Cocaine-associated cerebral vasculitis.

Cocaine use is associated with a variety of serious neurological complications, including cerebral infarction, intracerebral and subarachnoid hemorrhage, transient ischemic attacks, migraines, and seizures. We report two cases of intracerebral hemorrhage with biopsy-proven cerebral vasculitis associated with the use of cocaine. The first case involved a 32-year-old man who presented with headache, left-sided hemiparesis, and severe hypertension and who was found to have a large right putaminal hemorrhage on cranial tomographic (CT) scan. Cerebral angiography did not show vasculitic changes, but brain tissue obtained during hematoma evacuation revealed a nonnecrotizing leukocytoclastic angiitis of the small vessels. The second case involved a 20-year-old man who presented with headache, agitation, and speech difficulty that progressed to disorientation and dysphasia. He had a large left temporoparietal hematoma seen on CT scan. Cerebral angiography was consistent with vasculitis, and brain tissue obtained during hematoma evacuation revealed a small vessel vasculitis. In both cases, thorough clinical and laboratory investigations found no evidence of systemic vasculitis or an etiologic agent other than cocaine. We also critically reviewed the previously reported cases of cocaine-associated cerebral vasculitis and the relevant medical literature to discuss the "cocaine-associated vasculitis syndrome" in the context of more established vasculitidies, including hypersensitivity vasculitis. In addition, we outline a diagnostic and therapeutic approach to patients with possible cocaine-associated vasculitis.