Vitamin E, or tocopherol, is a lipid-soluble antioxidant that inhibits lipid peroxidation and scavenges reactive oxygen species. Additionally, it may inhibit platelet aggregation and cellular proliferation and decrease the availability of clotting factors, such as vitamin K. Vitamin E supplementation is beneficial in preventing cardiovascular events. However, toxicity due to its anticoagulatory effects may cause hemorrhage. We present a case of intracerebral hemorrhage in a patient with elevated vitamin E levels and no known risk factors.

A 66-year-old woman, previously healthy, not on any prescription medications but was on Vitamin E daily, presents with headache and left-sided weakness. On presentation, vital signs are normal, and the exam revealed a right gaze preference, left homonymous hemianopsia, and left upper and lower extremity drift. Computed tomography angiogram (CTA) head showed a right frontal hematoma and distal M2 occlusion. The following day, a magnetic resonance image (MRI) brain showed a stable right frontal intraparenchymal hematoma with no underlying infarction. We sent serum levels for α-tocopherol, which were elevated at 25.8 mg/L.Vitamin E supplementation was discontinued, and the patient was discharged to acute inpatient rehabilitation.

Vitamin E's ability to inhibit platelet aggregation or inhibition of vitamin K-dependent factors is the leading explanation for hemorrhage. The effects of platelet aggregation inhibition in healthy individuals are still unknown. There are a handful of case reports of healthy patients with no significant history on vitamin E supplements presenting with hemorrhage and no other etiology found. However, data has not been overwhelming, and an increased sample size is needed. The CTA head revealed a distal M2 occlusion, but it felt incidental as the bleeding site was at a remote location. MRI did not suggest an underlying infarction. We aim to raise awareness amongst clinicians to inquire about the patient's supplementation regimen and advocate for further investigation.