Cocaine-induced hypertensive hemorrhage

CLINICAL HISTORY

A 39-year-old man with a history of cocaine use presented with acute left hemiparesis.

FINDINGS

Initial noncontrast CT revealed an acute hemorrhage centered in the posterior right putamen (Figure 1). A CT angiogram was performed to exclude an underlying vascular lesion and to predict potential expansion of the hematoma. No underlying lesion was seen, but a focal area of increased density consistent with active extravasation was identified on the contrast-enhanced CT (Figure 2). A subsequent noncontrast CT, performed six hours later, demonstrated significant enlargement of the hematoma (Figure 3).

DIAGNOSIS

Enlarging cocaine-induced hemorrhage with expansion predicted by admission postcontrast CTA.

DIFFERENTIAL DIAGNOSIS

Differential considerations for a spontaneous intracerebral hemorrhage in this young patient include underlying vascular lesions, such as an arteriovenous malformation, cavernoma, middle cerebral artery aneurysm or pseudoaneurysm, underlying neoplasm (especially thyroid or melanoma), venous infarction, vasculitis, coagulopathy, moyamoya disease, and drug-induced hypertension. In our patient, the location and clinical history are characteristic of a cocaine-induced hypertensive hemorrhage.

DISCUSSION

The epidemic use of sympathomimetic drugs such as methamphetamine, cocaine, and ecstasy is rapidly replacing traditional etiological factors as the cause of ICH among young adults. In many cases, these represent hypertensive hemorrhage; however, a significant number of these patients may harbor an underlying vascular lesion. Because there is an increased risk of aneurysmal and AVM hemorrhage in the setting of cocaine use, CTA should be a part of the initial evaluation of all young patients with nontraumatic ICH.

The second important teaching point of this case is the fact that contrast extravasation on CTA may predict hematoma expansion. This can affect treatment strategies, including warfarin reversal, activated factor VII administration, and blood pressure management.

A recent study by Kim et al showed that contrast extravasation on admission CTA or contrast-enhanced CT independently predicted hematoma growth and mortality.

A study by Goldstein et al found that the presence of contrast extravasation increased the odds of hematoma expansion 18-fold.

Therefore, CTA is indicated in the initial imaging evaluation of ICH to look not only for an underlying vascular lesion, but also for a biomarker of ongoing bleeding.

Case submitted by Ashley H. Aiken, M.D., and Alisa D. Gean, M.D., both at the University of California, San Francisco and San Francisco General Hospital.

BIBLIOGRAPHY

Goldstein J, Fazen L, Snider R, et al. Contrast extravasation on CT angiography predicts hematoma expansion in intracerebral hemorrhage. Neurology 2007;68(12):889-894.
Jacobs IG, Roszler MH, Kelly JK, et al. Cocaine abuse: neurovascular complications. Radiology 1989;170(1 Pt 1):223-227.
Kibayashi K, Mastri AR, Hirsch CS. Cocaine induced intracerebral hemorrhage: analysis of predisposing factors and mechanisms causing hemorrhagic strokes. Hum Pathol 1995;26(6): 659-663.
Kim J, Smith A, Hemphill JC 3rd, et al. Contrast extravasation on CT predicts mortality in primary intracerebral hemorrhage. AJNR 2008;29(3): 520-525.
McEvoy AW, Kitchen ND, Thomas DG. Intracerebral haemorrhage and drug abuse in young adults. Br J Neurosurg 2000;14(5):449-454.