Use of cocaine in the USA, has reached epidemic proportions since 1983, when 
"crack" was introduced, its higher potency compared with cocaine HCl has been 
associated with a tremendous increase in the incidence of strokes. This study 
reports our experience with 55 cases of neurovascular events (25 ischemic and 30 
hemorrhagic) related to cocaine use in 54 patients. Only 15 patients had other 
risk factors for stroke. Twenty six patients smoked "crack", 10 snorted cocaine 
and 12 injected it intravenously. Strokes occurred within 3 h of cocaine use in 
15 patients with infarcts and 17 with hemorrhages. Ten infarcts occurred after 
an overnight binge. Of the hemorrhage group 9 were subarachnoid, 16 
intracerebral (8 basal ganglia, 7 hemispheric and one brain stem) and 5 
intraventricular. Computerized tomography (CT) showed an aneurysm of the 
anterior communicating artery, as well as one of the vein of Galen. Four 
aneurysms and 3 AVMs were identified on angiography. CT revealed 15 infarcts; it 
was normal in 7 patients with pure motor hemiparesis and in 3 with findings 
consistent with anterior spinal artery infarction. Several mechanisms may be 
responsible for the cerebrovascular complications. A sudden rise in systemic 
arterial pressure may cause hemorrhages, frequently in association with an 
underlying aneurysm or AVM. Vasospasm, arteritis, myocardial infarction with 
cardiac arrhythmias and increased platelet aggregation may provoke infarcts.