AUTHOR(S): Yapor, Wesley Y., M.D.; Gutierrez, Francisco A., M.D. Resurrection Medical Center and Northwestern University Medical School, Chicago, Illinois Neurosurgery 30; 288-290, 1992 ABSTRACT: A unique case is described of a 28-yearold man who had seizures and a hemorrhage within a previously unsuspected cerebellopontine angle schwannoma within minutes of nasally inhaling cocaine. A review of the literature on cocaineinduced seizures and cocaine-induced cerebral hemorrhage is also given. KEY WORDS: Cocaineinduced cerebral hemorrhage; Cocaineinduced intratumoral hemorrhage; Cocaineinduced seizures INTRODUCTION Cocaine abuse in the United States has increased to epidemic levels in both rural and urban areas (16). Its increased use has been associated with an increase in cardiovascular and neurological complications (3). A case is described that exemplifies two possible insults to the central nervous system: seizures and hemorrhage. The case is unique because the hemorrhage occurred within a previously unsuspected posterior fossa schwannoma within minutes of intranasal inhalation of cocaine. A review of the literature concerning cocaine-induced seizures and cocaine-induced intracranial hemorrhage is presented. CASE REPORT A 28-year-old man, who used cocaine frequently, was admitted to the emergency room after nasally inhaling one-half gram of cocaine. He developed the sudden onset of occipital and upper cervical pain, and he then lost postural control. While in a semiconscious state, he remembered lying on the floor, moving his head and arms uncontrollably. After several seconds, he was able to get up and nasally inhale another half gram of cocaine before coming to the hospital. He stated he had no medical problems until 2 years ago when a computed tomographic scan disclosed nothing abnormal in the cervical spine for pain in the left hand and neck. The patient's mother, uncle, and cousin were known to have neurofibromatosis. At examination, we found the patient to be alert, fully oriented, and very nervous. His only abnormal findings were bilateral, horizontal nystagmus, greater to the right, minimal atrophy of the intrinsic muscles in the left hand; and bilateral Babinski reflexes. A computed tomographic scan of the brain Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/2/288/2753007 by Frankfurt Univesity Library user on 06 March 2018 disclosed an irregular hemorrhage measuring 3 × 2 cm in the right posterior fossa with a left shift of the fourth ventricle and no enhancement with contrast (Fig. 1, A and B). Cervical roentgenograms were within normal limits. A magnetic resonance imaging scan of the brain delineated a tumor measuring 5 × 4 × 3.5 cm anterolaterally to the right cerebellar hemisphere and brain stem, extending from the foramen magnum up the clivus to the posterior clinoid process with a broad tentorial base (Fig. 2, A-D). There appeared to be loculated intratumoral cysts compatible with intratumoral hemorrhage. The magnetic resonance imaging scan of the patient's cervical spine revealed a lesion measuring 3 × 1.5 × 2 cm at the C7 to T1 levels posterior to the cord (Fig. 3, A and B). Nerve conduction velocity studies confirmed the presence of reduced amplitude, compound-muscle action potentials in the left ulnar nerve, and electromyography found chronic changes in the C8 and T1 myotomes although no paraspinous abnormalities were found. Audiological testing suggested normal hearing sensitivity bilaterally through test frequencies of 250 to 8000 Hz with excellent speech discrimination. Acoustic reflexes were absent bilaterally upon contralateral stimulation. Ipsilateral left reflexes were present at elevated levels, but ipsilateral right reflexes were absent at 500 to 1000 Hz and only present at 2000 Hz. Brain stem evoked responses revealed only the presence of Wave I on the right side at 90 decibel hearing level, and only the presence of repeatable Waves I to III at 90 decibel hearing level on the left side, suggestive of bilateral brain stem dysfunction. During surgery, the patient was found to have a right cerebellopontine angle schwannoma with a multiloculated hemorrhagic center. A subtotal resection was achieved, and, postoperatively, the patient was unchanged neurologically. The cervical lesion would be addressed after the patient recovered sufficiently from the suboccipital craniotomy. DISCUSSION Cocaine-induced seizures are the most common and most serious nervous system complication of drug abuse (17,23). After nasally inhaling or smoking cocaine, up to 25% of the heavy users will lose consciousness as the result of syncope or seizures (23) . Pascual-Leone et al. (21) reported that 8% of the patients seen for cocaine intoxication had a seizure within 90 minutes of cocaine use (21). Alldredge et al. (1) found that drug-induced seizures were related to cocaine in 32 of 49 cases; the others were related to amphetamines, heroin, phencyclidine, and a combination of agents. Cocaine ingestion can induce seizures regardless of the route of administration, and convulsions may be associated with either first use or subsequent use in occasional or chronic users (4,5,23,24). In a series reported by Choy-Kwong and Lipton (4) of 283 cocaine abusers, 8 patients (2.8%) had seizures, either partial or generalized. It is frequently assumed that seizures without a mass lesion (hematoma or neoplasm) are not a serious problem. Patients who have cocaine-induced seizures may develop Redistribution of this article permitted only in accordance with the publisher’s copyright provisions. Neurosurgery 1992-98 February 1992, Volume 30, Number 2 288 Cocaine-induced Intratumoral Hemorrhage: Case Report and Review of the Literature Case Report 6. Received for publication, June 10, 1991; accepted, final form, September 4, 1991. Reprint requests: Wesley Y. Yapor, M.D., 707 North Fairbanks Court, Suite 911, Chicago, Illinois 60611. 18. REFERENCES: (1-29) 1. 2. 3. 4. 5. Alldredge BK, Lowenstein DH, Simon RP: Seizure associated with recreational drug abuse. Neurology 39:1037-1039, 1989. Campbell BG: Cocaine abuse with hyperthermia, seizures and fatal complications. Med J Austr 149:387-390, 1988. Capella JA, Atetero JMC, Rei JF: Complications of cocaine abuse. Ann Intern Med 107:940, 1987. Choy-Kwong M, Lipton RB: Seizures in hospitalized cocaine users. Neurology 39:425427, 1989. 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Seizures can occur alone, or they can be associated with intracranial hemorrhage. All types of hemorrhage can occur, including subarachnoid hemorrhage, which may or may not be associated with aneurysms, arteriovenus malformations (12,13,22, 28) , or vasculitis (9). Subcortical and intracerebral hemorrhages are reported to be associated with cocaine use from a presumed, acute hypertensive mechanism (13,14,19,20). Cerebral infarcts have also been associated with cocaine abuse without a hemorrhagic component (6, 11,26) . In these cases, thrombogenesis and vasospasm have been implicated as etiological factors (7). A series by Jacobs et al. (8) of 3712 cocaine users found that 13 patients had neurological complications. Seven (54%) had cerebral infarcts without hemorrhage, 3 (23%) had intracerebral hemorrhage, and 3 (23%) had subarachnoid hemorrhage (8). A case of cocaine-induced seizures disclosing an unsuspected tumor has been documented (25), but we failed to find an intratumoral hemorrhage in the posterior fossa. It is possible that the hemorrhage in our patient may have occurred from the hypertensive effects of cocaine on the cardiovascular system (18), in association with increased cerebral blood flow in the posterior circulation, which has been documented in cocaine abusers (27). The seizures in our patient may have been precipitated by the cocaine alone or by altering the seizure threshold of a medial temporal lobe already irritated by the schwannoma, which extended into the temporal fossa (Fig. 2, B and C). The acute change in intracranial pressure produced by the hemorrhage may have contributed, if not caused, the patient's seizures. 25. 26. 27. 28. Redistribution of this article permitted only in accordance with the publisher’s copyright provisions. 29. "crack" smokers. So W J Med 150:213, 1989. Seaman M: Investigation of cocaine related seizures showing unsuspected brain tumor. Ann Emerg Med 19:734, 1990. Seaman ME: Acute cocaine abuse associated with cerebral infarction. Ann Emerg Med 19:34-37, 1990. Vollzow ND, Mullani N, Bould KC, Alder S, Krajewski K: Cerebral blood flow in chronic cocaine users: A study with positron emission tomography. Br J Psychol 152:641-648, 1988. Willis D, Harbit MD: A fatal attraction: Cocaine related subarachnoid hemorrhage. J Neurosci Nurs 21:171-174, 1989. Wojak JC, Flamm ES: Intracranial hemorrhage and cocaine abuse. Arch Pathol Lab Med 113:812-813, 1989. Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/2/288/2753007 by Frankfurt Univesity Library user on 06 March 2018 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/2/288/2753007 by Frankfurt Univesity Library user on 06 March 2018 Redistribution of this article permitted only in accordance with the publisher’s copyright provisions. Figure 1. A, B, C, and D, computed tomographic scans of the brain with right cerebellar hemorrhage associated with irregular lucency in area of cerebellar hemisphere and brain stem. Figure 3. A and B, magnetic resonance imaging scans of the cervical spine with a lesion measuring 3 × 1.5 × 2 cm extending from C7 to T1 posteriorly to the cord. Downloaded from https://academic.oup.com/neurosurgery/article-abstract/30/2/288/2753007 by Frankfurt Univesity Library user on 06 March 2018 Redistribution of this article permitted only in accordance with the publisher’s copyright provisions. Figure 2. A, B, C, and D, multiplainar images of hemorrhagic lesion extending above the tentorium and shifting the brain stem. Note the loculated appearance of the hemorrhagic component.