J Neurosurg 58:109-111, 1983

Cerebral angiitis and intracerebral hemorrhage
associated with methamphetamine abuse
Case report
YOUNG J. Yu, M.D., DAVID R. COOPER, M.D., DAVID E. WELLENSTEIN, M.D., AND
BRIAN BLOCK, M.D.
Divisions of Neurosurgery and Radiology, Niagara Falls Memorial Medical Center, Niagara Falls, and
Mount Saint Mary's Hospital, Lewiston, New York

~/ A case of reversible cerebral angiitis and intracerebral hemorrhage is reported in a methamphetamine
abuser. Characteristic radiographic changes were demonstrated by selective cerebral angiography and
computerized tomography. These vascular abnormalities disappeared after 1 month of treatment with
prednisone, during which time the patient denied further drug abuse.
KEY WORDS

cerebral angiitis

W

E are reporting a case of reversible cerebral
angiitis and intracerebral hemorrhage in a
methamphetamine abuser who had grand
mal seizures. The characteristic radiographic changes
were demonstrated by selective cerebral angiography
and computerized tomography. The vascular abnormalities were no longer present after 1 month of
treatment with prednisone and continued abstinence
from drugs. The pertinent literature is reviewed.
Case Report

This 16-year-old right-handed white male high
school student was in good health until the morning
of admission. He went to school that morning as
usual, where he developed nausea and vomiting. He
was sent home. He had a generalized seizure with a
complete loss of consciousness at home, as witnessed
by his mother. He had a second grand mal seizure on
the way to the emergency room. In the emergency
room he had a third seizure, lasting a couple of
minutes.
Examination. Approximately 30 minutes after the
third attack, examination in the emergency room
showed the results that follow. His blood pressure was
140/90 mm Hg. Respiration was shallow and regular.
There was sinus tachycardia, with a heart rate of 100
beats/min. He was a well developed, well nourished
J. Neurosurg. / Volume 58 / January, 1983

9 hemorrhage

drug abuse

9 methamphetamine

boy with no external evidence of injuries. His neck
was supple, his lungs were clear, and the abdomen
was soft. His liver and spleen were not palpable. There
was a scar in the lower back from a previous excision
of a nevus, about a year earlier. Neurological examintion was conducted while he was lying in bed with
restraints. He looked drowsy but arousable. His face
was flushed. At times he was slightly confused. He
spoke coherently when awake and followed simple
verbal commands. Funduscopic examination was unremarkable. Pupils were briskly reactive to light. External ocular movements were full. There was no
facial weakness. He moved all four extremities purposefully. Deep tendon reflexes were very brisk and
symmetrical. Plantar responses were flexor. There was
no ankle clonus. Double simultaneous stimulation,
stereognosis, and optokinetic nystagmus were normal.
Hospital Course. Intravenous fluid infusion was
started with 5% dextrose/0.45% NaC1 in the emergency room, and the patient was given Dilantin
(phenytoin). Lumbar puncture revealed an opening
pressure of 110 mm H20. Cerebrospinal fluid (CSF)
was grossly clear, with normal protein and sugar.
Microscopic examination revealed 30 red blood cells
and no white blood cells. Complete blood count,
urinalysis, and chemical profile were normal. Serological tests were normal. Culture of CSF revealed no
growth. Toxicology screening for barbiturate, ethanol,

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Y. J. Yu, et al.

FIG. 1. Computerized tomography scan showing an acute
intracerebral hemorrhage in the left anterior parietal lobe.
salicylate, glutethimide, and meprobamate was negative. No further seizures developed during the subsequent hospitalization. The patient was gradually mobilized. In the meantime, he complained of mild
frontal and retro-orbital headache.
Computerized tomography of the brain revealed an
increased density in the left anterior parietal lobe,
with some surrounding edema. This finding was consistent with acute intracerebral hemorrhage (Fig. 1).
Selective left internal and external carotid arteriography was carried out via a transfemoral approach. The
left internal carotid examination showed diffuse pro-

nounced irregularity of flow, indistinctness, and beading of the anterior and middle cerebral arteries (Fig.
2 left). The selective left external carotid angiogram
showed the superficial temporal artery to be normal.
A renal angiogram was also performed and was normal. Despite the normal external carotid angiographic
picture, a temporal artery biopsy was carried out and
found normal. Further laboratory work, including
testing for erythrocyte sedimentation rate, antinuclear
antibody, lupus erythematosis, and rheumatoid factor
were normal. Serum complement levels were normal.
Serum protein electrophoresis and immunoglobulin
electrophoresis were normal. Echocardiogram was
normal. These separate blood cultures showed no
growth.
The patient admitted that he had abused methamphetamine, LSD, and marijuana, at least for the preceding 6 months. Subsequently, he was placed on
prednisone, 20 mg three times daily, and continued
an uneventful hospital course, with the headache
gradually subsiding. He was discharged on Dilantin,
100 mg three times daily, as well as prednisone, which
was continued for an additional 1 month. The patient
has denied further drug abuse since his hospitalization. Six weeks after discharge the repeat selective
internal carotid arteriogram was entirely normal (Fig.
2 right). Clinical follow-up review over a l-year period
has been uneventful.
Discussion

Even though it is rather uncommon to see abuse of
a single drug, the literature2,3 suggests that metham-

FIG. 2. Left: Selective left internal carotid arteriogram showing diffuse pronounced irregularity,
indistinctness of the vessel outline, and beading of the anterior and middle cerebral arteries. Right:
Repeat carotid arteriogram after 1 month treatment with prednisone showing normal anterior and middle
cerebral arteries.
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J. Neurosurg. / Volume 58 / January, 1983

Angiitis and cerebral hemorrhage in drug abuse
phetamine is the most common denominator in multiple-drug abuse cases when vascular insult and/or
hemorrhage result. Citron, et al., 2 reported 14 cases of
necrotizing angiitis associated with drug abuse. The
drugs abused varied from narcotics and hallucinogens,
to stimulants and sedatives. Among these drugs, methamphetamine was the most common. The characteristic features 5 of the vascular pattern of necrotizing
angiitis observed included microaneurysms, indistinctness of vessel outlines, segmental luminal irregularities, and thrombosis of the vessels of the lung,
kidney, liver, pancreas, and small bowel. These
changes took place mainly in the medium-sized and
small arteries in most body organs and in the arterioles
in the brain. Fibrinoid necrosis was apparent in the
media and intima, with cellular infiltration. These
changes were not distinguishable from those of periarteritis nodosa. They were different from hypersensitivity angiitis, which frequently involves small arteries, capillaries, and venules. Margolis and Newton 6
described changes of the branches of the middle and
anterior cerebral arteries seen after intravenous administration of methamphetamine. These changes
were characterized by pronounced irregularity and
beading of these arteries.
Our patient was involved in approximately 6
months of constant methamphetamine abuse. Selective external carotid angiography revealed the superficial temporal artery to be entirely normal. As expected, the biopsy of superficial temporal artery
turned out to be normal in view of normal angiographic findings. But selective internal carotid angiography showed characteristic findings of diffuse
pronounced irregularity of flow and beading of the
anterior and middle cerebral arteries, as shown by
Margolis and Newton. 6 Arterial narrowing (spasm)
was also observed. These findings were reversible
changes, as clearly shown on the subsequent repeat
selective internal carotid angiography after a month
of prednisone and the end of the drug abuse.
It is interesting to note that these arterial changes

J. Neurosurg. / Volume 58 / January, 1983

were associated with the presence of an intracerebral
hemorrhage? Delaney and Estes 3 examined the literature for cases of intracranial hemorrhage associated
with amphetamine abuse. The incidence of intracranial hemorrhagic complications associated with amphetamine abuse was higher in males by two to one.
Seven patients died as a result of this complication.
The mortality rate associated with this complication
was nearly 50%.
In spite of the absence of the histological confirmation, the evidence suggests that our patient had
drug-induced arteritis of the cerebral vessels. This, in
turn, resulted in the intracerebral hemorrhage. The
vascular changes seen in the carotid angiography were
reversible after 1 month of treatment with steroid,
while the patient denied resumption of drugs. While
this paper was being prepared, a case of massive
intraventricular and subarachnoid hemorrhage in a
phencyclidine (PCP)-intoxicated patient was reported. 1
References

1. Bessen HA: Intracranial hemorrhage associated with
phencyclidine abuse. JAMA 248:585-586, 1982
2. Citron BP, Halpern M. McCarron M, et al: Necrotizing
angiitis associated with drug abuse. N Engl J Med
283:1003-1011, 1970
3. Delaney P, Estes M: Intracranial hemorrhage with amphetamine abuse. Neurology 30:1125-1128, 1980
4. Edwards KR: Hemorrhagic complications of cerebral
arteritis. Arch Neural 34:549-552, 1977
5. Halpern M, Citron BP: Necrotizing angiitis associated
with drug abuse. AJR 111:663-671, 1971
6. Margolis MT, Newton TH: Methamphetamine ("speed")
arteritis. Neuroradiology 2:179-182, 1971
Manuscript received March 19, 1982.
Accepted in final form August 24, 1982.
Address reprint requests to: Young J. Yu, M.D., Niagara
Neurologic Associates, 742 Main St., Niagara Falls, New
York 14301.

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