Drug Abuse and Intracerebral Hemorrhage

BACKGROUND AND CLINICAL INFORMATION: Head

Polydrug abuse is not an uncommon phenomenon. It may be difficult to correlate the hemorrhage to a specific drug. Cocaine and amphetamine are more commonly related to intracranial hemorrhage than opiates. Other underlying risks factors, which are not infrequently seen in drug abusers, such as chronic hypertension, smoking and alcohol abuse must not be ignored.

Drug abuse during pregnancy may induce seizures of the fetus leading to permenant demage of the developing fetal brain.

Immediate and delayed hemorrhage: Intracranial hemorrhage associated with drug abuse may occur immediately or within a few hours after the use of the drug or it can occur days or weeks after the drug abuse.

Durgs of abuse may cause intracerebral hemorrhage, subarachnoid hemorrhage and ischemic infarction. The more common drugs include cocaine, amphetamines, and several over-thecounter sympathomimetics such as phenylpropanolamine, ephedrine, and pseudoephedrine. Hemorrhage can be resulted from:

Abnormal high blood pressure induced by the drug of abuse, in particular cocaine.
It can be present as a delayed effect of drug abuse such as hemorrhage due to vasculitis or endocarditis associated with drug abuse.
One half of the patients with hemorrhage related to drugs have a pre-existing vascular malformation, usually an aneurysm or AVM. These drugs may also precipitate a seizure or hypertensive crisis and may result in an infarction in a developing fetus.

Cocaine:

Street drug: Cocaine is commonly available as either cocaine hydrochloride on the street (purity about 58%) or as "crack" which may attain a purity over 95%. While cocaine hydrochlorid decomposes when heated, crack has altered chemical properties that enable it to be smoked. Smoking crack provides an easy and effective method for obtaining both rapid systemic absorption and high plasma concentration.
Pharmacology: By inhibiting reuptake of catecholaminergic neurotransmitter (including epinephrine, nor-epinephrine, and dopamine), cocaine may induce systemic hypertension, tachycardia, and vascular spasm.
Blood pressure surge: Cocaine generates a very high transient increase in blood pressure due to vasoconstriction. Patients with berry aneurysms and vascular malformations are particularly susceptible to such hemorrhage resulted from this blood pressure surge. Death due to rupture of vascular malformations after cocaine use is a leading cause of fatal intracerebral hemorrhage in young patients in the United States.
Ischemic changes: Ischemic manifestation is the most frequent neurologic complication of cocaine abuse, followed by subarachnoid hemorrhage and intracerebral hemorrhage. Not infrequently, the hemorrhage is associated with an underlying vascular abnormality such as aneurysm or AVM of the brain.

GROSS PATHOLOGY: Head

Cocaine: Hemorrhage is most likely caused by the extremly high blood pressures that occurs during cocaine use. Hemorrhage associated with ruptured AVM tends to be lobar but those presumbly associated with the hypertension induced by cocaine abuse tends to be found in locations associated with hemorrhage commonly seen in chronic hypertension such as putamen. Biopsy proven vasculitis due to cocaine is reported but is rare. The vasculitis seems to be non-infectious and possibly allergic since the inflammatory infiltrate is mainly lymphocytic and some patients respond to immunosuppressive therapy.