The Journal of Emergency Medicine, Vol. 28, No. 2, pp. 165–167, 2005 Copyright © 2005 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/05 $–see front matter doi:10.1016/j.jemermed.2004.06.015 Selected Topics: Toxicology DELAYED ISCHEMIC STROKE ASSOCIATED WITH METHAMPHETAMINE USE Keiko Ohta, MD,* Masae Mori, MD,* Asako Yoritaka, MD,* Kouichiro Okamoto, MD,† and Shuji Kishida, MD* *Department of Neurology and †Department of Neurosurgery, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan Reprint Address: Keiko Ohta, MD, Department of Neurology, Tokyo Metropolitan Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-Ku, Tokyo, Japan, 113-8677 e Abstract—A 19-year-old woman had right occipital infarction 3 months after she had injected methamphetamine. No other possible causes of stroke could be found in this case. Magnetic resonance angiography revealed beading of the right posterior cerebral artery, which suggested vasculitis. Her symptoms were right-sided headache, left superior quadrant hemianopia, and left hypesthesia, which gradually improved without any treatment. Methamphetamine has been known to cause hemorrhagic and ischemic stroke relatively soon after administration. We report here that methamphetamine may also cause chronic cerebral vasculitis and delayed ischemic stroke. © 2005 Elsevier Inc. severe headache every time except the second, she stopped injection. But headache continued and about 3 months later she had an attack of severe right-sided headache. She also noticed blurred vision on the left side and numbness of the left arm and leg. She came to our hospital 2 days after the onset. Family history was unremarkable. She suffered from duodenal ulcer at age 16. Otherwise she was healthy and she had not suffered from any other diseases. She had smoked 20 to 40 cigarettes and had drunk 600 to 800 mL of alcoholic drinks daily for a few years. She declared that she had not used methamphetamine for 3 months before the onset, because when she had injected it last time, her headache had been too severe to bear. She also denied use of any other drugs including oral contraceptives. On physical examination, the patient’s blood pressure was 110/70 mm Hg. The general physical examination and mental status evaluation were unremarkable. The visual acuity was normal but visual field evaluation revealed left superior quadrant hemianopia. Motor function was normal. She had slight hypesthesia of the left face, arm and leg. We followed her as an outpatient for several weeks. Her symptoms continued and analgesics were not very effective for her headache. She entered our hospital for further examination. Results of laboratory investigations including complete blood count, serum chemistry, glucose, total e Keywords—methamphetamine; ischemic stroke; cerebral vasculitis; drug abuse; headache INTRODUCTION Methamphetamine is the most popular drug among young abusers in Japan. It may lead to hemorrhagic strokes relatively soon after administration (1). We report a delayed ischemic stroke in a methamphetamine user. CASE REPORT A 19-year-old woman had used methamphetamine intravenously four times over 2 months. Because she felt Selected Topics: Toxicology is coordinated by Kenneth Kulig, MD, of Denver, Colorado RECEIVED: 11 July 2003; FINAL SUBMISSION RECEIVED: 21 May 2004; ACCEPTED: 8 June 2004 165 166 K. Ohta et al. Figure 1. A) Fluid-attenuated inversion recovery (FLAIR) MR image shows high signal intensity in the medial part of the right occipital lobe (arrow). B) MR angiography shows segmental narrowing (beading) of the right posterior cerebral artery (arrow). cholesterol, C-reactive protein, VDRL, prothrombin time, and partial thromboplastin time were normal. Anti-cardiolipin antibody, lupus anticoagulant, antithrombin III, thrombin–antithrombin III complex (TAT), and perinuclear-antineutrophil cytoplasmic antibody (P-ANCA) were all negative. Cerebrospinal fluid was clear with one cell, normal protein and glucose. An electrocardiogram and an echocardiogram were also unremarkable. An immediate brain computed tomography (CT) scan was obtained, and a magnetic resonance imaging (MRI) study after 10 days showed right occipital infarction (Figure 1A). Magnetic resonance angiography (MRA) revealed segmental narrowing of the right posterior cerebral artery with the beaded appearance characteristic of vasculitis (Figure 1B). Her symptoms and mild headache continued but she did not want to take analgesics because they were not very effective. She was discharged 1 week after admission. We checked a repeat brain MRI and MRA about 4 months after the first examination. The right occipital infarction had faded with mild atrophy and the beading of the right posterior cerebral artery had recovered slightly in the proximal portion. Although left superior quadrant hemianopia remained, she said that she got used to the symptom. The headaches also continued but after we explained the result of the MRI, she stopped coming and has not been seen in follow-up since then. DISCUSSION The reported case concerns a young woman who had no other risk factors for cerebrovascular accidents than smoking and alcohol consumption. Absent were hypertension, hyperlipidemia, diabetes, intracranial vascular malformation, vasculitis caused by collagen disease, and any coagulation abnormalities. We conclude that the cause of cerebral infarction was methamphetamine abuse. Methamphetamine and amphetamine are sympathomimetic drugs. They are postulated to be the cause of acute drug-induced hypertension, vasoconstriction, and progressive necrotizing vasculitis (2– 4). There are many reports of intracranial hemorrhage occurring soon after administration of methamphetamine or amphetamine (5–7). Some cases were ischemic strokes, of which onset times since last use were up to 2 weeks (8 –10). We are unaware of any reported cases of delayed strokes following methamphetamine abuse, but we have noted the case report of 6-month delayed ischemic stroke associated with cocaine use which is also known to cause vascular complications (11). In addition, ephedra is another sympathomimetic drug and may cause vasculitis like methamphetamine. Wooten et al. reported late vasculitis related to ephedrine abuse (12). Recently, there are more reports that show ephedra increasing the risk of strokes (13,14). Because legal dietary supplements contain ephedra, we should expect to see more cases. 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