Bilateral internuclear ophthalmoplegia after smoking "crack" cocaine

A previously healthy 35-year-old man developed sudden diplopia after smoking "crack" cocaine. Neuroophthalmologic examination revealed findings consistent with a tegmental mesencephalic lesion which correlated closely with the computed tomographic documentation of a small midbrain hemorrhage. Cocaine abuse is a recognized cause of intracranial hemorrhage. In most patients, however, the bleeding is localized in the subarachnoid space or the subcortical white matter. To our knowledge, this is the first case of isolated midbrain hemorrhage secondary to cocaine abuse.