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Trainspotting: Neurological complications of IV drug use

Drug abuse is a worldwide problem responsible for a considerable number of deaths, functional dependence, and healthcare costs. Use continues to rise throughout the world and synthetic drugs have been added to the repertoire alongside cocaine, heroin, and methamphetamine. The acute intoxicating effects on the brain are well known; however, an understanding of the neurological complications is important in the acute period to guide workup and treatment. This panel is in the SMACC Brain pre-conference workshop will review neurological complications of intravenous drugs including endocarditis and the resultant septic emboli and stroke, intracerebral hemorrhages, and aneurysms. We will also dive into the less well-known neurological sequelae of other drugs including some not-so-uncommon zebras.

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Trainspotting: Neurological complications of IV drug use

  1. 1. BRAIN ON DRUGS: Chasing Dragons & Other Demons Rhonda Cadena, MD University of North Carolina Neurocritical Care/Emergency Medicine
  2. 2. I have no disclosures
  3. 3. Drugs Opiates Cannabis Amphetamines Cocaine 4.3 billion users 38 million abusers 21 million IVDU Cannabis Opiates Cannabis Amphetamines Others
  4. 4. US Drug Overdose Deaths (1999-2017) Prescription Opioids Heroin Cocaine Benzodiazepines Psychostimulants (Including Methamphetamine) CDC, Dec 2018
  5. 5. Aside from death, drugs may also have neurological complications that may leave the user with long term neurological sequelae Since these are young users, a significant financial burden to families and the society
  6. 6. IVDU and Neurological Complications of Endocarditis
  7. 7. DWI ADC ICH
  8. 8. Neurological complications > 56% stroke, 20% encephalopathy, 18% hemorrhage, 5% meningitis/abscess > Mostly occurred before treatment or within first 2 weeks > Worsen mortality Embolic events > 80% of cerebral emboli are clinically silent > Clinically apparent in 10-35% of patients with left-sided infective endocarditis Alteplase contraindicated if stroke due to endocarditis is suspected (but endovascular is not) Garcia-Cabrere et al. Circulation. 2013
  9. 9. Cerebral hemorrhage > Primary hemorrhages > Hemorrhagic conversion of embolic stroke > Rupture of infective (mycotic) aneurysm Mycotic/infective aneurysms > 1/5 of embolic events develop aneurysm > Typically more distal > Resolve with antibiotics > Surgery or endovascular treatment to obliterate vessel if severe or re-rupture
  10. 10. Treatment >Resuscitation and stabilization of multiorgan failure >Treatment of ICP >Neuro specific treatment (ICH,AIS,SAH) Broad spectrum antibiotics >Vancomycin, cefepime, aminoglycoside Neurosurgical evaluation >Medical vs surgical vs endovascular
  11. 11. Other Drugs
  12. 12. Infection Hemorrhage (ICH/SAH) Infarct Encephalopathy Seizures Vasculitis PRES Movement disorders Variations due to dose, route, additives, polysubstance interaction, and co-morbidities
  13. 13. COCAINE SAH/ICH >50% have underlying vascular abnormality >Acute rise in blood pressure ISCHEMIC STROKE >Vasoconstriction, vasospasm, or vasculitis >Accelerated atherosclerosis >Pro-thrombotic SEIZURES >Occur shortly after use
  14. 14. MOVEMENT DISORDERS “Crack Dancing”
  15. 15. AMPHETAMINE (methamphetamine/MDMA) INTRACEREBRAL HEMORRHAGE >Underlying vascular abnormalities ISCHEMIC STROKE >Vasoconstriction PRES >Reversible Movement disorders >Tremors, restless legs, punding Mobius 2014
  16. 16. METHCATHINONE (ephedrone, cat, jeff) Ataxia, postural disturbances, dysarthria, facial and lower extremity dystonia, bradykinesia >Permanent if used for more than 6 months Parkinsonism >Manganese intoxication in IV ephedrone
  17. 17. HEROIN ISCHEMIC STROKE >Vasospasm, vasculitis >Additives and embolism TOXIC LEUKOENCEPHALOPATHY >Impurities from heating the aluminum foil >Cerebellar and extrapyramidal signs (dystonia, akathisia, parkinsonism) INFECTION >Intravenous Offiah, Clin Rad 2007
  18. 18. SYNTHETIC OPIOIDS LEUKOENCEPHALOPATHY >Acute use or chronic users
  19. 19. SYNTHETIC CANNABINOIDS (SPICE) ISCHEMIC STROKES >Symmetric SEIZURES >Treatment with benzodiazepines MRI leptomeningeal enhancement >Reversible Serwani, 2015
  20. 20. ALOCOHOLISM INTRACEREBRAL HEMORRHAGE >Due to falls SEIZURES >Use or withdrawal VITAMIN DEFICIENCY >Wernicke’s encephalopathy