A 38-year-old normotensive man without significant past medical
history had a generalized seizure at home. Urine toxicity screening
revealed cocaine metabolites.
Cocaine-related intracranial hemorrhage
Axial head CT reveals a right thalamic hemorrhage with
intraventricular extension (figure 1). Posterior circulation brain
MR angiogram maximum intensity projection, lateral view (figure 2)
reveals two small right thalamic arteriovenous malformations (AVM)
supplied by dilated posterior cerebral artery perforating branches,
which were confirmed by catheter angiography, left vertebral artery
injection lateral projection (figure 3). Supportive care was
continued, and the vascular malformations were treated with the
Gamma Knife using stereotactic localization.
Known neurovascular complications of cocaine include cerebral
infarction related to vasospasm or hypertension, embolic infarction
from arrhythmia, intraparenchymal hemorrhage (IPH), and
subarachnoid hemorrhage. Intraparenchymal hemorrhage related to
typical chronic hypertension is usually due to vessel wall
degeneration resulting in local areas of arterial wall weakness,
from rupture of small microaneurysms arising from the small
perforating vessels, or from an acute rise in blood pressure.1
The mechanisms of cocaine-induced IPH are less well understood.
Hemorrhagic conversion of typical ischemic infarction likely
constitutes a considerable number of cases. However, most of these
hemorrhages are present in the central, deep gray structures of the
brain, locations typical of hypertension-induced hemorrhage.
Vasospasm of large arteries may jeopardize the small perforating
arteries arising from them, either induced directly by cocaine or
related to acute hypertension. Alternatively, vasospasm may affect
the small perforating vessels directly. The deep gray structures
are then prone to reperfusion injury after relief of ischemia.
Hemorrhage could also be a direct result of acute
However, many studies have shown a high incidence of underlying
vascular lesions among patients presenting with intracranial
hemorrhage after cocaine use, specifically arteriovenous
malformations and aneurysms. In a review of 14 cases of
cocaine-related intracranial hemorrhage, Mangiardi et al2 found an
underlying AVM or aneurysm in six of the 11 patients who underwent
angiography. Similarly, Jacobs et al3 identified vascular lesions
in three of eight patients presenting with intracranial
In elderly chronically hypertensive patients, bleeding often
occurs within deep gray matter including the putamen, thalamus, and
external capsule, usually from a single perforating artery arising
from the middle cerebral or posterior cerebral arteries.6 When
bleeding is identified in one of these typical locations in an
elderly patient with a history of hypertension, it is usually
assumed that the bleed is hypertensive in origin and additional
diagnostic workup is not performed. However, this methodology is
not employed universally, and additional imaging is commonplace,
depending on the institution and physicians involved. When the
clinical presentation or imaging findings are atypical (young age,
questionable history of hypertension, atypical location),
additional imaging is mandatory.
Although many of the reported cocaine-related intraparenchymal
hemorrhages are in a typical location for hypertensive hemorrhage
(putamen, pons, thalamus, external capsule), additional imaging
with MR or catheter angiography should be strongly considered.
1. Caplan L: Intracerebral hemorrhage
revisited. Neurology 38:624-627, 1988.
2. Mangiardi JR, Daras M, Geller ME, et al:
Cocaine-related intracranial hemorrhage. Report of nine cases and
review. Acta Neurol Scand 77:177-180, 1988.
3. Jacobs IG, Roszler MH, Kelly JK, et al:
Cocaine abuse: Neurovascular complications. Radiology 170:223-237,
4. Levine SR, Brust JCM, Futrell N, et al:
Cerebrovascular complications of the use of the "crack" form of
alkaloidal cocaine. N Engl J Med 323:699-704, 1990.
5. Brown E, Prager J, Lee H-Y, et al: CNS
complications of cocaine abuse: Prevalence, pathophysiology, and
neuroradiology. AJR Am J Roentgenol 159:137-47, 1992.
6. Laissy J-P, Normand G, Monroc M, et al:
Spontaneous intracerebral hematomas from vascular causes.
Predictive value of CT compared with angiography. Neuroradiology