A case of aortic dissection in a cocaine abuser: a case report and review of literature

An Uncommon Presentation of Acute Thoracic Aortic Dissection

We present a case of a 40-year-old Caucasian male with past medical history of polysubstance abuse (cocaine and methamphetamine), who presented to the emergency department (ED) complaining of intermittent cough with associated chest discomfort and shortness of breath for 2 weeks. Initial vital signs demonstrated borderline tachycardia (98 beats per minute), tachypnea (37 times per minutes), and hypoxia (oxygen saturation 89% on room air), and his physical exam was grossly unremarkable. A preliminary workup including a computed tomography angiography (CTA) revealed a type A aortic dissection with both thoracic and abdominal involvement for which the patient was admitted. This patient had resection of the ascending aorta with graft placement, cardiopulmonary bypass, aortic root replacement using composite prosthesis and left and right coronary reconstruction and reimplantation and survived a complicated hospital course. This case demonstrates the classic association known to exist between recreational drug use, specifically stimulants such as cocaine and amphetamines, and acute aortic dissection (AAD). However, such a presentation of borderline subacute, painless dissection in the setting of polysubstance use raises further questions, since uncommon AAD is typically found in higher-risk populations such as those with connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome), bicuspid aortic valve, chronic hypertension, or previous aortic pathology. We therefore suggest clinicians strongly consider uncommon AAD as part of their differential diagnosis in patients with known or highly suspected polysubstance abuse.

Internal carotid artery redundancy and dissection in a young cocaine abuser

Carotid artery redundancies are common findings on routine imaging studies and are usually considered to be benign variants. We present a case of a 40-year-old man, with a history of cocaine abuse, who was diagnosed with dissection of the right internal carotid artery and looping of the bilateral internal carotid arteries. This report attempts to highlight the possible association between carotid artery redundancy and dissection, especially in the context of vascular injury such as cocaine abuse, as in our case.

Cocaine mediated apoptosis of vascular cells as a mechanism for carotid artery dissection leading to ischemic stroke

In arterial dissection, blood may enter the arterial wall through an intimal tear, splitting the arterial wall and activating the coagulation cascade at the site of endothelial damage. Dissection of extracranial and intracranial vessels may lead to ischemic stroke through thromboembolic or hemodynamic mechanisms. Major blunt trauma or rapid acceleration-deceleration may cause dissection, but in patients with inherent arterial wall weakness, dissection can occur spontaneously or as a result of minor neck movement. Cocaine use has been associated with dissection of the aortic arch and coronary and renal arteries through cocaine-mediated hypertension. Recent preclinical studies have suggested, however, that cocaine may cause apoptosis of cells in the vascular wall. In this article, we postulate that cocaine may cause apoptosis of vascular endothelial and/or smooth muscle cells, thus weakening the vascular wall and resulting in a dissection-prone state. We review the literature and propose a biological basis for vasculopathy, vascular dissection, and ischemic stroke in the setting of cocaine use. Further research studies on vascular cells, as well as focused analysis of human pathological material, will be important in providing evidence for or against our hypotheses.

Spontaneous arterial dissection: phenotype and molecular pathogenesis

Arterial dissection (AD) is defined as the longitudinal splitting up of the arterial wall caused by intramural bleeding. It can occur as a spontaneous event in all large and medium sized arteries. The histological hallmark of AD is medial degeneration. Histological investigations, gene expression profiling and proteome studies of affected arteries reveal disturbances in many different biological processes including inflammation, proteolytic activity, cell proliferation, apoptosis and smooth muscle cell (SMC) contractile function. Medial degeneration can be caused by various rare dominant Mendelian disorders. Genetic linkage analysis lead to the identification of mutations in different disease-causing genes involved in the biosynthesis of the extracellular matrix (FBN1, COL3A1), in transforming growth factor (TGF) beta signaling (FBN1, TGFBR1, TGFBR2) and in the SMC contractile system (ACTA2, MYH11). Genome wide association studies suggest that the CDKN2A/CDKN2B locus plays a role in the etiology AD and other arterial diseases.

Cocaine and aortic dissection

Aortic dissection is a rare, potentially catastrophic vascular emergency. Early recognition of the clinical manifestations, rapid confirmation using imaging modalities, urgent administration of appropriate medication and expedient selection of definitive long-term therapy are key to preserving life and reducing morbidity. In recent years it has become increasingly clear that there is a relation between cocaine and aortic dissection. Cocaine serves as both a predisposing factor to aortic dissection due to its effect on aortic connective tissue and as a precipitating factor due to its propensity to produce abrupt and severe hypertension. While similarities exist in the clinical features and diagnostic methods between cocaine-related aortic dissection and aortic dissection unrelated to cocaine use, there are important differences in management between these two syndromes which are rooted in the pharmacology and physiology of cocaine. An understanding of these differences is key to effective early and long-term management of cocaine-related aortic dissection.

Constitution and properties of axonal membranes of crustacean nerves

The purification of axonal membranes of crustaceans was followed by measuring enrichment in [3H]tetrodotoxin binding capacity and in Na+, K+-ATPase activity. A characteristic of these membranes is their high content of lipids and their low content of protein as compared to other types of plasmatic membranes. The axonal membrane contains myosin-like, actin-like, tropomyosin-like, and tubulin-like proteins. It also contains Na+, K+-ATPase and acetylcholinesterase. The molecular weights of these two enzymes after solubilization are 280,000 and 270,000, respectively. The molecular weights of the catalytic subunits are 96,000 for ATPase and 71,000 for acetylcholinesterase. We confirmed the presence of a nicotine binding component in the axonal membrane of the lobster but we have been unable to find [3H]nicotine binding to crab axonal membranes. The binding to axonal membranes og of the sodium channel, has been studied in detail. The dissociation constant for the binding of [3H]tetrodotoxin to the axonal membrane receptor is 2.9 nM at pH 7.4. The concentration of the tetrodotoxin receptor in crustacean membranes is about 10 pmol/mg of membrane protein, 7 times less than the acetylcholinesterase, 30 times less than the Na+, K+-ATPase, and 30 times less than the nicotine binding component in the lobster membrane. A reasonable estimate indicates that approximately only one peptide chain in 1000 constitutes the tetrodotoxin binding part of the sodium channel in the axonal membrane. Veratridine, which acts selectively on the resting sodium permeability, binds to the phospholipid part of the axonal membrane. [3H]Veratridine binding to membranes parallels the electrophysiological effect. Veratridine and tetrodotoxin have different receptor sites. Although tetrodotoxin can repolarize the excitable membrane of a giant axon depolarized by veratridine, veratridine does not affect the binding of [3H]tetrodotoxin to purified axonal membranes. Similarly, tetrodotoxin does not affect the binding of [3H]veratridine to axonal membranes. Scorpion neurotoxin I, a presynaptic toxin which affects both the Na+ and the K+ channels, does not interfere with the binding of [3H]tetrodotoxin or [3H]veratridine to axonal membranes. Tetrodotoxin, veratridine, and scorpion neurotoxin I, which have in common the perturbation of the normal functioning of the sodium channel, act upon three different types of receptor sites.