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Drug Abuse


KEY FACTS

Terminology

  • Many drugs (prescription, illicit, or street) have adverse CNS effects

    • Illicit drug use often causes cerebrovascular disease

    • Amphetamines, cocaine > opioids, cannabis

  • Polydrug abuse (including EtOH) is common

  • Nitrous oxide (NO₂) abuse → vitamin B12 inactivation → subacute combined degeneration

Imaging

  • Best imaging clue: Young/middle-aged adult with ischemic or hemorrhagic stroke after recent drug administration

    • Hemorrhage: Intracranial, subarachnoid, intraventricular

    • Nonhemorrhagic ischemic stroke: Middle cerebral artery territory most common

  • Heroin, MDMA: Globus pallidus ischemia

  • Amphetamines: Hemorrhage, vasculitis, pseudoaneurysm, infarcts

  • NECT for suspected hemorrhage indicated: If NECT reveals hemorrhage, consider CTA/MRA/DSA

  • Consider drug abuse or dissection in young/middle-aged stroke patient

Top Differential Diagnoses

  • Intracranial hemorrhage in young adults

    • Vascular malformations; dural sinus thrombosis with hemorrhagic infarct; severe posterior reversible encephalopathy syndrome with secondary hemorrhage

  • Vasculitis

Pathology

  • 40-50% of drug-related intracranial hemorrhage is related to underlying vascular malformation (cerebral aneurysm, arteriovenous malformation)

Clinical Issues

  • 30% of strokes in patients < 45 years old are drug related

  • Cocaine, MDMA, amphetamines: Stroke, headache, seizures

Axial NECT in comatose patient after cocaine abuse shows focal hypodensities
in basal ganglia related to ischemia. Diffuse loss of corticomedullary differentiation is due to severe anoxia.

A 32-year-old woman methamphetamine abuser had sudden severe headache followed by coma. NECT shows diffuse subarachnoid
, intraventricular hemorrhage. Focal interhemispheric hematoma
surrounds a ruptured anterior communicating artery aneurysm
.

Axial DWI MR in a young male patient following ingestion of ecstasy (MDMA) shows symmetric diffusion restriction in the globi pallidi
and deep white matter
.

Axial T1 C+ MR in the same patient shows enhancement within the globi pallidi due to necrosis. MDMA causes rapid release of 5-hydroxytryptamine, which is 1 of the most potent vasoconstrictors in the brain, and it ultimately leads to necrosis of the involved regions of the brain. The occipital cortex and globi pallidi are most vulnerable.

TERMINOLOGY

Definitions

  • Many drugs (prescription, illicit, or street) have adverse effects on CNS

    • Major pathology is generally vascular or metabolic

    • Polydrug abuse (including EtOH) is common

  • Cerebrovascular disease caused by illicit drug use

    • Amphetamines and derivatives

      • –

        Cocaine

        • □

          Cocaine hydrochloride (HCl) is water soluble, ingested via mucosal membrane

        • □

          Alkaloid form (freebase, crack) is smokable

      • –

        3,4-methylenedioxymethamphetamine (MDMA, ecstasy)

    • Opioids and derivatives

      • –

        Heroin: IV use, inhaled (“chasing the dragon”)

      • –

        Other derivatives include morphine, hydrocodone, oxycodone, codeine

    • Cannabis/marijuana

    • EtOH abuse: Interference with normal clotting increases risk of spontaneous hemorrhage and extent of hemorrhage due to primary pathology

      • –

        Traumatic brain injury

      • –

        Hypertensive cerebral vascular disease

  • May interfere with critical metabolic pathways

    • Nitrous oxide (NO₂) abuse → vitamin B12 inactivation → subacute combined degeneration

  • May lead to nutritional deficiencies

    • Chronic EtOH abuse → thiamine deficiency → Wernicke encephalopathy

  • Organ damage from chronic drug abuse

    • EtOH → liver failure → manganese deposition in basal ganglia (BG)

IMAGING

General Features

  • Best diagnostic clue

    • Young/middle-aged adult with ischemic or hemorrhagic stroke in close temporal proximity to drug administration

  • Location

    • Hemorrhage: Intracranial (ICH), subarachnoid (SAH), intraventricular (IVH)

    • Nonhemorrhagic ischemic stroke: Usually, middle cerebral artery (MCA) territory

    • Vascular: Vasculitis, pseudoaneurysm

    • Cocaine: Infarctions in cerebrum, thalamus, brainstem, cerebellum, retina

    • Heroin, MDMA: Globus pallidus (GP) ischemia

    • Wernicke encephalopathy: Bilateral posterior thalamus, mammillary bodies, posterior mesencephalon

    • Liver failure: BG

    • NO₂: Posterior columns, spinal cord

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