A Case Report of Intracerebral Hematoma heart, brain, and other tissues.6-8 Although it has been appli- ed for heart and blood diseases, routinely and prophylacti- cally for thousands of years in China,2-4 little available clinical data showed that it could cause apparent bleeding. It contains hongsheng (red ginseng), maidong (liriope), and wuweizi (schisandra chinensis). There are many different types of red ginseng, such as rhizoma ginseng rhbra, radix ginseng rhbra (1 year), radix ginseng rhbra (2 year), North Korea radix ginseng rhbra, radix ginseng rhbra (ordinary), and radix ginseng rhbra (xinkaihe). All contains different amounts of ginsenoside Rg1, Re, and Rb1.9 Case reports and healthy volunteer trials have had confli- cting results, some reporting a potentiating10-14 and others a reductive influence.15-19 Previous studies10-13 have suggested that red ginseng was associated with an altered INR occurred in this patient. In 1998, Nakajima, et al.12 demon- strated that red ginseng was observed to increase the pro- duction of Interleukin 1 beta, which is known to play im- portant roles in the homeostatic activities of the human body such as increasing the production of tissue plasminogen activators, which suppress the formation of thrombin in the blood coagulation and fibrinolysis mechanisms. In a later study, Lü, et al.14 confirmed these findings. Their study revealed that Rg1 down regulates plasminogen inhibitor 1 (PAI-1), tissue factor pathway inhibitor, coagulation factor XIII, A1, and, coagulation factor II (thrombin) receptor (F2R). A recent study by Jin, et al.10 suggested that Korean red ginseng has a potent antithrombotic effect in vivo, which may be due to antiplatelet rather that anticoagulation activity. In contrast, Jiang et al.15 showed that co-adminis- tration of warfarin with ginseng did not affect the phar- macokinetics or pharmacodynamics of either S-warfarin or R-warfarin in healthy subjects in 2004. Recently, Lee, et al.16 also found that co-administration of panax ginseng and warfarin in ischemic stroke patients does not influence the pharmacologic action of warfarin. Later study by Jiang, et al.17 demonstrated that Asian ginseng could actually mo- destly increase the clearance of warfarin and decrease its effectiveness. In addition, Mu, et al.20 found that the admini- stration of wuweizi, another essential component of sheng- mai-yin, can increase the metabolism and decrease the levels of warfarin in animal models due to CYP2C9 induction. Drug interactions occur at varying rates in patients. The causes for variability include Genetics, diseases, diet/nutri- tion, environment, smoking, and alcohol use. The indivi- dual Genetic traits underlying increased or decreased the effect of drug co-administered other drugs are unknown. The Genetic trait needs further investigation for this case. Intracerebral bleeds due to trauma, rupture of an aneu- rysm or arteriovenous malformation (AVM), and bleeding within a tumor. A very small proportion is due to cerebral venous sinus thrombosis. High blood pressure raises the risk of spontaneous intracerebral hemorrhage by two to six times.21 The patient suffered from hypertention for many years, but he took antihypertensive (agent) at a regular base and blood pressure was well-controlled. He had no trauma history and head CT showed no other abnormalities. However, the effect of shengmai-yin on coagulation pro- gress was controversial. In this patient, loss of anticoagula- tion control was more likely after consumption of shengmai- yin, possibly due to its potentiating effect on the normal coagulation progress. Warfarin has a narrow therapeutic index. Patients should be counseled to avoid herbal medica- tion that can interact with warfarin. It is important to take a detailed history regarding the use of all drugs and herbal medicines, especially in patients with anticoagulant therapy. ACKNOWLEDGEMENTS The work was performed in First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China. This study was supported by Zhejiang Provincial Depart- ment of Science and Technology, No2006C30014. REFERENCES 1. Vaes LP, Chyka PA. Interactions of warfarin with garlic, ginger, ginkgo, or ginseng: nature of the evidence. Ann Pharmacother 2000;34:1478-82. 2. Xuejiang W, Magara T, Konishi T. Prevention and repair of cerebral ischemia-reperfusion injury by Chinese herbal medicine, shengmai san, in rats. Free Radic Res 1999;31:449-55. 3. Hu RC, Dai AG, Tan SX. Shengmai injection improves the cardiorespiratory function of catabasis of chronic cor pulmonale patients. J Shanxi Med Univ 2005;36:603-5. 4. Zhang YC, Chen RM, Zhao MH. [Effect of shengmai injection on hemodynamics in patients with dilated cardiomyopathy.] Zhongguo Zhong Xi Yi Jie He Za Zhi 2002;22:227-9. 5. Horn JR, Hansten PD, Chan LN. Proposal for a new tool to eva- luate drug interaction cases. Ann Pharmacother 2007;41:674-80. 6. Wang NL, Chang CK, Liou YL, Lin CL, Lin MT. Shengmai San, a Chinese herbal medicine protects against rat heat stroke by reducing inflammatory cytokines and nitric oxide formation. J Pharmacol Sci 2005;98:1-7. 7. Wang NL, Liou YL, Lin MT, Lin CL, Chang CK. Chinese herbal medicine, Shengmai San, is effective for improving circulatory shock and oxidative damage in the brain during heatstroke. J Pharmacol Sci 2005;97:253-65. 8. Ding XF, Chen G, Liu YL. [Effect of shengmai for injection on car- diogenic shock.] Zhongguo Zhong Yao Za Zhi 2007;32:2298-305. 9. Chen GY, Chen EP. HPLC-ELSD determination of ginsenoside Rg1, Re and Rb1 in red ginseng. China J Phar Anal 2007;27:754-6. 10. Jin YR, Yu JY, Lee JJ, You SH, Chung JH, Noh JY, et al. Anti- thrombotic and antiplatelet activities of Korean red ginseng extract. Basic Clin Pharmacol Toxicol 2007;100:170-5. Yonsei Med J http://www.eymj.org Volume 51 Number 5 September 2010 795