Neurovascular complications of cocaine use at a tertiary stroke center

"Aneurysmal Subarachnoid Hemorrhage and Cocaine Consumption: A Systematic Review and Metanalysis"

BACKGROUND

The use of cocaine can lead to a variety of neurologic complications, including cerebral vasoconstriction, ischemia, aneurysm formation, and aneurysm rupture. A previous study has shown that cocaine use is associated with an increased risk of subarachnoid hemorrhage (SAH). This study conducted a systematic review and meta-analysis of observational studies to assess the association between cocaine use and the risk of poor neurological outcomes and mortality in patients with SAH.

METHODS

A systematic review and meta-analysis were performed following the meta-analysis of observational studies in epidemiology (MOOSE) declaration for systematic reviews and the Cochrane Manual of Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs), nonrandomized clinical trials, and prospective and retrospective cohort studies that reported data about adults who suffered Aneurysmal Subarachnoid Hemorrhage (aSAH) after having consumed cocaine recreationally were included. Variables such as mortality, vasospasm, seizures, re-bleeding, and complications were analyzed.

RESULTS

After a thorough selection process, 14 studies involving 116,141 patients, of which 2227 had a history of cocaine consumption, were included in the analysis. There was a significant increase in overall unfavorable outcomes in aSAH patients with a history of cocaine use (OR 5.51 CI 95% [4.26-7.13] P = <0.0001; I2 = 78%), with higher mortality and poor neurologic outcomes. There were no significant differences in the risk of hydrocephalus, seizures, or re-bleeding. Cocaine use was found to increase the risk of vasospasm and overall complications.

CONCLUSIONS

This study insinuates that cocaine use is associated with worse clinical outcomes in aSAH patients. Despite the cocaine users did not exhibit a higher risk of certain complications such as hydrocephalus and seizures, they had an increased risk of vasospasm and overall complications. These findings highlight the importance of addressing the issue of cocaine consumption as a primary preventive measure to decrease the incidence of aSAH and improve patient outcomes.

Imaging of Drug-Related Vasculopathy

Illicit and recreational drugs, such as cocaine, heroin, amphetamines, and marijuana, can result in drug-related vasculitis or vasculopathy. Similarly, the use of certain antithyroid, oncologic, and immunosuppressive medications for therapeutic purposes can lead to vasculopathy. This in turn may result in significant complications in the central nervous system, including intracranial hemorrhage and stroke. Cocaine abuse can also lead to midline destructive lesions of the sinonasal complex. MR imaging, Vessel Wall imaging, and CT/CTA are valuable imaging tools for the evaluation of patients with suspected drug-induced vasculopathy or vasculitis. This article reviews the pathomechanism, clinical presentation, and imaging findings of vasculopathy related to drug abuse and prescribed medications.

Cocaine and Ischemic or Hemorrhagic Stroke: A Systematic Review and Meta-Analysis of Clinical Evidence

Cocaine consumption has increased over the last decade. The potent sympathomimetic effects of the drug can lead to serious neurovascular complications in the form of ischemic stroke (IS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH). This systematic review and meta-analysis were designed to describe the clinical features and outcomes of patients suffering from IS, ICH, or SAH occurring in the context of cocaine use. The PubMed, Embase, Cochrane, and Web of Science libraries were queried in December 2022. Studies were included if they provided information regarding the epidemiology, clinical presentation, or outcomes in cocaine-associated strokes. Odds ratios (OR) were pooled using a random-effects model. A total of 36 papers were included. Strokes associated with cocaine use were more prevalent in younger populations and those of African American descent. Cocaine use increased the odds of IS, ICH, or SAH (OR = 5.05, p < 0.001). The odds of mortality (OR = 1.77, p = 0.0021), vasospasm (OR = 2.25, p = 0.0037), and seizures (OR = 1.61, p < 0.001) were also worse when strokes were associated with cocaine use. In addition to counseling patients on the benefits of drug cessation, clinicians should remain vigilant of the potential complications in patients who are hospitalized with cocaine-associated strokes.

Strukturelle Gehirnveränderungen und Läsionen durch den Konsum illegaler Drogen und Psychedelika

Drogen können sowohl die Funktion wie auch die Struktur des Gehirns verändern. Gelegentlicher oder regelmäßiger Drogenkonsum ist in der Bevölkerung weit verbreitet. Daher ist die Kenntnis möglicher Nebenwirkungen und charakteristischer Bildbefunde bei Untersuchungen des Gehirns für den klinischen Alltag wichtig. Dieser Artikel beschreibt die für die am weitesten verbreiteten Substanzen typischen Komplikationen und morphologisch-radiologischen Veränderungen. Zu den möglichen Pathomechnismen gehören neurotoxische Effekte, die zu Leukenzephalopathie oder Hirnatrophie führen können, und vaskuläre Komplikationen wie Vasokonstriktion, Vaskulitis oder Hypertonus, durch die es zu intrazerebralen Blutungen oder Infarkten kommen kann. Da die klinische Präsentation oft unspezifisch ist, und die betroffenen Patienten ihren Drogenkonsum häufig verschweigen, ist das Erkennen typischer Bildbefunde essentiell für eine zuverlässige Diagnosestellung und zielgerichtete Therapie.

Headache Attributed to Non-vascular Intracranial Disorder: Neoplasms, Infections, and Substance Abuse

Evaluation of headaches warrants a careful history and neurologic assessment to determine the need for further workup and imaging. Identifying patients who are at risk for underlying pathology is important and this includes individuals with known or suspected malignancy and those who are immunocompromised and at increased risk for intracranial infection. While CT is helpful in the acute setting and to screen for intracranial hypertension, MRI is the modality of choice for the evaluation of underlying pathologies. Imaging in substance abuse may show injury related to direct toxicity or secondary to vascular complications.

Depression as a Risk Factor for Incident Ischemic Stroke Among HIV-Positive Veterans in the Veterans Aging Cohort Study

Background

HIV infection and depression are each associated with increased ischemic stroke risk. Whether depression is a risk factor for stroke within the HIV population is unknown.

Methods and Results

We analyzed data on 106 333 (33 528 HIV‐positive; 72 805 HIV‐negative) people who were free of baseline cardiovascular disease from an observational cohort of HIV‐positive people and matched uninfected veterans in care from April 1, 2003 through December 31, 2014. International Classification of Diseases, Ninth Revision (ICD‐9) codes from medical records were used to determine baseline depression and incident stroke. Depression occurred in 19.5% of HIV‐positive people. After a median of 9.2 years of follow‐up, stroke rates were highest among people with both HIV and depression and lowest among those with neither condition. In Cox proportional hazard models, depression was associated with an increased risk of stroke for HIV‐positive people after adjusting for sociodemographic characteristics and cerebrovascular risk factors (hazard ratio [HR], 1.18; 95% CI: 1.03–1.34; 0.014). The depression‐stroke relationship was attenuated by alcohol use disorders, cocaine use, and baseline antidepressant use, and unaffected by combined antiretroviral therapy use or individual antiretroviral agents. A numerically higher HR of depression on stroke was found among those younger than 60 years.

Conclusions

Depression is associated with an increased risk of stroke among HIV‐positive people after adjusting for sociodemographic characteristics, traditional cerebrovascular risk factors, and HIV‐specific factors. Alcohol use disorders, cocaine use, and baseline antidepressant use accounted for some of the observed stroke risk. Depression may be a novel, independent risk factor for ischemic stroke in HIV, particularly among younger people.

Mechanical Thrombectomy for Large Vessel Occlusions in Cocaine Associated Acute Ischemic Stroke: Small Case Series and Review of the Literature

INTRODUCTION

Cocaine through multifactorial pathogenetic mechanisms causes small and large vessel occlusions (LVO) leading to acute ischemic stroke. The optimal treatment for cocaine related LVO remains unknown. Mechanical thrombectomy (MT) poses a unique challenge, and successful MT are not widely reported.

MATERIAL AND METHODS

We report three patients with no other risk factors and a common history of cocaine metabolites found on presentation drug screen who underwent MT for MCA occlusions with subsequent failed recanalization or vessel re-occlusion due to persistent thrombosis and severe vasospasm.Two patients initially had good revascularization but then developed severe vasospasm and reoccluded, and the remaining patient had persistent severe distal vasospasm. Rescue therapy either with balloon angioplasty with stent placement or intraarterial vasodilator was used in all patients and was ineffective. All patient had large hemispheric strokes and developed malignant cerebral edema requiring hemicraniectomy in two of them. We also did literature review and summarized previously reported cases of cocaine associated vasospasm in MT and other endovascular procedures.

CONCLUSION

In this case series, cocaine induced vasospasm contributed to unsuccessful recanalization and reocclusion in patients undergoing MT with poor outcomes. Further studies are needed to ascertain strategies for improved outcomes in patients with LVO related to cocaine use.

Cocaine-induced ischemia in prefrontal cortex is associated with escalation of cocaine intake in rodents

Cocaine-induced vasoconstriction reduces blood flow, which can jeopardize neuronal function and in the prefrontal cortex (PFC) it may contribute to compulsive cocaine intake. Here, we used integrated optical imaging in a rat self-administration and a mouse noncontingent model, to investigate whether changes in the cerebrovascular system in the PFC contribute to cocaine self-administration, and whether they recover with detoxification. In both animal models, cocaine induced severe vasoconstriction and marked reductions in cerebral blood flow (CBF) in the PFC, which were exacerbated with chronic exposure and with escalation of cocaine intake. Though there was a significant proliferation of blood vessels in areas of vasoconstriction (angiogenesis), CBF remained reduced even after 1 month of detoxification. Treatment with Nifedipine (Ca²⁺ antagonist and vasodilator) prevented cocaine-induced CBF decreases and neuronal Ca²⁺ changes in the PFC, and decreased cocaine intake and blocked reinstatement of drug seeking. These findings provide support for the hypothesis that cocaine-induced CBF reductions lead to neuronal deficits that contribute to hypofrontality and to compulsive-like cocaine intake in addiction, and document that these deficits persist at least one month after detoxification. Our preliminary data showed that nifedipine might be beneficial in preventing cocaine-induced vascular toxicity and in reducing cocaine intake and preventing relapse.

Cerebrovascular and cardiovascular diseases caused by drugs of abuse

Drugs such as stimulants, sedatives, sleeping pills, and narcotics are associated with drug abuse and are therefore regulated by law. Physical dependence on these drugs is sometimes difficult to control despite an awareness of the problems they cause in daily life and the harm they can cause to the body. Drug dependence is a social problem worldwide, and the physical implications are serious. Many of these drugs cause cerebrovascular and cardiovascular diseases, which often require emergency medical treatment. Differential diagnosis is essential because of the likelihood of life-threatening events, especially among young people who exhibit cerebrovascular and cardiovascular diseases without any of the typical risk factors. Drugs of abuse, especially stimulants, induce a hyperadrenergic state that evokes vasoconstriction and tachycardia, as well as subsequent ischemic and hemorrhagic stroke, acute coronary syndrome, arrhythmias, and aortic dissection. Chronic drug abuse can also cause cardiac hypertrophy and left ventricular dysfunction. As a treatment for these conditions, sedative drugs can be effective but the use of vasodilators may also be required. There are concerns that the use of both alpha- and beta-adrenergic receptor blockers may cause tachycardia and increased blood pressure. Therefore, careful differential diagnosis and selection of therapeutic agents is required.

Cocaine Use in Adolescents and Young Adults

Cocaine use by adolescents and young adults continues to be a significant public health issue and the cause of medical and psychological morbidity and mortality. Although use rates are lower than those seen with alcohol, tobacco, and other illicit substances such as marijuana, cocaine is highly addictive and presents significant acute and long-term medical and psychological effects. This article reviews the epidemiology of cocaine use among adolescents and young adults, discusses the pharmacology and neurobiology of cocaine use and dependence, provides information regarding acute intoxication and systemic effects seen with more chronic use, and describes current assessment and treatment approaches.

A Mechanistic and Pathophysiological Approach for Stroke Associated with Drugs of Abuse

Drugs of abuse are associated with stroke, especially in young individuals. The major classes of drugs linked to stroke are cocaine, amphetamines, heroin, morphine, cannabis, and new synthetic cannabinoids, along with androgenic anabolic steroids (AASs). Both ischemic and hemorrhagic stroke have been reported due to drug abuse. Several common mechanisms have been identified, such as arrhythmias and cardioembolism, hypoxia, vascular toxicity, vascular spasm and effects on the thrombotic mechanism, as causes for ischemic stroke. For hemorrhagic stroke, acute hypertension, aneurysm formation/rupture and angiitis-like changes have been implicated. In AAS abuse, the effect of blood pressure is rather substance specific, whereas increased erythropoiesis usually leads to thromboembolism. Transient vasospasm, caused by synthetic cannabinoids, could lead to ischemic stroke. Opiates often cause infective endocarditis, resulting in ischemic stroke and hypereosinophilia accompanied by pyogenic arthritis, provoking hemorrhagic stroke. Genetic variants are linked to increased risk for stroke in cocaine abuse. The fact that case reports on cannabis-induced stroke usually refer to the young population is very alarming.

Enhanced neuronal and blunted hemodynamic reactivity to cocaine in the prefrontal cortex following extended cocaine access: optical imaging study in anesthetized rats

Cocaine addiction is associated with dysfunction of the prefrontal cortex (PFC), which facilitates relapse and compulsive drug taking. To assess if cocaine's effects on both neuronal and vascular activity contribute to PFC dysfunction, we used optical coherence tomography and multi-wavelength laser speckle to measure vascularization and hemodynamics and used GCaMP6f to monitor intracellular Ca²⁺ levels ([Ca²⁺ ]_in ) as a marker of neuronal activity. Rats were given short (1 hour; ShA) or long (6 hours; LgA) access cocaine self-administration. As expected, LgA but not ShA rats escalated cocaine intake. In naïve rats, acute cocaine decreased oxygenated hemoglobin, increased deoxygenated hemoglobin and reduced cerebral blood flow in PFC, likely due to cocaine-induced vasoconstriction. ShA rats showed enhanced hemodynamic response and slower recovery after cocaine, versus naïve. LgA rats showed a blunted hemodynamic response, but an enhanced PFC neuronal [Ca²⁺ ]_in increase after cocaine challenge associated with drug intake. Both ShA and LgA groups had higher vessel density, indicative of angiogenesis, presumably to compensate for cocaine's vasoconstricting effects. Cocaine self-administration modified the PFC cerebrovascular responses enhancing it in ShA and attenuating it in LgA animals. In contrast, LgA but not ShA animals showed sensitized neuronal reactivity to acute cocaine in the PFC. The opposite changes in hemodynamics (decreased) and neuronal responses (enhanced) in LgA rats indicate that these constitute distinct effects and suggest that the neuronal and not the vascular effects are associated with escalation of cocaine intake in addiction whereas its vascular effect in PFC might contribute to cognitive deficits that increase vulnerability to relapse.

Neuroimaging of Pediatric Arteriopathies

Pediatric arteriopathies are increasingly recognized in school-aged children with a variety of presenting symptoms ranging from headache, seizures, encephalopathy, and neuropsychiatric symptoms as well as focal neurologic deficits due to acute ischemic strokes. However, unlike the adult stroke population, there are differences in the clinical manifestations, the stroke mechanism, and risk factors in pediatric ischemic stroke. There has been increasing awareness and recognition of pediatric cerebral arteriopathies as a predominant stroke etiology. Prompt diagnosis of arteriopathies is essential to limit injury and prevent recurrent stroke. Based on predominant vessels involved and clinical symptoms, these arteriopathies can be broadly divided into two categories: large-medium size arteriopathies and small vessel arteriopathies. Each category can be further divided into inflammatory and noninflammatory according to their etiologies. The ability to distinguish between inflammatory and noninflammatory etiologies carries major prognostic implications for acute management and secondary stroke prevention as well as screening for systemic complications and counseling.

The Cardiovascular Effects of Cocaine

Cocaine is the leading cause for drug-abuse-related visits to emergency departments, most of which are due to cardiovascular complaints. Through its diverse pathophysiological mechanisms, cocaine exerts various adverse effects on the cardiovascular system, many times with grave results. Described here are the varied cardiovascular effects of cocaine, areas of controversy, and therapeutic options.

Substance Use, Intoxication, and Withdrawal in the Critical Care Setting

Substance use is common among individuals admitted to the critical care setting and may complicate treatment of underlying disorders. Management issues include the effects of intoxication as well as the risk posed by substance-withdrawal syndromes in patients being treated for critical illness. This article reviews the epidemiology of substance use in this population and the identification and treatment of common intoxication and withdrawal syndromes. The authors stress the importance of long-term planning as part of the overall treatment protocol beyond the acute presentation.

Cerebrovascular adaptations to cocaine-induced transient ischemic attacks in the rodent brain

Occurrence of transient ischemic attacks (TIA) and cerebral strokes is a recognized risk associated with cocaine abuse. Here, we use a rodent model along with optical imaging to study cocaine-induced TIA and the associated dynamic changes in cerebral blood flow velocity (CBFv) and cerebrovasculature. We show that chronic cocaine exposure in mice resulted in marked cortical hypoperfusion, in significant arterial and venous vasoconstriction, and in a sensitized vascular response to an acute cocaine injection. Starting after 10 days of exposure, an acute cocaine challenge to these mice resulted in a TIA, which presented as hemiparalysis and was associated with an abrupt exacerbation of CBFv. The severity of the TIA correlated with the decreases in cortical CBFv such that the greater the decreases in flow, the longer the TIA duration. The severity of TIA peaked around 17-22 days of cocaine exposure and decreased thereafter in parallel to a reorganization of CBFv from superficial to deep cortical layers, along with an increase in vessel density into these layers. Here, we document for the first time to our knowledge evidence of a TIA in an animal model of chronic cocaine exposure that was associated with profound decreases in CBFv, and we revealed that while the severity of the TIA initially increased with repeated exposures, it subsequently improved in parallel to an increase in the vessel density. This suggests that strategies to accelerate cerebrovascular recovery might be therapeutically beneficial in cocaine abusers.

Risk of Intracerebral Hemorrhage after Emergency Department Discharges for Hypertension

BACKGROUND

Recent literature suggests that acute rises in blood pressure may precede intracerebral hemorrhage. We therefore hypothesized that patients discharged from the emergency department with hypertension face an increased risk of intracerebral hemorrhage in subsequent weeks.

METHODS

Using administrative claims data from California, New York, and Florida, we identified all patients discharged from the emergency department from 2005 to 2011 with a primary diagnosis of hypertension (ICD-9-CM codes 401-405). We excluded patients if they were hospitalized from the emergency department or had prior histories of cerebrovascular disease at the index visit with hypertension. We used the Mantel-Haenszel estimator for matched data to compare each patient's odds of intracerebral hemorrhage during days 8-38 after emergency department discharge to the same patient's odds during days 373-403 after discharge. This cohort-crossover design with a 1-week washout period enabled individual patients to serve as their own controls, thereby minimizing confounding bias.

RESULTS

Among the 552,569 patients discharged from the emergency department with a primary diagnosis of hypertension, 93 (.017%) were diagnosed with intracerebral hemorrhage during days 8-38 after discharge compared to 70 (.013%) during days 373-403 (odds ratio 1.33, 95% confidence interval .96-1.84). The odds of intracerebral hemorrhage were increased in certain subgroups of patients (≥60 years of age and those with secondary discharge diagnoses besides hypertension), but absolute risks were low in all subgroups.

CONCLUSIONS

Patients with emergency department discharges for hypertension do not face a substantially increased short-term risk of intracerebral hemorrhage after discharge.

Cocaine Use and Risk of Ischemic Stroke in Young Adults

BACKGROUND AND PURPOSE

Although case reports have long identified a temporal association between cocaine use and ischemic stroke (IS), few epidemiological studies have examined the association of cocaine use with IS in young adults, by timing, route, and frequency of use.

METHODS

A population-based case-control study design with 1090 cases and 1154 controls was used to investigate the relationship of cocaine use and young-onset IS. Stroke cases were between the ages of 15 and 49 years. Logistic regression analysis was used to evaluate the association between cocaine use and IS with and without adjustment for potential confounders.

RESULTS

Ever use of cocaine was not associated with stroke with 28% of cases and 26% of controls reporting ever use. In contrast, acute cocaine use in the previous 24 hours was strongly associated with increased risk of stroke (age-sex-race adjusted odds ratio, 6.4; 95% confidence interval, 2.2-18.6). Among acute users, the smoking route had an adjusted odds ratio of 7.9 (95% confidence interval, 1.8-35.0), whereas the inhalation route had an adjusted odds ratio of 3.5 (95% confidence interval, 0.7-16.9). After additional adjustment for current alcohol, smoking use, and hypertension, the odds ratio for acute cocaine use by any route was 5.7 (95% confidence interval, 1.7-19.7). Of the 26 patients with cocaine use within 24 hours of their stroke, 14 reported use within 6 hours of their event.

CONCLUSIONS

Our data are consistent with a causal association between acute cocaine use and risk of early-onset IS.

Chronic cocaine disrupts neurovascular networks and cerebral function: optical imaging studies in rodents

Cocaine abuse can lead to cerebral strokes and hemorrhages secondary to cocaine's cerebrovascular effects, which are poorly understood. We assessed cocaine's effects on cerebrovascular anatomy and function in the somatosensory cortex of the rat's brain. Optical coherence tomography was used for in vivo imaging of three-dimensional cerebral blood flow (CBF) networks and to quantify CBF velocities (CBFv), and multiwavelength laser-speckle-imaging was used to simultaneously measure changes in CBFv, oxygenated (Δ[HbO2] ) and deoxygenated hemoglobin (Δ[HbR] ) concentrations prior to and after an acute cocaine challenge in chronically cocaine exposed rats. Immunofluorescence techniques on brain slices were used to quantify microvasculature density and levels of vascular endothelial growth factor (VEGF). After chronic cocaine (2 and 4 weeks), CBFv in small vessels decreased, whereas vasculature density and VEGF levels increased. Acute cocaine further reduced CBFv and decreased Δ[HbO2] and this decline was larger and longer lasting in 4 weeks than 2 weeks cocaine-exposed rats, which indicates that risk for ischemia is heightened during intoxication and that it increases with chronic exposures. These results provide evidence of cocaine-induced angiogenesis in cortex. The CBF reduction after chronic cocaine exposure, despite the increases in vessel density, indicate that angiogenesis was insufficient to compensate for cocaine-induced disruption of cerebrovascular function.

Frequency and Risk Factors for Cerebral Arterial Disease in a HIV/AIDS Neuroimaging Cohort

BACKGROUND

Infection with HIV predisposes patients to a myriad of neurologic disorders, including cerebrovascular disease. The pathophysiology is likely multifactorial, with proposed mechanisms including infectious vasculitis, HIV-induced endothelial dysfunction and adverse effects of combination antiretroviral therapy (cART). Epidemiologic data on clinically evident cerebral vasculopathy in HIV-infected adults is scarce, even though stroke hospitalizations are rising in this patient population.

METHODS

A total of 6,298 HIV-infected adults (San Francisco General Hospital, 2000-2013) were screened to generate a cohort of patients with dedicated neuroimaging of the intra- and extracranial cerebral vasculature. We extracted information regarding the extent of HIV disease (including serial viral load and CD4 counts), cardiovascular disease risk factors and exposure to cART (cross-referenced with pharmacy records) and performed multivariate logistic regression analysis to identify predictors of vasculopathy.

RESULTS

Of 144 patients, 55 patients (38.2%) had radiographic evidence of cerebral vasculopathy. Twenty (13.9%) had a vasculopathy characterized by vessel dolichoectasia and intracranial aneurysm formation. Thirty-five patients (24.3%) had intra- and or extracranial stenosis/occlusion. cART use (OR 2.27, 95% CI 1.03-5) and tobacco abuse (OR 2.35, 95% CI 1.04-5.25) were independently associated with the development of any vasculopathy, whereas cART use was also an independent risk factor for the stenosis/occlusion subtype specifically (OR 2.87, 95% CI 1.11-7.45).

CONCLUSIONS

There was a high frequency of cerebral arterial disease in this neuroimaging cohort of HIV/AIDS patients. A history of cART use and a history of tobacco abuse were independent risk factors for vasculopathy, though these findings should be confirmed with large-scale prospective studies.

Changes in regional cerebral blood flow are associated with endothelial dysfunction markers in cocaine-dependent patients under recent abstinence

OBJECTIVES

Cocaine is a known risk factor for several vascular ischemic events. The underlying mechanisms leading to the complications are not fully understood, although thrombus formation and accelerated atherosclerosis are prominent findings. Evidence of endothelial dysfunction (ED), a key phenomenon in the pathogenesis of atherogenesis, has been demonstrated in cocaine-dependent individuals. Abnormal regional cerebral blood flow (rCBF) is a common finding among chronic cocaine users. The aim of this study was to evaluate whether brain perfusion changes were associated with ED markers in cocaine-dependent individuals.

METHODS

Circulating endothelial cells (CECs), soluble intercellular cell adhesion molecule, and the chemokine regulated on activation normal T cells expressed and secreted were measured in 27 DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition) cocaine-dependents patients. Regional cerebral blood flow was assessed using single-photon emission computed tomography at baseline (after recent cocaine consumption) and after 4 weeks of strict abstinence under standard benzodiazepine or antipsychotic therapy. We used statistical parametric mapping analysis to evaluate the covariates.

RESULTS

Endothelial cell damage/activation markers were significantly higher in cocaine-dependent individuals after recent consumption and were reduced after 1-month abstinence (P < 0.05). Global rCBF exhibited no significant difference between baseline and after abstinence. When regional perfusion was analyzed in association with ED covariates, significant differences were observed in bilateral cortical areas, including the limbic lobes.

CONCLUSIONS

We demonstrated an association between systemic ED markers and rCBF in cocaine-dependent patients. These findings suggest that vascular injury may play a role in the pathogenesis of abnormal rCBF.

Cocaine use as an independent predictor of seizures after aneurysmal subarachnoid hemorrhage

OBJECTIVE

Seizures are relatively common after aneurysmal subarachnoid hemorrhage (aSAH). Seizure prophylaxis is controversial and is often based on risk stratification; middle cerebral artery (MCA) aneurysms, associated intracerebral hemorrhage (ICH), poor neurological grade, increased clot thickness, and cerebral infarction are considered highest risk for seizures. The purpose of this study was to evaluate the impact of recent cocaine use on seizure incidence following aSAH.

METHODS

Prospectively collected data from aSAH patients admitted to 2 institutional neuroscience critical care units between 1991 and 2009 were reviewed. The authors analyzed factors that potentially affected the incidence of seizures, including patient demographic characteristics, poor clinical grade (Hunt and Hess Grade IV or V), medical comorbidities, associated ICH, intraventricular hemorrhage (IVH), hydrocephalus, aneurysm location, surgical clipping and cocaine use. They further studied the impact of these factors on "early" and "late" seizures (defined, respectively, as occurring before and after clipping/coiling).

RESULTS

Of 1134 aSAH patients studied, 182 (16%) had seizures; 81 patients (7.1%) had early and 127 (11.2%) late seizures, with 26 having both. The seizure rate was significantly higher in cocaine users (37 [26%] of 142 patients) than in non-cocaine users (151 [15.2%] of 992 patients, p = 0.001). Eighteen cocaine-positive patients (12.7%) had early seizures compared with 6.6% of cocaine-negative patients (p = 0.003); 27 cocaine users (19%) had late seizures compared with 10.5% non-cocaine users (p = 0.001). Factors that showed a significant association with increased risk for seizure (early or late) on univariate analysis included younger age (< 40 years) (p = 0.009), poor clinical grade (p = 0.029), associated ICH (p = 0.007), and MCA aneurysm location (p < 0.001); surgical clipping was associated with late seizures (p = 0.004). Following multivariate analysis, age < 40 years (OR 2.04, 95% CI 1.355-3.058, p = 0.001), poor clinical grade (OR 1.62, 95% CI 1.124-2.336, p = 0.01), ICH (OR 1.95, 95% CI 1.164-3.273, p = 0.011), MCA aneurysm location (OR 3.3, 95% CI 2.237-4.854, p < 0.001), and cocaine use (OR 2.06, 95% CI 1.330-3.175, p = 0.001) independently predicted seizures.

CONCLUSIONS

Cocaine use confers a higher seizure risk following aSAH and should be considered during risk stratification for seizure prophylaxis and close neuromonitoring.

Ocular manifestations of drug and alcohol abuse

PURPOSE OF REVIEW

The purpose of this study is to review commonly encountered adverse ocular effects of illicit drug use.

RECENT FINDINGS

Drug and alcohol abuse can produce a variety of ocular and neuro-ophthalmic side effects. Novel, so-called 'designer', drugs of abuse can lead to unusual ocular disorders. Legal substances, when used in manners for which they have not been prescribed, can also have devastating ophthalmic consequences.

SUMMARY

In this review, we will systematically evaluate each part of the visual pathways and discuss how individual drugs may affect them.

Update in intracerebral hemorrhage

Spontaneous, nontraumatic intracerebral hemorrhage (ICH) is defined as bleeding within the brain parenchyma. Intracranial hemorrhage includes bleeding within the cranial vault and encompasses ICH, subdural hematoma, epidural bleeds, and subarachnoid hemorrhage (SAH). This review will focus only on ICH. This stroke subtype accounts for about 10% of all strokes. The hematoma locations are deep or ganglionic, lobar, cerebellar, and brain stem in descending order of frequency. Intracerebral hemorrhage occurs twice as common as SAH and is equally as deadly. Risk factors for ICH include hypertension, cerebral amyloid angiopathy, advanced age, antithrombotic therapy and history of cerebrovascular disease. The clinical presentation is "stroke like" with sudden onset of focal neurological deficits. Noncontrast head computerized tomography (CT) scan is the standard diagnostic tool. However, newer neuroimaging techniques have improved the diagnostic yield in terms of underlying pathophysiology and may aid in prognosis. Intracerebral hemorrhage is a neurological emergency. Medical care begins with stabilization of airway, breathing function, and circulation (ABCs), followed by specific measures aimed to decrease secondary neurological damage and to prevent both medical and neurological complications. Reversal of coagulopathy when present is of the essence. Blood pressure management can be key and continues as an area of debate and ongoing research. Surgical evacuation of ICH is of unproven benefit though a subset of well-selected patients may have improved outcomes. Ventriculostomy and intracranial pressure (ICP) monitoring are interventions also used in this patient population. To date, hemostatic medications and neuroprotectants have failed to result in clinical improvement. A multidisciplinary approach is recommended, with participation of vascular neurology, vascular neurosurgery, critical care, and rehabilitation medicine as the main players.

Rheumatic manifestations of cocaine use

PURPOSE OF REVIEW

Cocaine use is associated with several rheumatic syndromes. This review summarizes these clinical manifestations and highlights recent developments linked to levamisole-adulterated cocaine.

RECENT FINDINGS

Cocaine use has been linked to several distinctive syndromes that can be difficult to distinguish from idiopathic rheumatic diseases. These disorders can range in severity from purely cosmetic damage to organ and/or life-threatening disease that includes sinonasal destruction and vasculitis. Many of these illnesses are associated with antineutrophil cytoplasmic antibodies (cytoplasmic, perinuclear and atypical perinuclear patterns). With the recent introduction of levamisole as a cocaine adulterant, a newly reported syndrome has emerged that is associated with neutropenia, retiform purpura with cutaneous necrosis and autoantibodies consisting of high-titre perinuclear antineutrophil cytoplasmic antibodies (p-ANCAs) with specificities for 'atypical' antigens.

SUMMARY

Cocaine use is associated with clinical syndromes that closely mimic other primary rheumatic diseases. Given the high prevalence of cocaine use and its adulteration with levamisole, clinicians should be familiar with these rheumatic manifestations in order to avoid misdiagnosis and unnecessary treatment with potentially toxic therapies.

Ethical Considerations in Deep Brain Stimulation for the Treatment of Addiction and Overeating Associated With Obesity

The success of deep brain stimulation (DBS) for movement disorders and the improved understanding of the neurobiologic and neuroanatomic bases of psychiatric diseases have led to proposals to expand current DBS applications. Recent preclinical and clinical work with Alzheimer's disease and obsessive-compulsive disorder, for example, supports the safety of stimulating regions in the hypothalamus and nucleus accumbens in humans. These regions are known to be involved in addiction and overeating associated with obesity. However, the use of DBS targeting these areas as a treatment modality raises common ethical considerations, which include informed consent, coercion, enhancement, threat to personhood, and manipulation of the reward center. Pilot studies for both of these conditions are currently investigational. If these studies show promise, then there is a need to address the ethical concerns related to the initiation of clinical trials including the reliability of preclinical evidence, patient selection, study design, compensation for participation and injury, cost-effectiveness, and the need for long-term follow-up. Multidisciplinary teams are necessary for the ethical execution of such studies. In addition to establishing safety and efficacy, the consideration of these ethical issues is vital to the adoption of DBS as a treatment for these conditions. We offer suggestions about the pursuit of future clinical trials of DBS for the treatment of addiction and overeating associated with obesity and provide a framework for addressing ethical concerns related to treatment.

Electroacupuncture reduces cocaine-induced seizures and mortality in mice

The aims of this study were to characterize the protective profile of electroacupuncture (EA) on cocaine-induced seizures and mortality in mice. Mice were treated with EA (2 Hz, 50 Hz, and 100 Hz), or they underwent needle insertion without anesthesia at the Dazhui (GV14) and Baihui (GV20) acupoints before cocaine administration. EA at 50 Hz applied to GV14 and GV20 significantly reduced the seizure severity induced by a single dose of cocaine (75 mg/kg; i.p.). Furthermore, needle insertion into GV14 and GV20 and EA at 2 Hz and 50 Hz at both acupoints significantly reduced the mortality rate induced by a single lethal dose of cocaine (125 mg/kg; i.p.). In the sham control group, EA at 50 Hz applied to bilateral Tianzong (SI11) acupoints had no protective effects against cocaine. In addition, EA at 50 Hz applied to GV14 and GV20 failed to reduce the incidence of seizures and mortality induced by the local anesthetic procaine. In an immunohistochemistry study, EA (50 Hz) pretreatment at GV14 and GV20 decreased cocaine (75 mg/kg; i.p.)-induced c-Fos expression in the paraventricular thalamus. While the dopamine D₃ receptor antagonist, SB-277011-A (30 mg/kg; s.c), did not by itself affect cocaine-induced seizure severity, it prevented the effects of EA on cocaine-induced seizures. These results suggest that EA alleviates cocaine-induced seizures and mortality and that the dopamine D₃ receptor is involved, at least in part, in the anticonvulsant effects of EA in mice.

Characteristics and outcomes of cocaine-related spontaneous intracerebral hemorrhages

To date there is only one single-center study that has exclusively reported characteristics, location, and outcomes of spontaneous intracerebral hemorrhages (ICH) among cocaine users. We aimed to describe the radiological location and characteristics along with clinical outcomes of spontaneous ICH in a similar population. We conducted a retrospective chart review of consecutive patients admitted to a tertiary care hospital, with a spontaneous ICH, who had a urine drug screen performed within 48 hours of admission. Exposure to cocaine was defined by a positive urine drug screen within 48 hours of hospital admission. Demographics, radiographic features of ICH, and short-term clinical outcomes of patients with a positive urine drug screen were analyzed and compared with the cocaine negative group. Among the 102 patients analyzed, 20 (19.6%) had documented exposure to cocaine. There was a predominance of males in both groups with significantly more Blacks in the cocaine positive group (P = 0.0246). A statistically significant number of patients with cocaine use had ICH in a subcortical location (P = 0.0224) when compared to cocaine negative patients. There was no difference in GCS, ICH volume, intraventricular extension, ICU days, hospital days, hospital cost, mortality, and ICH score. ICH in cocaine use is more frequently seen in the subcortical location.

Trends in substance abuse preceding stroke among young adults: a population-based study

BACKGROUND AND PURPOSE

Approximately 5% of strokes occur in adults aged 18 to 44 years. Substance abuse is a prevalent risk factor for stroke in young adults. We sought to identify trends in substance abuse detection among stroke patients.

METHODS

Using a population-based design, we sought to identify all patients aged 18 to 54 years experiencing a stroke (ischemic or hemorrhagic) in the Greater Cincinnati and Northern Kentucky Study region during 1993 to 1994, 1999, and 2005. Demographic and clinical characteristics and substance use data were obtained retrospectively from chart review and adjudicated by physicians.

RESULTS

The number of young patients identified with a stroke increased from 1993 to 1994 (297) to 2005 (501). Blacks (61% vs 51%; P<0.02) and men (61% vs 47%; P<0.002) reported substance abuse (current smoking, alcohol, or illegal drug use) more frequently than did whites and women. Overall use of substances increased across study periods, 45% in 1993 versus 62% in 2005 (P=0.003). The trend was significant for illegal drug use (3.8% in 1993 vs 19.8% in 2005) and ever smoking (49% in 1993 vs 66% in 2005). Documentation of both cocaine and marijuana use increased over time. In 2005, half of young adults with a stroke were current smokers, and 1 in 5 abused illegal drugs.

CONCLUSIONS

Substance abuse is common in young adults experiencing a stroke. The observed increase in substance abuse is contributing to the increased incidence of stroke in young adults. Patients aged younger than 55 years who experience a stroke should be routinely screened and counseled regarding substance abuse.

Etiologies of intracerebral hematomas

Intracerebral hemorrhage (ICH) remains a life-threatening disease that carries significant morbidity and mortality despite recent diagnostic and management advances. Various conditions are associated with increased risk of intracerebral hemorrhage. Understanding the etiology of these conditions and their pathophysiological contribution to ICH will likely lead to better therapeutic and preventative measures and improve the morbidity and mortality associated with intracerebral hemorrhage. We will review the current literature regarding important etiologies/risk factors of intracerebral hemorrhage.

Cocaine-induced cortical microischemia in the rodent brain: clinical implications

Cocaine-induced stroke is among the most serious medical complications associated with its abuse. However, the extent to which acute cocaine may induce silent microischemia predisposing the cerebral tissue to neurotoxicity has not been investigated; in part, because of limitations of current neuroimaging tools, that is, lack of high spatiotemporal resolution and sensitivity to simultaneously measure cerebral blood flow (CBF) in vessels of different calibers (including capillaries) quantitatively and over a large field of view. Here we combine ultrahigh-resolution optical coherence tomography to enable tracker-free three-dimensional (3D) microvascular angiography and a new phase-intensity-mapping algorithm to enhance the sensitivity of 3D optical Doppler tomography for simultaneous capillary CBF quantization. We apply the technique to study the responses of cerebral microvascular networks to single and repeated cocaine administration in the mouse somatosensory cortex. We show that within 2-3 min after cocaine administration CBF markedly decreased (for example, ~70%), but the magnitude and recovery differed for the various types of vessels; arterioles had the fastest recovery (~5 min), capillaries varied drastically (from 4-20 min) and venules showed relatively slower recovery (~12 min). More importantly, we showed that cocaine interrupted CBF in some arteriolar branches for over 45 min and this effect was exacerbated with repeated cocaine administration. These results provide evidence that cocaine doses within the range administered by drug abusers induces cerebral microischemia and that these effects are exacerbated with repeated use. Thus, cocaine-induced microischemia is likely to be a contributor to its neurotoxic effects.