After smoking "crack" cocaine and consuming large quantities of ethanol, a 28–year old man developed multiple cerebral hematomas. He was hypertensive for several days, but angiography revealed no evidence of vascular malformation or vasculitis. The multifocality of the hematomas and lack of underlying disease suggest that the hemorrhages resulted from cocaine–induced acute hypertension or arterial spasm, being possibly potentiated by heavy ethanol consumption. This literature suggests that cocaine use should always be considered as a possible cause of stroke, especially in the younger age group, and in patients who lack other known vascular risk factors. Toxicology screening should, therefore, be included alongside standard investigations in this group of patients, or when a history of substance misuse is suspected.