Stroke is the third commonest cause of death and single largest cause of adult disability worldwide. Whilst the majority of strokes in older individuals are due to large or small vessel arterial disease or cardiac disease in association with classical vascular risk factors, strokes occurring in younger individuals may have atypical etiologies. Recreational substance misuse is on the increase worldwide, particularly in young adults in developed countries with commonly used substances including cocaine, amphetamines, heroin and other opiates, marijuana and gammahydroxybutyrate (GHB). Adverse vascular sequelae of inappropriate use of these substances is well recognized but the link between acute stroke and substance misuse is often underestimated. Both ischemic and hemorrhagic strokes may be caused by recreational substance misuse and this paper reviews the available evidence and discusses the potential pathophysiological links.