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Cocaine use is associated with multiple neurovascular complications, including ischemic and hemorrhagic strokes. Intracerebral hemorrhage is especially prevalent in patients with acute cocaine intoxication as defined by positive urine toxin assays.1 In addition, intracerebral hemorrhage in patients with cocaine intoxication are more severe, often associated with intraventricular hemorrhage, and have a poorer prognosis than intracerebral hemorrhage from other causes.2 Still, the majority of patients with cocaine-associated strokes will present with ischemic strokes. Whether intravenous tissue-type plasminogen activator (tPA) can be safely used in patients presenting with ischemic strokes and recent cocaine use is unknown, and their risk toward hemorrhagic conversion is not fully characterized. We describe 2 cases of cocaine-associated ischemic stroke with immediate hemorrhagic transformation after intravenous tPA infusion.A 55-year-old man presented to the emergency department 20 minutes after the sudden onset of left arm weakness while using cocaine. Examination revealed left hemiparesis-hemiataxia and noncontrast head computed tomography (CT) was normal except for bilateral white matter hypointensities suggestive of leukoaraiosis and a nasal septum perforation indicative of chronic intranasal cocaine use (Figure 1). A bolus of intravenous tPA was administered for acute ischemic stroke, with a symptom onset to administration time of 45 minutes. During the intravenous tPA infusion, the systolic blood pressure remained below 170 mm Hg. Immediately after the tPA bolus infusion, a CT-angiogram and postcontrast CT were acquired (Figure 1B). While being transported to the neuro-ICU, the patient complained of new headache and right arm weakness before quickly progressing to coma requiring emergent intubation as tPA infusion completed. Review of initial studies revealed contrast extravasation in the dorsal pons during tPA infusion (Figure 1B, black arrow). A magnetic resonance imaging scan revealed multifocal infarcts and hemorrhages raising suspicion for …

Immediate Hemorrhagic Transformation After Intravenous Tissue-Type Plasminogen Activator Injection in 2 Cocaine Users