A case of stroke attributed to a herbal energy drink containing sympathomimetic phenylpropanoid compounds is reported in a 21-year-old man treated at the University of Virginia, Charlottesville. Within hours after 250 ml of XS Cranberry-Grape Blast while on a hike, the patient, a type 1 diabetic, developed severe headache, photophobia and hemiataxia. Diffusion-weighted MR imaging revealed an acute brainstem infarction and bilateral subarachnoid hemorrhage. Cerebral angiography showed multiple areas of narrowing and dilatation in distal segments of middle and posterior cerebral arteries. A screen for drugs of abuse was negative. The drink contained a mixture of herbal compounds including ginseng and Chinese magnolia vine. In addition, the patient routinely drank the caffeine containing Red Bull Sugar Free. 
COMMENT. The patient’s diabetes may have increased the risk of vasculopathy and stroke with this high energy, ginseng-containing drink. In a report from Taiwan (Ped Neur Briefs June 1995) , ginseng-associated cerebral arteritis and headache were reported in a 28-year-old woman who had taken an infusion of ginseng root (25 mg stewed in rice wine) for fatigue. The patient had never experienced headache following smaller quantities of ginseng (Chinese practice usually recommends 0.5 to 2gm). Cerebral angiogram revealed multiple areas of alternating focal constriction and beading in anterior and posterior cerebral arteries and superior cerebellar artery, consistent with arteritis. The headache resolved gradually in 10 days. Experimentation with unusually large doses of ginseng to improve stamina or concentration may carry a risk of headache, vasculitis and stroke.