The neurovascular complications of cocaine

"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.

Prevalence of and factors associated with stroke in hypertensive patients in Thailand from 2014 to 2018: A nationwide cross-sectional study

Stroke is a significant cause of death and disability. In Thailand, it imposes a major health burden, and the prevalence of stroke is increasing, particularly in patients with hypertension (HT), diabetes mellitus (DM), and dyslipidemia (DLP). We aimed to determine the trends in the prevalence of stroke and the associated factors among Thai patients with HT. Nationwide cross-sectional studies were conducted annually in 2014, 2015 and 2018 based on data obtained from the Thailand DM/HT study. Nationally, representative patients with HT in Thailand were sampled with stratified one-stage cluster sampling. A total of 104,028 participants were included in this study. The prevalence of stroke remained constant, with prevalence rates of 4.0%, 3.8%, and 3.9% in 2014, 2015 and 2018, respectively (p for trend = 0.221). Our findings suggested that the management of stroke patients who are covered by the universal coverage scheme should be evaluated. Effective interventions, including promoting smoking cessation, attenuating cholesterol levels, and controlling blood pressure should be provided to hypertensive patients to prevent ischemic stroke. Young adults with HT should be more concerned about the possibility of stroke. The use of prophylactic low-dose aspirin should be carefully monitored to prevent hemorrhagic stroke.

Imaging of Non-atherosclerotic Vasculopathies

Non-atherosclerotic vasculopathies (NAVs) may present with various neurological symptoms ranging from headache, stroke, visual symptoms, and various types of intracranial hemorrhage. NAVs result from different etiologies which include collagenopathies, immunological, hematological, and infection mechanisms, and other rarer unidentifiable or idiopathic causes. NAV etiologies account for about 10–15% and 20–25% of adult and pediatric stroke cases, respectively, and therefore, diagnosing the underlying cause of NAV becomes clinically very important. Clinical diagnosis of NAV is challenging because the clinical presentation is very non-specific and overlapping with various other central nervous system disorders. Before the advent of non-invasive techniques, making a diagnosis of non-atherosclerotic vasculopathy as a cause of the stroke was very challenging. Today with newer techniques such as high-resolution magnetic resonance (MR), MR and computed tomography perfusion, and angiogram, there are number of pointers which can give us a lead about the non-atherosclerotic causes. Imaging may provide the first lead to the clinician regarding the diagnosis or possible differential diagnosis so that the targeted and focused biomarkers (blood, cerebrospinal fluid, or/and in some cases biopsies) may be obtained to clinch the diagnoses. The purpose of the article is to enumerate the causes, clinical features, and illustrate the imaging findings of the various non-atherosclerotic vasculopathic disorders and discuss “pearls” to their diagnosis. In this article, we have also discussed the latest advances in vascular imaging and elaborated on few uncommon non-atherosclerotic vasculopathies. These are very relevant clinically in the day-to-day practice for the radiologist, neurologist, and the neurointerventionalist.

Delayed cerebral ischemia causing cortical blindness due to repeat cocaine use weeks subsequent to aneurysmal subarachnoid hemorrhage

Cocaine is a known vasoactive drug associated with poor clinical outcomes and high in-hospital mortality related to aneurysmal subarachnoid hemorrhage; however, the association of prior cocaine use with the incidence of vasospasm and delayed cerebral ischemia remains controversial. We report a case of a 42-year-old male with a history of active cocaine use who presented with a severe headache. Imaging demonstrated diffuse cisternal subarachnoid hemorrhage due to a ruptured basilar apex aneurysm, which was successfully treated with endovascular coil embolization. Despite expedited endovascular treatment and an initially benign clinical course, he suffered from delayed cerebral ischemia resulting in cortical blindness due to bilateral posterior cerebral artery vasospasm secondary to repeat cocaine use weeks after his initial ictus. To our knowledge, the present case is the first to describe delayed cerebral ischemia resulting in a severe neurologic deficit due to repeat cocaine use weeks subsequent to aneurysm rupture. We review the current literature on the association of cocaine use with the incidence of vasospasm and delayed cerebral ischemia as well as the effects of cocaine on the cerebrovasculature.

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.

Histologic Changes In Recreational Drug Misuse

Use of recreational drugs is associated with a number of histologic changes. These may be related to the method of administration or due to systemic effects of the drugs. This paper reviews the histopathological features seen following recreational drug use. With injection, there may be local effects from abscess formation and systemic effects may result in amyloidosis. Injections have been associated with necrotizing fasciitis, anthrax, and clostridial infections. Systemic effects include infective endocarditis, with the risk of embolization, and abscesses may be seen in organs in the absence of infective endocarditis. Viral complications of injection include hepatitis and human immunodeficiency virus (HIV) infection. Injecting crushed tablets can result in intravascular granulomata in the lungs. Smoking drugs is associated with intraalveolar changes, including blackand brown-pigmented macrophages in crack cocaine and cannabis smoking, respectively. Snorting may result in intraalveolar granulomata forming when crush tablets are used and there may be systemic granulomata. Stimulants are associated with cardiovascular and cerebrovascular pathology, including contraction band necrosis and myocardial fibrosis, as well as coronary artery dissection. Stimulants may cause hyperpyrexia and rhabdomyolysis, which may be associated with changes in multiple organs including myoglobin casts in the kidney. Opioids cause respiratory depression and this can be associated with inhalational pneumonia and hypoxia in other organs if there is resuscitation and a period of survival. Ketamine use has been associated with changes in the urothelium and the liver. This paper reviews histology changes that may be seen in drug-related deaths using illustrative cases.

Neurotoxicology and drug-related disorders

Neuropsychiatric disorders caused by toxic substances pose a great diagnostic challenge due to the large variety of changes caused in the central and peripheral nervous system. The pathogenetic mechanisms at work are multifaceted and partly not solved. In human drug abusers (cannabis, opiates, cocaine, amphetamines, methamphetamine and "designer drugs"), a broad spectrum of central nervous system alterations are observed including infarction, intracerebral and subarachnoidal hemorrhage, hypoxic-ischemic leukoencephalopathy, infections, neuronal loss, specific astroglial and microglial reaction patterns, and vascular changes, including the endothelial cell as well as the basal lamina.

[Party and designer drugs : From ecstasy and crystal meth to angel's trumpet]

BACKGROUND

The growing abuse of party and designer drugs increases the number of emergency cases related to drug consumption.

OBJECTIVES

Presentation of the scenario as well as the diagnostic and therapeutic principles of emergency management and characterization of the most frequently abused drugs and its effects.

MATERIALS AND METHODS

Evaluation of drug statistics, and work-up and discussion of expert publications and recommendations.

RESULTS

In 2014, there were 1032 drug-related deaths, which is 3 % more incidents than in 2013. However, there is a drastically and steadily increasing consumption of newer enhancing drugs such as crystal meth. Throughout Europe, there are about 1500 designer drugs that are disguised as so-called spice mixtures or bath salts. In addition to stimulating substances, hallucinogenic and sedative drugs are also consumed. Common nonspecific symptoms of emergency drug overdose are psychosis, impaired consciousness, seizures, and disorders of various internal organs. Based on the clinical presentation, different neurotransmitter syndromes can be distinguished and the drug etiology can be diagnosed and proven by laboratory assays. Therapy includes symptom-oriented measures.

CONCLUSIONS

Knowledge of different party and designer drugs and their complications enables prompt emergency management.

Secondary demyelination disorders and destruction of white matter

Demyelinating disorders of the central nervous system are characterized by the breakdown of myelin, with or without preservation of the associated axons. Primary demyelinating diseases typically involve loss of myelin with relative sparing of axons. Secondary demyelinating disorders represent a spectrum of white matter disease characterized by damage to neurons or axons with the resultant breakdown of myelin. The pathologic changes seen in secondary demyelinating disorders are varied, ranging from pure demyelination to necrosis with subsequent demyelination. Secondary demyelinating diseases are associated with a wide variety of conditions, including infections/vaccinations, nutritional/vitamin deficiencies, chemical agents, genetic abnormalities, and vascular insult.

Neuropathology of substance use disorders

Addictions to licit and illicit drugs are chronic relapsing brain disorders that affect circuits that regulate reward, motivation, memory, and decision-making. Drug-induced pathological changes in these brain regions are associated with characteristic enduring behaviors that continue despite adverse biopsychosocial consequences. Repeated exposure to these substances leads to egocentric behaviors that focus on obtaining the drug by any means and on taking the drug under adverse psychosocial and medical conditions. Addiction also includes craving for the substances and, in some cases, involvement in risky behaviors that can cause death. These patterns of behaviors are associated with specific cognitive disturbances and neuroimaging evidence for brain dysfunctions in a diverse population of drug addicts. Postmortem studies have also revealed significant biochemical and/or structural abnormalities in some addicted individuals. The present review provides a summary of the evidence that has accumulated over the past few years to implicate brain dysfunctions in the varied manifestations of drug addiction. We thus review data on cerebrovascular alterations, brain structural abnormalities, and postmortem studies of patients who abuse cannabis, cocaine, amphetamines, heroin, and "bath salts". We also discuss potential molecular, biochemical, and cellular bases for the varied clinical presentations of these patients. Elucidation of the biological bases of addiction will help to develop better therapeutic approaches to these patient populations.

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.

Cocaine use and surgical outcomes of cervical spondylotic myelopathy: a retrospective study

The purpose of this study was to determine the average age of individuals diagnosed with cervical spinal myelopathy who are known cocaine users vs nonusers, as well as the postoperative change in neurological condition between cocaine users and nonusers. Medical records of patients diagnosed with cervical spinal myelopathy between January 1990 and May 2006 were reviewed. Ninety-four patients were identified who underwent any surgical intervention with at least 2 years of follow-up. Group 1 comprised patients with cervical spinal myelopathy who had used cocaine, and group 2 comprised patients with cervical spinal myelopathy who had not used cocaine. All patients were clinically evaluated by the Nurick grade preoperatively and at most recent follow-up. Mean follow-up was 25 months. Mean age at presentation was 52 years (range, 44-62 years) in group 1 and 56 years (range, 42-88 years) in group 2. Average duration of symptoms prior to surgical intervention was 18.6 months in group 1 and 10 months in group 2. Average Nurick grade at presentation was 2.7 for group 1 and 2.7 for group 2. Average postoperative Nurick grade was 1.9 for group 1 and 1.33 for group 2. Change in Nurick grade was 0.8 for group 1 and 1.11 for group 2. Linear regression analysis comparing change in Nurick grade (from pre- to postoperative) was conducted, showing a correlation of -0.45 with a P value of .044. To the authors' knowledge, this is the first study demonstrating that cocaine use has an effect on postoperative improvement of neurological function in cervical spondylotic myelopathy.

Cocaine intoxication

Cocaine, a natural alkaloid derived from the coca plant, is one of the most commonly abused illicit drugs. Cocaine is commonly abused by inhalation, nasal insufflation, and intravenous injection, resulting in many adverse effects that ensue from local anesthetic, vasoconstrictive, sympathomimetic, psychoactive, and prothrombotic mechanisms. Cocaine can affect all body systems and the clinical presentation may primarily result from organ toxicity. Among the most severe complications are seizures, hemorrhagic and ischemic strokes, myocardial infarction, aortic dissection, rhabdomyolysis, mesenteric ischemia, acute renal injury and multiple organ failure.

The growing problem of illicit substance abuse in the elderly: a review

OBJECTIVE

To explore and integrate the extant data on the subject of illicit substance use and abuse in the elderly and to determine shortcomings in the current understanding of the problem and potential topics of future research.

DATA SOURCES

Ovid MEDLINE was searched (1960-2011) using the keywords substance use disorders and geriatrics; PsycINFO was searched (1967-2011) using the keywords drug abuse and geriatrics.

DATA EXTRACTION

The searches of Ovid MEDLINE and PsycINFO returned 35 and 85 results, respectively. Other relevant articles were identified by checking reference lists of the identified studies. A total of 26 articles with a focus on use of illicit substances, excluding alcohol, over-the-counter drugs, and prescription drugs, in the elderly were determined to be applicable to the review.

DATA SYNTHESIS

Limited data were available to combine between studies, but certain conclusions could be generalized among separate sources.

RESULTS

Geriatric substance abuse is a topic of growing interest, importance, and research; however, most of the existing literature has focused on licit substances. Illicit substance abuse has been incorrectly assumed to end as patients age, whereas in reality, elderly drug users are increasingly common and have a unique profile quite different from that of their younger counterparts.

CONCLUSIONS

Geriatric substance abuse is a common problem and includes both licit and illicit substances. There are not yet reliable screening instruments or treatment methods for identification and treatment of illicit substance abuse in the elderly. A high index of suspicion and consideration of illicit substance use as a real possibility are vital for early recognition and diagnosis of such abuse in the elderly.

Epidemic of illicit drug use, mechanisms of action/addiction and stroke as a health hazard

Drug abuse robs individuals of their jobs, their families, and their free will as they succumb to addiction; but may cost even more: a life of disability or even life lost due to stroke. Many illicit drugs have been linked to major cardiovascular events and other comorbidities, including cocaine, amphetamines, ecstasy, heroin, phencyclidine, lysergic acid diethylamide, and marijuana. This review focuses on available epidemiological data, mechanisms of action, particularly those leading to cerebrovascular events, and it is based on papers published in English in PubMed during 1950 through February 2011. Each drug's unique interactions with the brain and vasculature predispose even young, healthy people to ischemic or hemorrhagic stroke. Cocaine and amphetamines have the strongest association with stroke. However, the level of evidence firmly linking other drugs to stroke pathogenesis is weak. Large epidemiological studies and systematic evaluation of each drug's action on the brain and cardiovascular system are needed to reveal the full impact of drug use on the population.

Sexual intercourse and cerebral aneurysmal rupture: potential mechanisms and precipitants

Aneurysmal subarachnoid hemorrhage (SAH) is a significant cause of death in young and middle-aged individuals and causes tremendous morbidity in affected patients. Despite the identification of various risk factors, the series of events leading to the formation, growth, and rupture of intracranial aneurysms is poorly understood. Cerebral aneurysm rupture has been associated with sexual intercourse and other forms of physical exercise. In fact, multiple case series reported that coitus was the immediate preceding activity in 3.8–14.5% of patients suffering from aneurysmal SAH. This may be related to the large elevations in mean arterial blood pressure that occur in both males and females during sexual intercourse (130–175 and 125–160 mm Hg, respectively). While coitus and physical exercise share important physiological similarities, each may differentially affect the probability that a preformed aneurysm will rupture. In this literature review and synthesis, the authors analyze the physiological human response to sexual intercourse in an effort to delineate those factors that may precipitate aneurysmal rupture. The authors' analysis is based on the original data collected by Masters and Johnson. To the authors' knowledge, this is the first review to address the link between sexual intercourse and intracranial aneurysmal rupture. While actual measurements of the physiological variables relevant to SAH were not performed in this article, the authors make reasonable assumptions based on the available data to help elucidate the mechanism of sexually induced aneurysmal rupture.

Assessing white matter integrity as a function of abstinence duration in former cocaine-dependent individuals

Current cocaine-dependent users show reductions in white matter (WM) integrity, especially in cortical regions associated with cognitive control that have been associated with inhibitory dysfunction. A key question is whether these white matter differences are present following abstinence from drug use. To address this, WM integrity was examined using diffusion tensor imaging (DTI) obtained on 43 cocaine abstinent patients (abstinence duration ranged between five days and 102 weeks) and 43 non-using controls. Additionally, a cross-sectional comparison separated the patients into three groups (short-term, mid-term and long-term) based upon duration of cocaine abstinence. The 43 cocaine abstinent patients showed lower fractional anisotropy (FA) in the left anterior callosal fibers, left genu of the corpus callosum, right superior longitudinal fasciculus, right callosal fibers and the superior corona radiata bilaterally when compared against non-using controls. Higher FA in the cocaine abstinent patients was observed in the splenium of the corpus callosum and right superior longitudinal fasciculus. Differences between the cocaine abstinent groups were observed bilaterally in the inferior longitudinal fasciculus, right anterior thalamic radiation, right ventral posterolateral nucleus of the thalamus, left superior corona radiata, superior longitudinal fasciculus bilaterally, right cingulum and the WM of the right precentral gyrus. The results identified WM differences between cocaine abstinent patients and controls as well as distinct differences between abstinent subgroups. The findings suggest that specific white matter differences persist throughout abstinence while other, spatially distinct, differences discriminate as a function of abstinence duration. These differences may, therefore, represent brain changes that mark recovery from addiction.

Cocaine-induced intracerebral hemorrhage in a patient with cerebral amyloid angiopathy

Intracerebral hemorrhage (ICH) is a well-recognized complication of recreational cocaine use. The precise mechanism of the cocaine-induced hemorrhagic event is unclear, although multiple factors have been implicated. We report a case of a 62-year-old woman who suffered left parieto-occipital ICH with herniation and death, following a cocaine binge. Microscopic examination also revealed extensive cerebral amyloid angiopathy (CAA) in the vicinity of the hemorrhage. We additionally studied brain tissue in eight subjects between ages of 60 and 80 who were positive for cocaine metabolites at autopsy; of these, none had vascular amyloid-β deposits by immunohistochemistry. Whereas we found no evidence that chronic cocaine use is a risk factor for CAA, given the age-associated nature of CAA and the aging population using cocaine, CAA-induced hemorrhage in the setting of cocaine use may be more common than recognized. This is the first reported case of CAA-associated ICH precipitated by cocaine.

Associations between duration of illicit drug use and health conditions: results from the 2005-2007 national surveys on drug use and health

PURPOSE

To estimate and compare prevalence rates of lifetime health conditions by inferred duration of illicit drug use among the general U.S. adult population and to investigate associations between duration of use of each specific illicit drug (marijuana, cocaine, heroin, hallucinogens, or inhalant) and each lifetime health condition after controlling for potential confounding factors.

METHODS

Data from respondents aged 35 to 49 (N = 29,195) from the 2005-2007 National Surveys on Drug Use and Health (NSDUH) were analyzed.

RESULTS

The prevalence rates of a broad range of health conditions by duration of use of specific illicit drug among persons 35 to 49 years of age in the United States were estimated and compared. After adjustment for potential confounding factors, the results of 20 multivariate logistic regression models indicated positive associations between duration of marijuana use and anxiety, depression, sexually transmitted disease (STD), bronchitis, and lung cancer; between duration of cocaine use and anxiety and pancreatitis; between duration of heroin use and anxiety, hepatitis, and tuberculosis; between duration of hallucinogen use and tinnitus and STD; and between duration of inhalant use and anxiety, depression, HIV/AIDS, STD, tuberculosis, bronchitis, asthma, sinusitis, and tinnitus.

CONCLUSIONS

This study provides initial analyses on the relationships between illicit drug use and health conditions based on a large nationally representative sample. These results can help prepare for treating health problems among former and continuing illicit drug users.

Influence of cocaine on ruptured intracranial aneurysms: a case control study of poor prognostic indicators

Object

The purpose of this study was to determine whether cocaine use is a significant prognostic factor for outcome measures such as Hunt and Hess grade and Glasgow Outcome Scale (GOS) score among patients presenting with ruptured intracranial aneurysms (IAs).

Methods

The authors performed a MEDLINE/PubMed search for cases of ruptured IAs associated with cocaine use. Fourteen cases from the authors' experience were combined with 50 from a literature review, for a total of 64 cases associated with cocaine use. These 64 cases were compared with 65 cases without cocaine use (controls), which had been obtained from an aneurysm database. Logistic regression analysis was performed to determine significant prognostic factors for a poor Hunt and Hess grade and a poor GOS score, and a general linear model was applied to identify significant factors for these measures among cocaine users.

Results

There were 40 women in each group. The mean age was 32.3 ± 8.1 years in the cocaine group and 49.7 ± 10.6 years in the control group; thus, patients in the cocaine group were significantly younger (p < 0.01). Cocaine was snorted in 21% of cases, smoked in 55%, and intravenously injected or taken in through a combination of routes in 24%. Fifty-one percent of cocaine users and 7.7% of nonusers presented with a poor GOS score (p < 0.01). Fifty-six percent had ictus during cocaine abuse. At the end of a 30-day follow-up, 51% of the patients in the cocaine group had a good GOS score compared with 92% in the control group (p < 0.01). Controlling for the effects of other significant factors, cocaine use had a significant effect on Hunt and Hess grade (p < 0.03) and GOS score (p < 0.01). The odds of having a poor Hunt and Hess grade among cocaine users were 4.2 times greater than those in nonusers, and the odds of having a poor GOS score among cocaine users were 38.8 times greater.

Conclusions

Aneurysms were significantly smaller and ruptured at a younger age among cocaine users compared with nonusers. Although the poor clinical grade was not significantly different between the 2 groups, outcome was significantly worse in cocaine users.

Cocaine and thrombosis: a narrative systematic review of clinical and in-vivo studies

Purpose

To systematically review the literature pertaining to the link between cocaine and either arterial or venous thrombosis.

Procedures

Narrative systematic review of Medline, CINAHL, Embase, Psycinfo and Cochrane databases supplemented by hand trawling of relevant journals and reference lists up to April 2007. In-vivo studies and those with clinical endpoints were included in the review.

Results

A total of 2458 abstracts led to 186 full-text papers being retrieved. 15 met the criteria for inclusion in the review. The weight of evidence would support cocaine as a pro-thrombotic agent. There is evidence of it activating thrombotic pathways. The effect of cocaine upon clinical endpoints has not been quantified though there is evidence of an association between cocaine and myocardial infarction particularly amongst young adults. Cocaine may also be a causal agent in cerebrovascular accident though studies lacked sufficient power to determine a statistically significant effect. There is a gap in the evidence pertaining to the issue of cocaine and venous thrombosis.

Conclusion

Clinicians should consider questioning for cocaine use particularly amongst young adults who present with cardiac symptoms. More epidemiological work is required to quantify the effect of cocaine upon both arterial and venous clotting mechanisms.

Les complications cardiovasculaires aiguës de la cocaïne. À propos de deux observations

Concerning any socioprofessional category, some addictive drugs like cocaine are responsible for many complications. The authors relate two case reports of young patients who suffered from cardiovascular accidents due to this drug. The first one was diagnosed with an ischemic stroke caused by carotid artery dissection and a leg distal vascular obliteration, the second one with a myocardial infarction with transient left ventricular dysfunction. Through these two case reports, the authors take stock of the pathophysiological and therapeutic knowledge of cardiovascular accidents after cocaine intake.

Neuroimaging in drug and substance abuse part I: cocaine, cannabis, and ecstasy

Multiple neurological complications of cocaine abuse have been described including both ischemic and hemorrhagic cerebrovascular events, atrophy in the case of chronic abuse, and an increase in incidence of congenital malformations in the setting of maternal use. The abuse of cannabis may cause a number of neurovascular changes that, in turn, may result in ischemic events, however, a direct connection between these has not been fully established. The use of MDMA (ecstasy), a popular recreational drug, has been related to ischemic and hemorrhagic cerebrovascular events, as well as atrophy. Neuroimaging studies are vital in the assessment of the extent of neurologic damage in these patients.

Absence of acute cerebral vasoconstriction after cocaine-associated subarachnoid hemorrhage

INTRODUCTION

Cocaine use has been associated with neurovascular complications, including arterial vasoconstriction and vasculitis. However, there are few studies of angiographic effects of cocaine on human cerebral arteries. Information on these effects could be obtained from angiograms of patients with cocaine-associated subarachnoid hemorrhage (SAH) who underwent angiography shortly after cocaine use.

METHODS

We screened patients with SAH retrospectively and identified those with positive urine toxicology for cocaine or its metabolites. Quantitative arterial diameter measurements from angiograms of these patients were compared to measurements from control patients with SAH who were matched for factors known to influence arterial diameter. Qualitative comparisons of small artery changes also were made.

RESULTS

Thirteen patients with positive cocaine toxicology were compared to 26 controls. There were no significant differences between groups in the mean diameters of the intradural internal carotid, sphenoidal segment of the middle cerebral, precommunicating segment of the anterior cerebral, or basilar arteries (p greater than 0.05 for all comparisons, unpaired t-tests). There also were no significant differences between groups when expressing diameters as the sum of the precommunicating segment of the anterior cerebral + sphenoidal segment of the middle cerebral + supraclinoid internal carotid artery + basilar artery divided by the diameter of the petrous internal carotid artery (p greater than 0.05, unpaired t-tests). Qualitative assessments showed two arterial irregularities in the distal vasculature in each group.

CONCLUSION

No quantitative evidence for narrowing of large cerebral arteries or qualitative angiographic evidence for distal narrowing or vasculitis could be found in patients who underwent angiography after aneurysmal SAH associated with cocaine use.

Endovascular Management of a Patient after SAH

Treatment of acute aneurysmal subarachnoid hemorrhages consists of occluding the aneurysm to prevent rebleed, attempting to prevent vasospasm, and maintaining blood flow to the brain through vessels in vasospasm. Endovascular treatment has been shown to be as safe as, or safer, than surgical clipping for patients with SAH. Engineering solutions to our clinical problems continue to improve endovascular outcomes. This article reviews the current state of endovascular therapy.

Non-traumatic cortical subarachnoid haemorrhage: diagnostic work-up and aetiological background

Only 15% of all subarachnoid haemorrhages (SAHs) are not of aneurysmal origin. Among those, circumscribed SAHs along the cortical convexity are rare and have only been described in singular case reports so far. Here, we present a collection of 12 cases of SAH along the convexity, of non-traumatic origin. Over a period of 10 years, 12 cases of circumscribed SAH along the convexity were identified at our clinic. The clinical presentations, neuroradiological SAH characteristics, further diagnostic work-up to identify the underlying aetiologies, the therapy and clinical outcome were analysed. The patients' chief complaints were unspecific cephalgia, focal or generalised seizures and focal neurological deficits. Typical signs of basal SAH, such as nuchal rigidity, thunderclap-headache or alteration of consciousness, were rare. Magnetic resonance imaging (MRI) and digital subtraction angiography (DSA) revealed different aetiologies, namely postpartal posterior encephalopathy (three), cerebral vasculitis (two), dural sinus thrombosis (two), cortical venous thrombosis (one), intracerebral abscesses (one) and cerebral cavernoma (one). Two cases remained unresolved. Treatment of the underlying disease and symptomatic medication led to good clinical outcome in almost all cases. On the basis of these findings, we demonstrate that the clinical presentation, localisation and aetiology of cortical SAH differ clearly from other SAHs. A diagnostic work-up with MRI and eventually DSA is essential. Mostly, the causative disease can be identified, and specific treatment allows a favourable outcome.

White matter hyperintensities in subjects with cocaine and opiate dependence and healthy comparison subjects

The prevalence, severity, and location of white matter signal hyperintensities (WMH) on brain magnetic resonance images were compared in patients with cocaine or opiate dependence and healthy subjects. Patients with cocaine (n=32) and opiate dependence (n=32), whose diagnoses were confirmed with the Structured Clinical Interview for DSM-IV, and age- and sex-matched healthy subjects (n=32) were scanned using a 1.5 T whole body GE magnetic resonance scanner. Axial proton-density and T2-weighted images were obtained as well as fluid-attenuated inversion recovery axial images. The severity of WMH was assessed separately for deep (and insular) and periventricular WMH, using a modified composite version of the rating scales of Fazekas and Coffey. The cocaine-dependent group had greater severity of WMH than the opiate-dependent group, which in turn had greater severity of WMH than the healthy comparison group (odds ratios=2.54 and 2.90, respectively). The cocaine-dependent group had greater lesion severity of deep and insular WMH than the opiate-dependent group and the healthy comparison group (odds ratio>3.25 for deep WMH; odds ratio>4.38 for insular WMH). For periventricular WMH, there were no significant differences between the three groups. The frontal lobes were the predominant locations of WMH in both substance-dependent groups. The greater prevalence and severity of WMH in cocaine-dependent subjects than in opiate-dependent subjects may reflect the fact that cocaine induces more ischemia via vasoconstriction than opiates. Also, there was a trend for lower WMH severity in substance-dependent women relative to the healthy comparison group, possibly due to estrogen's protective effect against cerebrovascular accidents.

Aspirin or amiloride for cerebral perfusion defects in cocaine dependence

Cocaine dependent (CD) patients have regional cerebral blood flow (rCBF) deficits that may be related to occlusion of blood vessels by vasoconstriction and abnormal platelet aggregation. This study determined whether aspirin, which reverses platelet aggregation, or amiloride, a vasodilator, significantly reversed this rCBF hypoperfusion. This 1-month randomized trial compared clusters of voxels with significant hypoperfusion in recently abstinent CD patients after aspirin (325 mg daily), amiloride (10 mg daily) or placebo treatment. Forty-nine primary CD patients and 18 non-drug abusing controls were compared using single photon emission computed tomography (SPECT) neuroimaging with 99mTc-hexamethyl-propyleneamine-oxime and statistical parametric mapping (SPM). Platelet aggregation to adenosine diphosphate (ADP) was examined after treatment to determine whether rCBF improvement was related to decreased platelet aggregation. Following treatment, areas of hypoperfusion were improved with amiloride, unchanged with aspirin, and worsened with placebo in comparison to baseline levels. Platelet aggregation after ADP showed no significant change during the month, but reduced rCBF significantly improved after 1-month treatment with amiloride compared with placebo and cocaine abstinence alone.

Major risk factors for aneurysmal subarachnoid hemorrhage in the young are modifiable

BACKGROUND AND PURPOSE

To identify risk factors for subarachnoid hemorrhage (SAH) and intracerebral hemorrhage, we designed a case-control study of men and women 18 to 49 years of age (the Hemorrhagic Stroke Project [HSP]). This report focuses on SAH.

METHODS

Patients were recruited from 44 hospitals in the United States. Cases with SAH must have had a ruptured aneurysm documented by angiography or surgery. Two controls, identified by random digit dialing and matched to each patient for age, sex, race, and telephone exchange, were sought for each case subject.

RESULTS

Between 1994 and 1999, 425 patients with SAH were enrolled in HSP, and 312 cases met the criteria for aneurysmal SAH. The present analyses also included 618 matched controls. Of the 312 cases, 66% were current cigarette smokers compared with 30% of controls (adjusted odds ratio [OR], 3.73; 95% CI, 2.67 to 5.21). Cocaine use within the previous 3-day period was reported by 3% of cases and no controls (bivariate exact OR, 24.97; 95% exact CI, 3.95 to infinity; adjusted estimate not calculable). Other independent risk factors in the multivariable model included hypertension (adjusted OR, 2.21; 95% CI, 1.48 to 3.29), low body mass index (OR, 1.59; 95% CI, 1.08 to 2.35), primary family history of hemorrhagic stroke (OR, 3.83; 95% CI, 1.73 to 8.46), caffeine in pharmaceutical products (OR, 2.48; 95% CI, 1.19 to 5.20), lower educational achievement (OR, 2.36; 95% CI, 1.44 to 3.87), and nicotine in pharmaceutical products (adjusted estimate not calculable).

CONCLUSIONS

Aneurysmal SAH may be largely a preventable disease among the young and middle-aged because several prevalent risk factors can be modified by medication (eg, hypertension) or behavioral change (eg, cigarette smoking, cocaine use). The association of caffeine and nicotine in pharmaceutical products and aneurysmal SAH warrants further study.

The neuropathology of cocaine abuse

Cocaine abuse represents a worldwide significant forensic issue as it is becoming widely recognized as one of the most dangerous illicit drugs in common use today. Besides cardiovascular complications, psychiatric and neurologic symptoms are the most common manifestations of cocaine toxicity. The latter include seizures, movement disorders and cerebrovascular complications. In chronic cocaine abusers morphological, physiological, and neurochemical abnormalities have been demonstrated by using neuroradiological techniques such as computed tomography, magnetic resonance imaging, positron emission tomography or single photon emission computed tomography. The spectrum of neuropathologic changes encountered in the brains of cocaine abusers is broad, but the major findings consist of ischemic and hemorrhagic stroke, subarachnoid and intracerebral hemorrhages and cerebral ischemia. Especially persons with underlying arteriovenous malformation or aneurysm are at risk for such events. Except for a few instances of vasculitis, the etiology of cocaine-related cerebrovascular accidents is still unclear. Besides pharmacologically-induced vasospasm, impaired hemostasis and platelet function and decreased cerebral blood flow have been proposed. At the cellular level, abnormalities in the expression of transcription factors and changes of brain neurotransmitter systems have been reported.

Diagnostic imaging for intracerebral hemorrhage

Magnetic resonance imaging (MRI) is an excellent tool for the diagnosis and evaluation of intracerebral hemorrhage with its unique specificity to hemoglobin degradation products in different stages. Computed tomography (CT) remains the diagnostic test of choice in the setting of acute intracerebral hemorrhage because of its exquisite sensitivity and specificity for small amounts of intracerebral hemorrhage (although there is emerging evidence that MRI may be as sensitive as CT). The effects of the biochemical evolution of intracerebral hemorrhage on the temporal MRI signal changes are described. This article discusses imaging features of the common causes of intracerebral hemorrhage.