Over five million Americans using cocaine regularly, and a survey in South London showed an increase in crack cocaine use from 16% to 59% amongst drug users. Common manifestations such as chest pain, hypertension, and psychiatric disturbances occur, but we must be alert for other serious unexpected presentations. Misdiagnoses are likely, especially as an accurate history may not be forthcoming, with cocaine toxicity masquerading as other common diseases. Subarachnoid haemorrhage, strokes of varying aetiologies, seizures, headache and sudden death are recognised associations of cocaine abuse. Seizures, for instance, have been reported to make up almost 10% of cocaine related admissions to emergency departments, and patients with prior seizure history, poor compliance with antiepileptic medication, alcohol abuse and poor diet or sleep habits are at greater risk. Simple management principles coupled to a high index of suspicion, are efficacious in the assessment and treatment of cocaine toxicity. Introduction Cocaine is one of the major drugs of abuse in the United States, with over five million Americans using the drug regularly 1 . This has recently become a problem in Great Britain, with a survey among injecting drug users in south London showing an increase in crack cocaine use from 16% in 1990 to 59% in 1993. In the North Thames region of London in 1995-6, 4% of young people used cocaine as their main drug of abuse, with a further 7% using crack cocaine 2 . When asked if it were either the main or secondary drug of abuse, these figures rose to 12% & 16% respectively. 1 in 50 young people in Great Britain have tried cocaine and 1 in 100 have tried crack. A Department of Health study revealed that the only drug in Great Britain to show a significant increase in proportion of misuse was cocaine, increasing from 1% of 16 – 24 year olds in 1994 to 3% in 1998 3 .Cocaine has commonly recognised manifestations such as chest pain, hypertension, and psychiatric disturbances such as psychosis, paranoia, agitation, anxiety and depression, but more unexpected presentations may occur, many neurological, which may commonly be ascribed to other causes 4 . Subarachnoid haemorrhage, strokes of varying aetiologies, seizures, headache and sudden death are all relatively common associations of cocaine abuse 5 . This review summarises the relevant literature in relation to cerebrovascular effects of cocaine, and makes recommendations on important areas of management. Methodology A medical literature search was carried out using Medline (1966 to 2003), in both Ovid and Pubmed versions, and Internet search engines, using the keywords below. Papers were identified and evaluated, and further references were drawn from hand-searches of their bibliographies. Key words used were: cocaine, crack cocaine, cocaine-related disorders, toxicity, drug toxicity, overdose, cerebrovascular accident, and cerebrovascular disorders. History, Types & Patterns Of Use Cocaine, or benzoylmethylecgonine, is an alkaloid derived from the leaves of the coca plant, Erythroxylon coca 6 . It acts as a local anaesthetic with sympathomimetic and vasoconstrictor properties and has been widely abused as a mental stimulant. The Indians of Peru, Bolivia and Colombia have traditionally chewed coca mixed with lime for 2000 years, to reduce fatigue and hunger and to enable sustained periods of heavy labour. Coca Cola, and tonic drinks such as Vin Mariani, contained cocaine until 1903. Thirty years after the isolation of alkaloidal cocaine by the German chemist Gaedke in 1855, Sigmund Freud praised the use of cocaine as a central nervous system stimulant 6 . The Harrison Narcotics Act of 1914 finally forbade its inclusion in proprietary medicines and restricted its use to prescription only. Cocaine was little used until the 1960s when its popularity underwent a resurgence, along with other illicit drugs. The common route of use at this time was sniffing or snorting the hydrochloride sal
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