SAN DIEGO—Physicians should not categorically refrain from testing older stroke patients for the possibility of cocaine abuse, a team from Columbia University College of Physicians and Surgeons in New York City reported at the 58th Annual Meeting of the American Academy of Neurology. In their study of all 154 stroke patients admitted to Harlem Hospital during a recent 12-month period, more than three quarters of patients with cocaine-associated strokes were 50 or older. Cocaine use within 72 hours prior to stroke was documented by direct patient interview and urine testing.

"Our study suggests stroke related to cocaine abuse is no longer exclusively a problem of younger patients," remarked James M. Noble, MD, Co–Chief Resident in Neurology at Harlem Hospital and Columbia University Medical Center. Based on the findings, Dr. Noble urged physicians to consider testing for urinary cocaine metabolites in stroke patients regardless of age or other risk factors.

Cocaine is an established risk factor for stroke, with more than 600 reported cases since 1977, Dr. Noble observed. Since then, several case series have consistently shown a predominance of cocaine-associated strokes in younger patients. Accordingly, cocaine use is generally suspected only in younger stroke patients who do not have established stroke risk factors, he added. Little information is available on the temporal association between stroke and cocaine use in older patients.

Dr. Noble and his coauthors interviewed subjects about illicit drug use, with a particular emphasis on use of cocaine. If patients were unable to respond because of neurologic deficits, the information was obtained from family members or close acquaintances.

Overall, 21 patients (14%), all African-Americans, had had strokes that were temporally associated with reported intranasal, IV, or smoked cocaine. Three more patients had urine that tested positive for cocaine metabolites, but these patients denied cocaine use. Twenty patients (83%) were 50 or older. All of them had other stroke risk factors, the investigators noted.

The frequency of established risk factors for stroke such as hypertension, diabetes, atrial fibrillation, and hypercholesterolemia was similar in patients with or without associated cocaine use. However, the rate of prior stroke was more than twice as high (42%) in patients with cocaine-associated strokes and was often the only stroke risk factor in younger individuals, Dr. Noble said. "Given that two thirds of all stroke patients in this series were not screened by urine toxicology, the rate of cocaine-associated stroke is probably higher than what we observed."

Dr. Noble emphasized that his team tested only young people without reported substance abuse and that they confirmed suspected cocaine abuse in older individuals with known history of recent or remote cocaine abuse.

Finally, he noted that the finding of high prevalence of cocaine-associated stroke has implications for acute stroke treatment, including blood pressure management as well as secondary prevention strategies. In particular, the use of IV tissue plasminogen activator (t-PA) for acute ischemic stroke in the setting of cocaine intoxication needs to be further explored, as evidenced by the 78-year-old cocaine-abusing patient in the study cohort who received IV t-PA for stroke and suffered a fatal intracranial hemorrhage.

NR

—Jill Stein

Suggested Reading
Nanda A, Vannemreddy P, Willis B, Kelley R. Stroke in the young: relationship of active cocaine use with stroke mechanism and outcome. Acta Neurochir Suppl. 2006;96:91-96.

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