Role of perfusion imaging in differentiating multifocal vasospasm-related ischemia versus thromboembolic stroke in a setting of cocaine abuse.

Cerebrovascular complications related to cocaine abuse are reaching epidemic proportions. Contemporary treatments for acute stroke have made it essential to gather all possible diagnostic information before proceeding with intervention. We describe a cocaine abuser who presented with acute right sided neurological deficits and deteriorating mental status. An MRI demonstrated right sided acute and chronic infarcts in the border zones of the right anterior cerebral arteries (ACA) and middle cerebral arteries (MCAs). Subsequent CT angiography (CTA)/CT perfusion (CTP) identified multifocal cerebral vasospasm of the bilateral ACAs and MCAs, preserved cerebral blood volume (CBV) and decreased cerebral blood flow (CBF) in bilateral frontoparietal regions. Early diagnosis of multifocal vasospasm related ischemia directed appropriate therapy and excluded thrombolytic intervention. After 3 weeks, patient's presenting symptoms gradually resolved. We report a unique case of cocaine induced multifocal vasospasm exhibiting late (>3 weeks) reversibility of focal neurological deficits. Furthermore, we illustrate the benefits of CTA/CTP imaging in the setting of cocaine abuse, differentiating multifocal vasospasm induced hypoperfusion/ischemia from focal thromboembolic ischemia/infarct and allowing for appropriate medical management in the crucial hyperacute setting.