Unraveling the Complexity of Cocaine-Induced Vasculitis: A Radiological Case Report in a 58-Year-Old Woman with Polysubstance Use Disorder

Purpose: We present an instance of cocaine-induced vasculitis in a 58-year-old woman, highlight the rarity and danger of this condition, and share specific imaging findings in its recognition. The patient presented for headaches one week after cocaine use, and work-up with magnetic resonance angiography (MRA) revealed multifocal cerebral arterial segmental narrowing and dilations of the right M1, left P2, and left A2 and A3 segments. She was managed conservatively, and follow-up computed tomographic angiography (CTA) at 6 weeks showed near complete resolution, although there was one persistent focus of narrowing in each of the right M1 and left P2 territories, respectively.
This study is prompted by the rarity of cocaine-induced vasculitis and the need for clinicians to recognize specific imaging findings indicative of this condition. The theorized mechanism of action involves antineutrophillic cytoplasmic antibody (ANCA) associated autoimmune mediated inflammation, attributed to the levamisole component often contaminating street formulations of cocaine, along with the direct vasoconstrictive properties of cocaine that further exacerbate its vascular manifestations.

Methods/Materials: Imaging upon admission and 6-week follow up was used to assess the extent of the patient's disease and monitor vascular changes over a course of time.

Results: Results of MRA upon admission along with 6-week follow up CTA of the head are depicted in the attached image. The patient demonstrated resolution of vascular anomalies in both the right M1 segment and left P2 segment upon CTA of the head but continued to show persistent narrowing in areas of the right M1 segment alongside persistent occlusion of the left P2 segment [Figure 2].

Conclusions: While vascular resolutions are present in our reported patient, it is difficult to trace back the root cause of the resolutions to either the natural course of the disease or the treatment itself, calling for more follow-up imaging to further understand the extent of the disease and impacts of treatment on vascular structure that become afflicted in cocaine-induced vasculitis.