors that may precipitate aneurysmal rupture. The authors' analysis is based on the original data collected by Masters and Johnson. To the authors' knowledge, this is the first review to address the link between sexual intercourse and intracranial aneurysmal rupture. While actual measurements of the physiological variables relevant to SAH were not performed in this article, the authors make reasonable assumptions based on the available data to help elucidate the mechanism of sexually induced aneurysmal rupture.

Abbreviations used in this paper: BP = blood pressure; CBF = cerebral blood flow; CPP = cerebral perfusion pressure; HR = heart rate; ICP = intracranial pressure; MABP = mean arterial BP; RR = respiratory rate; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Matthew R. Reynolds, M.D., Ph.D., Department of Neurological Surgery, Barnes–Jewish Hospital, Campus Box 8057, 660 South Euclid Avenue, St. Louis, Missouri 63110. email: ReynoldsM@wudosis.wustl.edu.

Please include this information when citing this paper: published online June 11, 2010; DOI: 10.3171/2010.4.JNS09975.

© AANS, except where prohibited by US copyright law.

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Figures

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    A–H: Graphic depiction of muscle tone, RR, HR, MABP, ICP, CPP, autonomic activity, and aneurysm wall tension as a function of each sexual phase. These data were assembled from multiple studies in human sexual physiology,5,7,47,48,64 and the plots represent average values during each sexual phase (in arbitrary units). Notably, most physiological parameters are increased in a linear fashion during the transition from the excitement to the orgasmic phase (A, C, and D). In contrast, RR is increased late in the plateau phase (B). This hyperventilatory state would be expected to stabilize the ICP, thereby increasing the CPP in proportion to the rising MABP (D–F). Given that the CPP (and therefore, aneurysm wall tension) is greatest during orgasm, one would expect aneurysmal rupture to occur during this period (H). Please see the text for details.

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    A–H: Graphic depiction of muscle tone, RR, HR, MABP, ICP, CPP, autonomic activity, and aneurysm wall tension as a function of increasing levels of physical exercise. As noted in Fig. 1, the plots represent average values during each level of physical activity. It is important to note that, unlike sexual intercourse, the RRs in both males and females increase in a linear fashion during each level of exercise. As a result, there is no precipitous rise in CPP because the progressively increasing MABP is counterbalanced by the increasing ICP. The cumulative result is decreased tension across the aneurysm wall and, ultimately, a lower risk of aneurysmal rupture.

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