Stroke with neuropsychiatric sequelae after cannabis use in a man: a case report

Over the past few years, ischemic stroke associated with cannabis use has been reported in the literature. Typically, this accident concerns young, frequent cannabis smokers and usually occurs following cannabis consumption with simultaneous intake of alcohol, which is also thought to play a role in the cerebrovascular event [1]. In most case reports, the outcome of the neurovascular event was favorable and the patients rapidly recovered from stroke within hours or a few days.

Here we report the case of a young man who presented to our hospital with stroke that led to four days of deep coma, followed by neuropsychiatric sequelae. Moreover, this stroke occurred in the absence of alcohol intoxication.

A recent review of the literature revealed 15 cases of stroke related to cannabis use, involving different arterial territories [2]. Three observations concerned cerebellar infarction in adolescent boys, which were fatal in two cases, and a much less severe infarction for the third, who recovered relatively well after his cerebellar stroke, since he presented with only mild dysdiadochokinesia in his right hand several weeks later [3]. The 12 other reported observations concerned cerebral stroke in young men. Contrary to our case report, the outcomes of these strokes were favorable for the majority of the patients, all of whom rapidly recovered from the cerebrovascular event except for a 22-year-old man who presented residual left-sided weakness after severe left hemiparesis [3]. Unlike our patient, none of the reported cases of cannabis-related stroke involved severe neuropsychiatric sequelae. As a consequence of his stroke, our patient now has cognitive impairment with behavioral disorders and recurrent seizures, and there may be a link between these three sequelae. Indeed, in the literature, a similar case of frontal syndrome with sexual disorders related to anterior cerebral infarction has been reported [4]. The risk of seizure in patients with lacunar infarct seems to be more dependent on the degree of cognitive impairment than on the severity of the stroke [5]. It has been suggested that the seizures are due not to lacunar infarcts but more probably to neurodegenerative processes that are also responsible for mental deterioration [5].

Since the latest case report by Mateo et al. [1], which described the case of a patient who had recurrent strokes after cannabis use but recovered, the link between cannabis and stroke has become highly plausible [1, 6]. However, none of the various mechanisms that have been proposed to explain the association between stroke and cannabis use is satisfactory. The hypothesis of cardioembolism related to the arrhythmic properties of cannabis is generally not confirmed by clinical findings. The hypothesis that cannabis may induce vasospasm easily explains the transient cerebrovascular event usually reported in these circumstances, but this mechanism has not been demonstrated [2]. Postural hypotension has also been suggested, but, as in our case, most of the described patients were normotensive. The latest hypothesis is either toxic or immune inflammatory vasculopathy induced by smoking cannabis [1]. Indeed, arteritis similar to Buerger's disease involving peripheral vessels has been described after cannabis use, but there have been no descriptions of cerebral vasculitis [2]. It has also been suggested that concomitant alcohol ingestion may contribute to the neurologic event [1]. However, our present case report provides evidence that concomitant alcohol intoxication is not essential to either the occurrence of severe stroke during cannabis use or its severity. There is thus a need to investigate other mechanisms that can explain how cannabis, the most widely used illicit drug in the world, may lead to stroke in some users.

Stroke related to cannabis use can be followed by severe neuropsychiatric sequelae. Concomitant alcohol intoxication is not essential to the occurrence of this neurologic event or to its severity.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.