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I examined two young men who developed cerebral infarction associated with heavy marijuana
smoking. Both were light tobacco smokers, but they did not drink alcohol or use other street
drugs. Diagnostic work-up for nonatherosclerotic causes of stroke was unremarkable. I
postulate that marijuana-associated alterations in systemic blood pressure resulted in vaso-
spasm, leading to strokes in these patients. (Stroke 1991;22:406-409)
FIGURE 1. Case 1. Computed tomogram of brain with FIGURE 2. Case 2. Computed tomogram of brain with
contrast shows poorly defined focal area of low attenuation in contrast shows enhancing lesion in left caudate nucleus and
right periventricular white matter with mass effect on ventricle left globus pallidus andputamen. Left side of body appears on
consistent with acute ischemic infarct. Left side of body right side of figure.
appears on right side of figure.
weeks prior to the onset of symptoms. There was a
performed using four concentrations of adenosine medical history of undifferentiated personality disor-
diphosphate, collagen, epinephrine, arachidonic der. His family history was unremarkable.
acid, and ristocetin. There was no significant differ- This patient's blood pressure was 155/105 mm Hg
ence in platelet function among the different samples on admission. There was right hemiparesis, dysar-
of blood. The in vitro test involved collection of blood thria, and lower facial weakness. Results of studies
samples 0.5 and 2 hours after the patient smoked identical to those performed for case 1 were also
marijuana; A9-tetrahydrocannabinol (THC) in the within normal ranges. Results of magnetic resonance
range of 0.1-10 Mg/ml was added to the samples. imaging (MRI), angiography, and duplex studies of
There was no significant difference between platelet his carotid system were normal. Toxicological evalu-
function in these two different samples. ation of the patient's urine and plasma showed only
Physical therapy resolved this patient's dysarthria cannabinoids. An initial CT scan of the brain was
and sensory deficit. Left-sided paresis remained and normal. A contrast CT scan of the brain (Figure 2)
worsened and was associated with palpitations and obtained ^1 week after the stroke demonstrated a
dizziness whenever he smoked marijuana. He needed left basal ganglia infarct and a small left parietal lobe
antihypertensive medications to control his blood infarct. Brain MRI revealed a left basal ganglia
pressure. One month after the stroke, the patient infarct. Cerebral angiography was not performed due
discontinued his marijuana smoking. His blood pres- to the patient's refusal. On a low-sodium diet the
sure then returned to normal without medical ther- patient's blood pressure returned to normal within 1
apy, and his hemiparesis improved to some extent. week, and after 3 months of physical and occupa-
tional therapy there was marked improvement of his
Case 2 neurological deficits.
A previously healthy, 32-year-old right-handed
black man experienced the sudden onset of right arm Discussion
and leg weakness and slurred speech s0.5 hour after Marijuana use became popular in the United
smoking a marijuana cigarette. He denied the use of States in the 1960s and remains the most commonly
alcohol or other street drugs. He had smoked one used illicit recreational drug. It is usually smoked in
half pack of tobacco cigarettes per day for 9 years and cigarette form but may be consumed orally. Phanna-
marijuana heavily during the preceding 14 years. He cokinetic studies indicate that smoking is almost
had increased his marijuana smoking during the 2 equivalent to intravenous administration except that
lower peak plasma concentrations of THC are at- sympathetic nervous system stimulation, and para-
tained. In addition to its psychotropic effects, mari- sympathetic nervous system blockage.27-28 More stud-
juana may induce hypotension, tachycardia, an in- ies are needed to determine if marijuana is a risk
crease in the concentration of carboxyhemoglobin, factor for stroke, especially in combination with
nausea, hunger, conjunctival congestion, and dryness tobacco smoking.
of the mouth and throat. 1011 Heavy smoking may be
associated with chronic bronchitis, airway obstruc- Acknowledgments
tion, and squamous metaplasia of the respiratory I thank Philip Gorelick, MD, and David W. Schmidt
tract.14 for their valuable comments and suggestions in the
Stroke symptoms have been described after mari- preparation of this manuscript. I also wish to thank
juana smoking in only four prior cases.19"12 While the Alfredo Giner Sorolla, PhD, for analyzing the mari-
neurological deficits were carefully documented, sup- juana cigarettes that were used in these cases, Thomas
porting studies such as CT, MRI, toxicology, and
Klein, PhD, for supplying the marijuana extract for the
angiography were not carried out. Thus, the under-
in vitro test, Margie Morgan for typing the manuscript,
lying pathophysiological mechanism of neurological
deficit in these cases is obscure. and Nancy Bernal, MA, for library assistance.
Both of my patients had large, deep cerebral References
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Stroke. 1991;22:406-409
doi: 10.1161/01.STR.22.3.406
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