Intended for healthcare professionals

Clinical Review Lesson of the week

Intracerebral haemorrhage in young adults: the emerging importance of drug misuse

BMJ 2000; 320 doi: (Published 13 May 2000) Cite this as: BMJ 2000;320:1322
  1. Andrew W McEvoy, research fellow (,
  2. Neil D Kitchen, senior lecturer,
  3. David G T Thomas, professor
  1. University Department of Neurosurgery, Institute of Neurology, National Hospital for Neurology and Neurosurgery, London WC1N 3BG
  1. Correspondence to: A W McEvoy
  • Accepted 24 September 1999

In young people with haemorrhagic stroke, think of drug misuse and look for an underlying vascular cause

It has been recognised for some time that many disorders such as vascular malformations, hypertension, bacterial endocarditis, collagen vascular diseases, tumours, eclampsia, and blood dyscrasias can cause non-traumatic intracerebral haemorrhage in young adults. However, with the epidemic in the misuse of amphetamine, cocaine, and ecstasy—primarily among young people—traditional aetiological factors for haemorrhagic stroke are becoming overshadowed.

The association between amphetamine ingestion and intracerebral haemorrhage was first reported by Gericke in 1945, and it has become increasingly recognised in recent years.110 Previous reports, although noting the occurrence of intracerebral haemorrhage and subarachnoid haemorrhage, found no evidence of an underlying vascular abnormality on detailed microscopic examination of the cerebral vessels.29 The haemorrhages were explained by a necrotising angiitis related to amphetamine misuse associated with hypertension.7 9 11 In 1996, a necropsy study of 14 patients with intracerebral haemorrhages related to cocaine use found no evidence of an abnormal cerebral vasculature.12 Further investigation to seek an underlying cause was thought to be unnecessary.

There have, however, been two recent reports of ruptured arteriovenous malformations after amphetamine misuse and a single case after ecstasy misuse.10 13 The growing pandemic of cocaine use in Western society is providing increasing evidence of its association with intracerebral haemorrhage.1419 It is becoming increasingly evident that misuse of cocaine in people with underlying vascular abnormalities may lead to haemorrhage.

Cases and outcomes

In the past seven months we have treated 13 patients who had sustained intracerebral haemorrhage and had misused one or more of these illegal substances. Ten of the patients were well enough to undergo cerebral angiography. We were surprised to find intracranial aneurysm in six and arteriovenous malformations in …

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