Two cases of Sexual Activity-Related Deaths due to Vascular Dissection: investigating the Potential Link to phosphodiesterase type 5 inhibitor administration.

Abstract

Abstract: Sexual activity-related sudden death (SArSD) is an uncommon phenomenon in forensic pathology, typically associated with preexisting vascular abnormalities that rupture due to sudden changes in blood pressure or heart rate during sexual activity. The current report presents two cases of SArSD in men with positive anamnesis for chronic sildenafil use. In Case 1, the cause of death was determined to be an intracranial hemorrhage that occurred shortly before sexual intercourse. In Case 2, death was attributed to the rupture of an abdominal aortic aneurysm, occurring during sexual activity and linked to substance abuse. While both deaths were attributed to SArSD, the potential role of sildenafil in promoting aneurysm formation or rupture remains a subject of debate. Intracerebral hemorrhages associated with sildenafil use appear to exhibit a consistent pattern, commonly affecting the basal nuclei, thalamus, and adjacent cerebral regions, particularly the lateral temporal lobe. Notably, in many cases descri-bed in literature sildenafil doses exceeding 50 mg were reported. The combined effects of sildenafil and substances (such as cocaine) in such events remain largely unexplored, underscoring the need for further research to elucidate their interaction. Cases of vascular dissections occurring independently of sexual activity suggest that sildenafil use warrants caution, particularly in individuals with underlying vascular vulnerabilities. Although rare clinical cases and autopsy findings have suggested a potential association between phosphodiesterase type 5 inhibitors (PDE5i) and hemorrhagic events, such as intracerebral hemorrhages or aneurysm ruptures, current evidence does not indicate that PDE5i have a significant or direct impact on blood pressure capable of causing the acute rupture of a healthy vessel. Nevertheless, further clinical and forensic studies are essential to elucidate the relationship between chronic or acute PDE5i use and hemorrhagic cerebrovascular accidents or aortic dissections.