Table 1

Methamphetamine-related stroke reported in case studies and case series. Haemorrhagic strokes are detailed first, followed by ischaemic*

AuthorAgeSexDrugClinical featuresNature of strokeAngiographyOutcomes
HAEMORRHAGIC STROKES
Gericke et al (1945)36MAmphetamineHeadache, right hemiparesis within 4 hours. Died within 24 hours.Subdural and subarachnoid haemorrhage, and intracerebral haemorrhage in occipital and parietal lobesNot performed.
Craniotomy.
Death
Poteliakhoff and Roughton (1956)42MAmphetamine (Benzedrine)Headache, left hemiparesis. Hypertension (180/100) at 48 hoursIntracerebral haemorrhage: posterior parietal haematoma, subarachnoid haemorrhageNot performed.
Ventriculography suggested posterior parietal mass
Recovery
Coroner’s report (1967)16MAmphetamineDied within hoursIntracerebral haemorrhageNot performed. No further detailDeath
Kane et al (1969)24MMethamphetamineHeadacheIntracerebral haemorrhageNot performed. Organic brain impairment testing: cognitive impairment on right sideResidual left-sided spastic hemiplegia
Goodman and Becker (1970)26MAmphetamineHeadache. BP: 130/60 at 72 hoursRight intracerebral haemorrhageRight fronto-parietal haematomaSlowly resolving left hemiparesis
18MDextroamphetamineHeadache, seizures.
BP: 134/80 at 48 hours. Mild fever: 99.6oF
Subarachnoid haemorrhageNo abnormality found at bilateral carotid or vertebral angiographyRecovery
Weiss et al (1970)25MMethamphetamineHeadache within minutes. Seizure at 24 hours.
No hypertension at 24 hours
Subarachnoid haemorrhage and right intracerebral frontal haemorrhageRight frontal lobe massMild left hemiparesis
26MMethamphetamineHeadache within 2 hours. BP: 130/80 at 24 hoursSubarachnoid haemorrhage and right intracerebral posterior-temporal haemorrhageRight temporal lobe massLeft hemiparesis
Margolis and Newton (1971)35FMethamphetamine (also heroin addict)Confusion and hallucinations within hours. BP: 134/80. Feverish: 100.2oFSubarachnoid haemorrhage and intracerebral haemorrhage in right external capsulePossible aneurysms in right and left middle cerebral arteriesBilateral hemiparesis with improvement on right  side
Rumbaugh et al (1971a)48 38FAmphetamine (and heroin)Headache and aphasia; right hemiparesis.
Temporal relationship unclear
Left intracerebral haemorrhageBeading in branches right callosomarginal artery and extensive small arterial branch occlusionsRight upper hemiparesis and aphasia
37MMethamphetamine (Methedrine) and heroinComa. Temporal relationship unclearUnclear but intracerebral haemorrhage assumedExtensive small artery occlusive changes‘Returned home’
32FAmphetamineComa. Temporal relationship unclearUnclear but intracerebral haemorrhage assumedSmall artery occlusive changesConvalescent home
24MAmphetamineRight hemiparesisLeft intracerebral haemorrhageBeaded irregular arterial changes and small arterial occlusive changesRight hemiparesis and convalescent home
29FAmphetamineSeizures. Temporal relationship unclearUnclear but intracerebral haemorrhage assumedSmall arterial occlusive changesNot stated
21FMethamphetamine (Methedrine)Coma. Temporal relationship unclearUnclear but intracerebral haemorrhage assumedBeading of intracranial vessels; small arterial occlusionsNot stated
Hall et al (1973)26MMethamphetamineHeadache and right hemiparesis. Death within hoursLeft intracerebral haemorrhageLeft frontal mass. No AVM detectedDeath
Yatsu et al (1975)26FMethamphetamineHeadache. Temporal relationship unclearRight intracerebral haemorrhageRight posterior-temporal haematomaDeath
Chynn (1975)19FAmphetamine (and cocaine/marijuana)Headache and stupor. Hypertension (160/100) at 12 hoursSubarachnoid haemorrhage and possible intracerebral haemorrhageBeading in left middle cerebral artery. Return to normal appearance on repeat angiogram 16 days laterRight hemiparesis
Edwards43 21FMethamphetamineHeadache within minutes; confusion within hoursSubarachnoid haemorrhageSegmental narrowing of medium-sized arteries (cerebral arteritis). Some arterial occlusions. No aneurysm or AVMRecovery
Olsen (1977)25MMethamphetamine (Methedrine)Headache and coma within 2 hours. Hypertension (190/160) and fever 103.2oF at 4 hoursSubarachnoid haemorrhageDiffuse beading of intracranial vesselsDeath
Kessler et al 44 22MAmphetamine, cocaine and heroinHeadache and coma within minutes. Hypertension (170/120) at 8 hoursMultiple small intracerebral haemorrhages and subarachnoid haemorrhageLeft frontal haematoma. Stenosis and dilatation of tributaries of middle cerebral artery consistent with cerebral arteritisMild dysphasia and right hemiparesis
LoVerme (1979)25FMethamphetamineHeadache and seizures. Temporal relationship unclearLeft frontal intracerebral haemorrhageLeft frontal avascular massRecovery: right hemiparesis resolved
Delaney and Estes (1980)24FMethamphetamineHeadache, confusion, right hemiparesis within hours. Death within 48 hoursSubarachnoid haemorrhage and left frontal haematomaNo evidence of aneurysm, AVM or vasculitisDeath
Cahill et al (1981)25MDextro-amphetamine, methylphenidateHeadache, seizures and hypertension (180/120). Temporal relationship unclearSubarachnoid haemorrhageBeaded appearance in multiple middle and anterior cerebral cortical branches of right carotid artery. Steroid treatment commenced. 3 weeks later angiogram normalRecovery. No residual deficit
D’Souza and Shaberg (1981)17ML- and D-l amphetamineHeadache within an hour. Left haemiplegia and hypertension (210/120) at 3 hoursRight insular intracerebral haemorrhageNormal: no aneurysm or AVMRecovery
Shukla (1982)24MAmphetamineHeadache and stupor, hypertension (150/95) within hoursRight intracerebral haemorrhageRight thalamic avascular mass. No aneurysm or AVMLeft hemiplegia
Harrington et al 39 19MAmphetamineHeadache, vomiting, hypertension (170/104) within 2 hoursLeft frontal intracerebral haemorrhageIrregularity and partial occlusion of several small cerebral vessels. CT: increased density left frontal lobeRecovery
19MAmphetamineHeadache and right hemiparesis within 24 hoursLeft tempero-parietal intracerebral haemorrhageNo abnormalities.
CT: left tempero-parietal mass with midline shift.
Minimal right-sided sensory/motor signs
Lukes (1983)28MMethamphetamineHeadache within 1 hour. Blurred vision, stupor, hypertension (160/95) at 24 hoursSuperiotemporal intracerebral haemorrhageRight superio temporal AVM. No arterial narrowing or beadingLeft homonymous hemianopia
Matick et al 45 25MDextroamphetamineStupor, seizures, hypertension (240/100) at 24 hours.Subarachnoid haemorrhageAneurysm in left anterior temporal branch of middle cerebral artery. Multiple widespread areas of luminal irregularityMild left hemiparesis
Salanova and Taubner (1983)52 18MAmphetamineHeadache and right hemiparesis within hoursLeft intracerebral haemorrhageHaematoma in internal capsule and basal ganglia. Diffuse narrowing of intracranial arteries. Improved at 18 day angiogram following steroid treatmentMild residual right hemiparesis
Yu et al (1983)51 16MMethamphetamineVomiting, seizures, hypertension (140/90). Temporal relationship unclear.Intracerebral haemorrhage in left anterior parietal lobeIrregularity of flow; beading of anterior and middle cerebral arteries. Appearance normal at re-exam after 1 month of treatment with prednisoloneRecovery
Ogasawara et al 46 23FMethamphetamineHeadache, vomiting, gait disturbance within minutes. Right hemiparesis at 26 hoursIntracerebral haemorrhage in left parietal-frontal lobe and left lateral ventricleIrregular segmental arterial narrowing and beading of anterior and middle cerebral arteriesRecovery ‘fair’
Conci et al 34 18MAmphetamineHeadache, vomiting, confusionLeft intracerebral haemorrhageLeft intracerebral haematoma left caudate nucleus. Spasm and beadingResidual dysarthria and hypertonus of lower limbs and left upper limb
Lessing and Hyman (1989)21MAmphetamineRight hemiplegia within hoursLeft fronto-parietal intracerebral haemorrhageNot done at baseline. Normal at 10 weeks with no evidence of AVM or aneurysm.
CT: left fronto-parietal haemorrhage with midline shift
Minimal right-handed signs (clumsiness)
Imanse and Vanneste (1990)31MAmphetamineHeadache, seizure within minutes. Hypertension (190/110) and fever (38.5°C) at 1 hourIntracranial intraventricular haemorrhage with extension to left frontal paraventricular areaNormal
CT: extensive intraventricular haemorrhage
Moderate short-term memory disturbances
Shibata et al 47 22FMethamphetamineSeizure, loss of consciousness within minutes. Hypertension (160/100).Subarachnoid and intracerebral haemorrhageHaematoma. No aneurysm or AVM. At biopsy, many vessels showed medial necrosisDeath
Harries and De Silva (1992)30FAmphetamine and ecstasyHeadache and right hemiparesis within hoursLeft fronto-parietal intracerebral haemorrhageNormal at 6 weeks.
Baseline CT: haematoma
Survival, no further details
22FAmphetamineHeadache, seizure, right hemiparesis within hoursLeft frontal intracerebral haemorrhageLeft carotid angiogram normal.
CT: frontal haematoma
Not stated
Hughes et al (1993)22FAmphetamineHeadache within hours; hemiparesis within 12 hoursLeft fronto-parietal intracerebral haemorrhageNot performed.
CT: large haemorrhage, oedema, midline shift
Residual right hemiparesis
Yen et al 62 37MMethamphetamineVomiting, right hemiplegia, fever, hypertension (240/140) at 5 hoursLeft putaminal intracerebral haemorrhage, intraventricular haemorrhage and subarachnoid haemorrhageNot performed.
CT: large intracerebral haemorrhage. Normal carotid and vertebral duplex ultrasound
Death
17MMethamphetamineConfusion and vomiting within 3 hoursRight fronto-tempero-parietal intracerebral haemorrhage with intraventricular haemorrhageNo vascular beading, AVM or aneurysmRecovery of right hemiplegia (almost asymptomatic)
24MMethamphetamineHeadache and right hemiplegia within 72 hoursRight parietal intracerebral haemorrhage with subarachnoid haemorrhageRight middle cerebral artery AVMMinimal right-sided weakness
32MMethamphetamineConfusion, headache, right hemiparesis within 24 hours. Hypertension (140/90) at 72 hoursCaudate intracerebral haemorrhage with intraventricular haemorrhageNo vascular beading, AVM or aneurysmMild weakness (right hemiparesis) and hemianopia
Selmi et al 37 19FMethamphetamineHeadache, vomiting, left hemiparesis within hoursRight fronto-parietal intracerebral haemorrhage; subarachnoid haemorrhageVessel biopsy: varying luminal diameterRecovery
Davis and Swalwell (1994 and 1996)41 †42MMethamphetamineNot statedSubarachnoid haemorrhageRupture of berry aneurysm at junction of left internal carotid artery and posterior communicating branch. No small vessel vasculitisDeath
27FMethamphetamineNot statedSubarachnoid haemorrhageRupture of berry aneurysmDeath
38FMethamphetamineNot statedSubarachnoid haemorrhageRupture of berry aneurysmDeath
26FMethamphetamine and cocaineNot statedSubarachnoid haemorrhageRupture of berry aneurysmDeath
El-Omar et al (1996)23FAmphetamineLeft hemiparesis. Temporal relationship unclearRight frontal intracerebral haemorrhageNormalMild left hemiparesis
Chaudhuri et al (1999)19FAmphetamineHeadache, seizures, left hemiplegia. Temporal relationship unclear. Death 5 days postadmissionRight basal ganglia intracerebral haemorrhageNot performed.
MRI: haemorrhage in white matter with midline shift
Death
Perez et al 72 29FMethamphetamineWeakness and hypertension (250/160). Temporal relationship unclear. Pregnant with h/o pregnancy-induced hypertensionCerebellar and brainstem haemorrhageNot performed.
CT: large cerebellar and brainstem haemorrhage
Death
Buxton and McConachie (2000)49 27MAmphetamineHeadache, vomiting within 24 hoursRight temporal intracerebral haemorrhageNormalRecovery
26MAmphetamineHeadache within 24 hoursIntracerebral (brainstem) haemorrhageNormalRecovery
32MAmphetamineHeadache within 24 hoursSubarachnoid haemorrhageBeadingRecovery
30MAmphetamineHeadache within 24 hoursRight frontal intracerebral haemorrhageNormalRecovery
30MAmphetamineHeadache, left hemiplegia within 24 hoursRight frontal intracerebral haemorrhageNormalLeft hemiparesis
24MAmphetamineRight hemiplegia within 24 hoursLeft frontal intracerebral haemorrhageNormalRight hemiparesis
28MAmphetamineHeadache, coma within 24 hoursLeft parietal intracerebral haemorrhageNormalRight hemiparesis and dysphasia
McEvoy et al 42 22FAmphetamineHeadache, vomiting. Temporal relationship unclearSubarachnoid haemorrhageNormalRecovery
19MAmphetamine and ecstasyHeadache, vomiting. Temporal relationship unclearLeft occipital intracerebral haemorrhage and subarachnoid haemorrhageLeft occipital AVMRecovery
28MAmphetamine and ecstasyHeadache, vomiting. Temporal relationship unclearSubarachnoid haemorrhageAneurysm in anterior communicating arteryRecovery
29MAmphetamine and ecstasyHeadache, vomiting. Temporal relationship unclearSubarachnoid haemorrhageAneurysm in posterior communicating arteryRecovery
27MAmphetamineHeadache, confusion, left hemiparesis. Temporal relationship unclearRight parietal intracerebral haemorrhageRight parietal AVMSevere residual disability
Zhu et al (2000)†35MMethamphetamineNot statedSubarachnoid haemorrhageMicroscopy from autopsy not detailedFall leading to death
26FMethamphetamineNot statedIntracerebral haemorrhageMicroscopy from autopsy not detailedDeath
Agaba et al (2002)21MAmphetamine and ecstasyHeadache, vomiting within 24 hoursRight frontal intracerebral and left extradural haemorrhageNo AVMRecovery
Miranda et al (2002)21FAmphetamine (and heroin intravenously)Headache, vomiting within hoursRight intracerebral haemorrhage in internal capsuleNo AVM. No vascular abnormalityResidual left-sided weakness
Moriya and Hashimoto (2002)43MMethamphetamineFound deadIntracranial intraventricular haemorrhageAutopsy: no cerebral vasculature abnormalitiesDeath
Inamasu et al (2003)32FMethamphetamineLeft hemiplegia, comatose within hours.Right parietal intracerebral haemorrhageNegativeResidual left hemiparesis
Chen et al (2003)31MAmphetamineHeadache, vomiting. Temporal relationship unclearSubarachnoid haemorrhageAneurysm in right internal carotid arteryRecovery
McGee et al 59 31MMethamphetamineHeadache, left hemiparesis within 10 hoursBilateral subarachnoid haemorrhage and intracerebral right frontal haemorrhageNo AVM, aneurysm or inflammation. No vasculitisDeath
Berankova et al 73 31MMethamphetamineComa within 1 hourIntracerebral haemorrhage in cerebellumAutopsy: cerebral oedema with bleeding into cerebellumDeath
Klys et al (2005)24FAmphetamineConfusion, loss of consciousness within 24 hours; later right hemiparesis and hypertension (170/100)Right-sided intracerebral haemorrhageTwo haematomas in deep structures; one in thalamusDeath
Schuff et al (2005)40MAmphetamine (and heroin)Not detailedBasal ganglia cerebral haemorrhageNo AVM, no vasculitis at autopsyDeath
Ago et al (2006)‡20‡MMethamphetamineComa within hoursSubarachnoid haemorrhages in the left and right parietal lobes and cerebellumSAH and intracerebral haematomas in hippocampus, hippocampal gyri, midbrain and ponsDeath due to methamphetamine poisoning (renal failure secondary to rhabdomyolysis)
Pilgrim et al (2009)64 †44MMethamphetamine and amphetamineCoronary artery disease at autopsyIntracranial haemorrhageAutopsy: brain haemorrhage and methamphetamine toxicityDeath
30FMethamphetamineCardiac hypoxic damage, pulmonary oedema at autopsySubarachnoid haemorrhageAutopsy: ruptured right middle cerebral artery aneurysmDeath
19MMethamphetamine, amphetamine, MDMACardiomegaly, pulmonary oedema, enlarged liver at autopsySubarachnoid haemorrhageAutopsy: ruptured berry aneurysmDeath
16FMethamphetamineNephrotic syndrome at autopsyIntracerebral haemorrhageCerebral AVMDeath
Chiu et al 65 29FMethamphetamineLeft hemiparesis and headache within 48 hoursIntracerebral (brainstem) haemorrhageNo abnormality on angiogram.
MRI: large brainstem haemorrhage
Left-sided hemiparesis and dysarthria
ISCHAEMIC STROKES
Aldrich et al (1983)§25MAmphetamineRight hemiparesis. Diagnosis of syphilis made based on positive TPHATwo ischaemic strokes secondary to occlusion of right internal carotid artery and narrowing of left internal carotid arteryWidespread occlusions in medium and small calibre vessels. Mild intimal thickening of superficial temporal arteryFirst: decreased motor function right hand; second right hemiparesis. Both resolved. Recovery
Rothrock et al 50 35MMethamphetamineHeadache, right hemiplegia within 12 hours. Smoker and alcohol abuse.Left midfrontal cortical ischaemic strokeOcclusion of supraclinoid portion of left internal carotid arteryNon-fluent aphasia and mild right face and arm weakness
22MMethamphetamineHeadache, left hemiplegia. 2 weeks after last useRight fronto-parietal ischaemic strokeMild segmental narrowing ‘beading’ of right internal carotid artery. Poor filling of branchesMild left hemiparesis
23MMethamphetamineRight hemiplegia and aphasia within 12 hoursLeft frontal ischaemic strokeOcclusion of left internal carotid arteryModerate non-fluent aphasia and right arm weakness
Lambrecht et al 60 37MAmphetamine and caffeineDrowsy, hypertension (230/130) within 3 hours. Right hemiplegia after 9 hours. SmokerIschaemic stroke in distribution of left anterior cerebral arteryNot performed.
CT: infarction in distribution of left anterior cerebral artery
Mild right-sided weakness
Yen et al 62 34MMethamphetamineRight hemiplegia, hypertension (184/104) at 30 hoursParietal cerebral ischaemic strokeNo vascular beading, AVM or aneurysmMinimal weakness (right hemiparesis)
31MMethamphetamineRight hemiparesis at 4 hoursLeft tempero-parietal cerebral ischaemic strokeNot performed.
CT: tempero-parietal cerebral infarction
Outcome unknown (loss to follow-up)
Imanishi et al (1997)37MmethamphetamineComa, drug toxicity, hyperpyrexial (43.1°C). Temporal relationship unclearCerebral ischaemic stroke in left thalamus and basal gangliaAutopsy: cerebral infarction secondary to bacterial embolus. No vasculitisDeath
Perez et al 72 36MMethamphetamineRight upper limb weakness within 12 hours. Hypertension (199/140) at 36 hours.
H/o hypertension and smoking
Ischaemic stroke left basal gangliaNot performed.
CT: radiolucency left basal ganglia consistent with an ischaemic infarct. Doppler carotid arteries: negative
Recovery
29FMethamphetamine, cocaine, marijuanaRight hemiplegia. Temporal relationship unclear SmokerLeft middle cerebral artery distributionNot performed.
CT: left middle cerebral artery distribution infarct with visible thrombus. Carotid Doppler: thrombus left internal carotid artery
Residual aphasia and right hemiparesis
Ohta et al (2005)56 ¶19FMethamphetamineHeadache, blurred vision, left hemiplegia. 3 months since last useDelayed ischaemic stroke right occipital lobeNarrowing and beading of right posterior cerebral arteryResidual left superior quadrant hemianopia and headache
McIntosh et al 38 36FMethamphetamineRight hemiparesis, aphasia within 12 hours. Smoker, oral contraceptive pillIschaemic stroke left frontal lobe (middle cerebral artery)MRI: small infarct in the left frontal lobe. Narrowing in left internal carotid artery intimal flap and intramural thrombus indicative of carotid dissectionRecovery with mild expressive aphasia and right hemiparesis
29FMethamphetamineRight hemiparesis, aphasia 4 days post useIschaemic stroke in left frontal lobe (middle cerebral artery)MRI: large left middle cerebral artery infarct. Narrowing in left common carotid artery, intimal flap and filling defect indicative of carotid dissectionRecovery with moderate expressive aphasia and mild right hand weakness
De Silva et al 57 30FAmphetamineRight hemiparesis, aphasia within 24 hoursLeft parietal ischaemic stroke (left middle cerebral artery)Irregularity of left middle cerebral artery. Beading. Vasculitis or vasospasm deemed cause. Microembolic signals at site suggest thrombosis leading to embolism in distal arteriesNot stated
Christensen et al 33 33MMethamphetamine and amphetamineComa within hoursBilateral cerebral ischaemic stroke extending from frontal to occipital lobesExtensive necrosis of cerebral white matter bilaterally and of left cerebellar hemisphere. Extent of tissue damage deemed suggestive of vasospasm of large vesselsDeath
Yew et al 74 33MMethamphetamineRight hemiparesis, dysphasia. Temporal relationship unclear. Smoker. H/o hypertension and cardiac failureIschaemic stroke in left basal ganglia (left total anterior circulation)Not performed.
CT: infarction left basal ganglia commensurating with left total anterior circulation
ECG: Left ventricle hypertrophy and severely impaired function
Recovery
Azarpira et al 75 33MCrystal methamphetamineRight hemiparesis and aphasia, chest pain, hypertension (180/120) within hours. SmokerRight-sided ischaemic stroke (and myocardial infarction)Not performed.
CT: right ischaemic stroke with midline shift. ECG: anterior wall myocardial infarction. Cause might be cerebral vasoconstriction or cardiac source of embolism
Brain death and death (support withdrawn)
  • *Full references for all studies not otherwise referenced in the text are provided in online supplementary file s2.

  • †Autopsy series.

  • ‡In 20s.

  • §Also had syphilis.

  • ¶Infarction occurred 3 months following intravenous methamphetamine use (on patient’s report).

  • AVM, arteriovenous malformation; BP, blood pressure; CT, computerized tomography; h/o, history of; MDMA, Methylene dioxy methamphetamine; TPHA, Treponema pallidum hemagglutination assay.