Medicine's Dark Side: Can It Cause Strokes?

Drug use and misuse can cause strokes, even in healthy people with no prior health issues. Illicit drugs such as cocaine, amphetamines, ecstasy, heroin, phencyclidine, lysergic acid diethylamide, and marijuana have been linked to strokes. Cocaine and amphetamines have the strongest association with strokes, with amphetamine use increasing the odds of a stroke by almost four times that of non-users. Drug use can damage blood vessels in the brain and heart, increasing the risk of high blood pressure, which is the leading risk factor for strokes. Additionally, misuse of prescription drugs, especially painkillers and sedatives, can also increase the risk of strokes.

Illicit drug use and stroke

Illicit drug use is a significant cause of strokes in young people, especially in geographic areas where their use is frequent. In a large multi-centre study in the Baltimore-Washington area, 12.1% of stroke cases were linked to recent use of illicit drugs, and drugs were the probable cause in 4.7% of cases.

The main illicit drugs associated with stroke are cocaine, amphetamines, ecstasy, heroin, phencyclidine, lysergic acid diethylamide, and cannabis/marijuana.

Cocaine

Cocaine is the second most commonly used illicit drug and is also the most common one associated with stroke. It can be used as a central nervous system stimulant, vasoconstrictor, and local anaesthetic. There is evidence that using cocaine within the last 24 hours is strongly associated with an increased risk of stroke, especially with crack cocaine. The frequent use of cocaine (more than once a week) may increase the risk twofold, even after excluding acute users. Possible mechanisms causing stroke include acute hypertensive crisis, platelet activation and aggregation, and infections leading to endocarditis and secondary vasculitis.

Amphetamines

Amphetamine use can increase the odds of stroke by almost four times that of non-users and results in greater disability and mortality rates. Amphetamine-like substances can be used as central nervous system stimulants and appetite suppressors. The pathophysiology of amphetamine-induced strokes includes acute hypertensive crisis, platelet activation and aggregation with thrombus formation, and direct myocardial toxicity with contraction-band necrosis.

Heroin

Most strokes caused by heroin are ischemic. Heroin can be injected intravenously or subcutaneously, snorted, or smoked. The possible mechanisms of heroin-induced strokes include cardioembolism in the setting of infective endocarditis, pulmonary hypertension caused by a granulomatous reaction to foreign bodies in the lungs, and arteritis and vasculitis.

Ecstasy

There are a small number of case studies of both ischemic and hemorrhagic strokes occurring within hours of ingesting ecstasy. The possible etiologies of ecstasy-induced strokes are similar to those of cocaine- and amphetamine-related strokes. These include cardiac arrhythmias, cardiomyopathy, vasospasm, and necrosis in the vasculature of the globus pallidus and occipital cortex, and high fever triggering the clotting cascade.

Phencyclidine

There have been five reported cases of phencyclidine-associated stroke, and all of them were hemorrhagic. Phencyclidine's sympathomimetic hypertensive effect may be the provoking factor.

Lysergic Acid Diethylamide

There have been four reported cases of stroke related to lysergic acid diethylamide, all involving acute ischemic stroke in patients under the age of 25. Similar to ergot alkaloids, lysergic acid diethylamide affects serotonin receptors and may cause vessel constriction.

Cannabis/Marijuana

Evidence supporting cannabis's role in stroke is scarce, considering its widespread use. However, one study demonstrated that marijuana users had an odds ratio for acute ischemic stroke of 1.76, even when controlling for other risk factors. Proposed mechanisms for marijuana-associated cerebral infarction include hypotension, vasospasm, and arrhythmia with resulting cardioembolism.

Mechanisms of Stroke

The mechanisms of stroke associated with illicit drug use include hypertensive surges, vasospasm, enhanced platelet aggregation, cerebral vasculitis, accelerated atherosclerosis, and cardioembolism.

Misuse of prescription drugs

The three classes of medication that are most commonly misused are opioids, central nervous system (CNS) depressants, and stimulants. Opioids are typically prescribed to treat pain, while CNS depressants, including tranquilizers, sedatives, and hypnotics, are used to treat anxiety and sleep disorders. Stimulants, on the other hand, are often prescribed to treat attention-deficit hyperactivity disorder (ADHD).

When prescription drugs are misused, the risks and potential side effects may not be fully understood or anticipated by the user. This is especially true when these drugs are taken in higher doses or in combination with other medications. For example, opioids and sedatives, when misused, can slow down breathing and reduce the amount of oxygen the brain needs to function properly, increasing the risk of stroke.

The misuse of prescription drugs has been on the rise over the past two decades, leading to an increase in treatment admissions for prescription drug use disorders and overdose deaths. It is important to follow the instructions provided by a medical professional when taking prescription medication to avoid misuse and reduce the risk of associated health complications.

Alcohol abuse and stroke

Alcohol abuse can lead to medical complications, including stroke. While the underlying mechanism is still unclear, regular light-to-moderate alcohol consumption seems to decrease the risk of ischemic stroke by reducing atherothrombotic events. However, recent and current heavy drinking increases the risk of both hemorrhagic and ischemic strokes.

Heavy drinking has been identified as a risk factor for a type of stroke caused by bleeding in the brain, known as intracerebral hemorrhage, rather than a blood clot. This type of stroke often leads to a more severe form of the condition and a higher chance of dying within 24 months, especially for younger patients. Regular heavy drinkers are also more likely to engage in other lifestyle habits that increase their risk, such as tobacco smoking, and are more prone to blood irregularities and liver problems.

Research has shown that young and middle-aged men are more likely to suffer from alcohol-related strokes than women or elderly persons, possibly because they are more likely to be current heavy drinkers. Alcoholic cardiomyopathy, caused by regular heavy drinking or binge drinking, can lead to cardioembolic brain infarction. Cardiac arrhythmias resulting from excessive alcohol consumption can also precipitate thrombus formation and propagate existing thrombi from the heart.

The American Heart Association recommends limiting alcohol intake to no more than two drinks per day for men and no more than one drink per day for non-pregnant women. Pregnant women are advised to abstain from alcohol consumption. It is crucial to seek professional help if struggling with alcohol addiction.

Cocaine use and stroke

Cocaine is a stimulant that increases the risk of stroke in users. It is the most commonly used class A drug in England and Wales, and the first report of cocaine-induced stroke was in 1977. Since then, there has been a significant rise in the number of case reports describing both ischaemic and haemorrhagic strokes associated with cocaine use.

Cocaine is a central nervous system stimulant that acts by binding to specific receptors at pre-synaptic sites, preventing the reuptake of neurotransmitters. The exact mechanism of cocaine-induced stroke is unclear, but there are several factors that may contribute, including vasospasm, cerebral vasculitis, enhanced platelet aggregation, cardioembolism, and hypertensive surges associated with altered cerebral autoregulation.

The onset of stroke symptoms is usually immediate or within 3 hours of cocaine use, and 73% of patients with cocaine-induced stroke have no prior cardiovascular risk factors. Cocaine use is associated with both ischaemic and haemorrhagic strokes, with reports showing roughly equal proportions of the two types.

The growing number of case reports describing cocaine-related strokes and the increasing evidence supporting this link suggest that cocaine use should always be considered as a possible cause of stroke, especially in younger patients and those without known vascular risk factors.

People who use cocaine are more than six times more likely to suffer a stroke compared to those who do not, and this risk is especially high within 24 hours of taking the drug. Smoking crack cocaine raises the risk even further, up to eight-fold within 24 hours of use.

Amphetamine use and stroke

Amphetamines are synthetic sympathomimetics, which are used as mental stimulants. Their use has increased significantly, mainly because of the euphoria they induce. Amphetamine abuse has been associated with both types of stroke: ischemic and hemorrhagic.

The increase in blood pressure caused by amphetamines could lead to a cerebral vessel rupture or aneurysm rupture and a subsequent hemorrhagic stroke. On the other hand, acute ischemic stroke can be attributed to stimulant-induced cerebral vasoconstriction, which reduces blood flow, promotes platelet aggregation, and accelerates atherosclerosis and cardiac disturbances.

The risk of stroke is four times higher in amphetamine users than in non-users, and hemorrhagic stroke may occur twice as often as in the case of cocaine users. Studies have shown that adolescents who use amphetamines have a five-fold higher risk of stroke than those who do not use these drugs.

Intracranial hemorrhage following amphetamine abuse is associated with a transient increase in blood pressure. High blood pressure and vasoconstriction may also occur after consuming amphetamine-like substances. An in vivo study on mice revealed that even a single, acute exposure to amphetamines can induce a biphasic effect in cerebral blood flow: an initial transient increase, followed by a prolonged decrease that induces vasoconstriction of pial arterioles.

In summary, amphetamine abuse has been linked to an increased risk of both ischemic and hemorrhagic stroke, with a particularly high risk among adolescents. The underlying mechanisms include increased blood pressure, cerebral vasoconstriction, and direct toxic effects on cerebral vessels.

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