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Bögli SY, Capone C, Baumgartner MR, Quednow BB, Kraemer T, Keller E, Binz TM. Delirium in Neurocritical Care: Uncovering Undisclosed Psychotropic Substance and Medication Use and Stress Exposure by Hair Analysis. Neurocrit Care 2024:10.1007/s12028-024-02052-9. [PMID: 39009940 DOI: 10.1007/s12028-024-02052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/14/2024] [Indexed: 07/17/2024]
Abstract
OBJECTIVE In intensive care, delirium is frequent, prolongs the stay, increases health care costs, and worsens patient outcome. Several substances and medications as well as stress can impact the risk of delirium; however, assessment of previous exposure to psychotropic agents and stress by self-reports or third-party information is not always reliable. Hair analysis can be used to objectively assess medication and substance use (including chronic alcohol consumption), and allows for the determination of stress-related long-term changes in steroid hormones and endocannabinoids. METHODS Consecutive adult patients with acute brain injury admitted to the neurocritical care unit were included. Delirium was diagnosed using the Confusion Assessment Method for the Intensive Care Unit. Liquid chromatography coupled with tandem mass spectrometry was used to investigate psychoactive substances and medications, ethyl glucuronide, steroid hormones, and endocannabinoids in hair samples. Univariable and multivariable analyses were used to reveal any associations with the occurrence of delirium. RESULTS Of 50 consecutive patients, 21 (42%) were diagnosed with delirium. Detection of antipsychotics or antidepressants in hair was more frequent in patients with delirium (antidepressants: 43% vs. 14%, p = 0.040; antipsychotics: 29% vs. 0%, p = 0.021). These patients also displayed higher ethyl glucuronide levels (p = 0.049). Anandamide (AEA) concentrations were higher in patients with delirium (p = 0.005), whereas oleoylethanolamide (p = 0.045) and palmitoylethanolamide (PEA) (p = 0.017) concentrations were lower in patients with delirium. Backward stepwise logistic regression analysis revealed antidepressants and AEA/PEA to be independent relevant predictors of delirium. CONCLUSIONS Hair analysis provides crucial and otherwise unattainable information regarding chronic stress and the use of psychotropic substances and medications. Undisclosed antidepressant/antipsychotic use or intense chronic alcohol consumption is susceptible to treatment (continuation of medication or provision of low-dose benzodiazepines in case of alcohol). Chronic stress can be evaluated using stress markers and endocannabinoids in hair, potentially allowing for personalized delirium risk stratification and preventive measures.
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Affiliation(s)
- Stefan Yu Bögli
- Neurocritical Care Unit, Institute for Intensive Care Medicine and Department of Neurosurgery, University Hospital Zurich, University Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University Zurich, Frauenklinikstrasse 26, 8091, Zurich, Switzerland.
| | - Crescenzo Capone
- Neurocritical Care Unit, Institute for Intensive Care Medicine and Department of Neurosurgery, University Hospital Zurich, University Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Markus R Baumgartner
- Center for Forensic Hair Analytics, Zurich Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Boris B Quednow
- Experimental and Clinical Pharmacopsychology, Department of Adult Psychiatry and Psychotherapy, Psychiatric University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Thomas Kraemer
- Department of Forensic Pharmacology and Toxicology, Zurich Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Emanuela Keller
- Neurocritical Care Unit, Institute for Intensive Care Medicine and Department of Neurosurgery, University Hospital Zurich, University Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Tina Maria Binz
- Center for Forensic Hair Analytics, Zurich Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
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Banimostafavi ES, Taheri A, Malakian A, Zakariaei Z. Massive intracerebral hemorrhage following methamphetamine poisoning in a man: A case report. Int J Surg Case Rep 2024; 117:109489. [PMID: 38520890 PMCID: PMC10973807 DOI: 10.1016/j.ijscr.2024.109489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/27/2024] [Accepted: 03/06/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Methamphetamine (MAP) is a highly addictive stimulant known to have detrimental effects on the brain and various physiological systems, including an elevation in heart rate and blood pressure. Additionally, MAP use has been linked to the development of intracerebral hemorrhage (ICH), a serious and potentially fatal condition that is notably prevalent among young individuals. CASE PRESENTATION We present the case of a 42-year-old man who suffered a massive ICH due to hypertension resulting from MAP poisoning. The patient presented with symptoms of nausea, vomiting, and blurred vision for around two hours following the accidental inhalation of MAP. However, his condition was significantly improved through the implementation of neurosurgical intervention. CLINICAL DISCUSSION In recent years, the misuse of MAP among young adults has raised concerns about its association with ICH. ICH is a type of stroke where a blood vessel in the brain ruptures due to high blood pressure, causing bleeding. This medical emergency can lead to various symptoms, such as severe headaches, loss of consciousness, and paralysis. ICH is indeed a serious and life-threatening condition that necessitates prompt medical attention. It can also lead to long-term adverse effects for the individual affected. CONCLUSIONS The association with ICH and MAP abuse among young adults is a substantial public health issue. To gain a comprehensive understanding of the mechanisms underlying MAP abuse-induced elevation of ICH risk, further exploration is necessary.
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Affiliation(s)
- Elham Sadat Banimostafavi
- Department of Radiology, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Amirmasoud Taheri
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Abdollah Malakian
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zakaria Zakariaei
- Toxicology and Forensic Medicine Division, Mazandaran Registry Center for Opioids Poisoning, Orthopedic Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran.
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Vitt JR, Cheng RC, Chung J, Canton MT, Zhou B, Ko N, Meisel K, Amorim E. The Clinical Impact of Recent Methamphetamine Exposure in Aneurysmal Subarachnoid Patients. RESEARCH SQUARE 2023:rs.3.rs-2694424. [PMID: 37034745 PMCID: PMC10081452 DOI: 10.21203/rs.3.rs-2694424/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Background Methamphetamines (MA) are a frequently used drug class with potent sympathomimetic properties that can affect cerebral vasculature. Conflicting reports in literature exist about the effect of exposure to MA on vasospasm risk and clinical outcomes in aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to characterize the impact of recent MA use on the timing, severity and features of vasospasm in aneurysmal subarachnoid as well as neurological outcomes. Methods We retrospectively screened 441 consecutive patients admitted to a tertiary care hospital with a diagnosis of SAH who underwent at least one cerebral digital subtraction angiogram (DSA). Patients were excluded if no urinary toxicology screen was performed within 24 hours of admission, if there was a diagnosis of non-aneurysmal SAH, or if ictus was greater than 72 hours from hospital admission. Vasospasm characteristics were collected from DSA and transcranial doppler (TCD) studies and demographic as well as clinical outcome data was abstracted from the chart. Results 129 patients were included and 24 tested positive for MA. Among the 312 excluded patients, 281 did not have a urinary toxicology screen and 31 had a non-aneurysmal pattern of SAH or ictus occurring greater than 72 hours from hospital admission. No significant differences were found in respect to patient age, sex, or admission Hunt and Hess Score or Modified Fisher Scale based on MA use. There was no difference in the severity of vasospasm or time to peak severity using either TCD or DSA criteria on multivariate analysis. Aneurysms were more likely to be in the anterior circulation for both groups, however the MA cohort experienced less vasospasm involving the anterior circulation and more isolated posterior circulation vasospasm. There was no difference in delayed cerebral ischemia (DCI) incidence, length of ICU stay, need for ventriculoperitoneal shunt placement, functional outcome at discharge or hospital mortality. Interpretation Recent MA use was not associated with worse vasospasm severity, time to vasospasm, or DCI in aSAH patients. Further investigations about localized MA effects in the posterior circulation and impact on long-term functional outcomes are warranted.
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Affiliation(s)
| | | | - Jason Chung
- University of California San Francisco Department of Neurological Surgery
| | | | - Bo Zhou
- University of California San Francisco Weill Institute for Neurosciences
| | - Nerissa Ko
- University of California San Francisco Weill Institute for Neurosciences
| | - Karl Meisel
- University of California San Francisco Weill Institute for Neurosciences
| | - Ediberto Amorim
- University of California San Francisco Weill Institute for Neurosciences
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Kumar A, Choudhary N, Prabhakar A, Bhatia V. Delayed collapse of flow diverter due to acute severe vasospasm: another concern for flow diversion in ruptured aneurysms. J Neurointerv Surg 2023; 15:176-177. [PMID: 35701107 DOI: 10.1136/neurintsurg-2022-018984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/05/2022] [Indexed: 01/14/2023]
Abstract
In vivo morphological change of flow diverter stents (FDS) is a known phenomenon and can be seen secondary to various device- and vasculature-related factors such as improper sizing of the device, twisting of the device in tortuous anatomy, insufficient proximal landing zone, and insufficient chronic resistive force of the stent, etc. However, we have encountered a case where severe vasospasm due to aneurysmal subarachnoid hemorrhage led to the collapse of the proximal end of the FDS. Development of vasospasm and consequent possible failure of the device should be taken into consideration when planning flow diversion in ruptured aneurysms.
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Affiliation(s)
- Ajay Kumar
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Neha Choudhary
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anuj Prabhakar
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Bhatia
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Chalet FX, Briasoulis O, Manalastas EJ, Talbot DA, Thompson JC, Macdonald RL. Clinical Burden of Angiographic Vasospasm and Its Complications After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review. Neurol Ther 2023; 12:371-390. [PMID: 36609962 PMCID: PMC10043150 DOI: 10.1007/s40120-022-00436-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/22/2022] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Angiographic vasospasm (VSP), the narrowing of intracranial arteries, is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and often results in delayed cerebral ischemia (DCI) and cerebral infarction. The objective of this systematic review was to summarize the clinical burden of angiographic VSP and its related complications (DCI and cerebral infarction) after aSAH. METHODS Systematic searches of MEDLINE, Embase, and the Cochrane Library were conducted (in January 2021) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies reporting clinical outcomes of angiographic VSP and its related complications after aSAH. Study outcomes included measures of functional status (modified Rankin Scale [mRS], Glasgow Outcome Scale [GOS], extended Glasgow Outcome Scale [GOS-E], modified Barthel Index, or the modified National Institutes of Health Stroke Scale), cognitive status (Montreal Cognitive Assessment or the Mini Mental State Exam), clinical events (rebleeding), and mortality. Study selection, data extraction, and qualitative analyses were conducted. RESULTS Of 5704 abstracts reviewed, 110 studies were selected: 20 comparative and 39 regression-based studies were included in the qualitative synthesis, 51 descriptive studies were excluded. Most studies (51) were observational and conducted in a single country (53). The occurrence of angiographic VSP and its related complications after aSAH resulted in significantly poorer functional outcomes in three of nine comparative and 11 of 13 regression-based studies, measured by the mRS, and in five of six comparative and eight of nine regression-based studies, measured by the GOS and GOS-E. Angiographic VSP and its related complications were significantly associated with poor cognitive status in all five regression-based studies. Numerically or significantly higher mortality rates in patients with versus those without angiographic VSP and its related complications were reported in five of ten comparative studies and in eight of nine regression-based studies. Six studies looked at specific VSP populations (e.g., by severity or timing of VSP). CONCLUSION Patients with angiographic VSP and its related complications often had poor functional, neurological, and cognitive outcomes and reduced odds of survival both in hospital and at follow-up. We estimate that angiographic VSP and its related complications, DCI and cerebral infarction, lead to an approximately threefold higher odds of poor functional and cognitive outcomes, and about a twofold increase in the odds of death.
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Affiliation(s)
| | - Orestis Briasoulis
- Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | | | - Darren A Talbot
- Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | | | - R Loch Macdonald
- Community Health Partners, Community Neurosciences Institute, Fresno, CA, 93701, USA
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Dabhi N, Mastorakos P, Sokolowski JD, Kellogg RT, Park MS. Effect of drug use in the treatment of acute ischemic stroke: A scoping review. Surg Neurol Int 2022; 13:367. [PMID: 36128166 PMCID: PMC9479649 DOI: 10.25259/sni_561_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/27/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Drugs of abuse have been associated with ischemic stroke; however, the clinical presentation, outcomes, and treatment data in this population are limited. The overall safety and efficacy of thrombolytic therapy and thrombectomy in these patients remain unclear. This scoping review summarizes published complications and clinical outcomes in patients with recent abuse of cocaine, methamphetamine (MA), cannabis, decongestant, opioids, alcohol, and 3,4-methylenedioxymethamphetamine (MDMA) presenting with acute ischemic stroke.
Methods:
We conducted a scoping review of the primary literature that assessed outcomes data of thrombolytic therapy or thrombectomy in drug users with acute ischemic stroke. We searched PubMed, Ovid Medline, and Web of Science. Demographic and stroke characteristics, treatment, complications, and clinical outcomes at last follow-up were collected and summarized.
Results:
We identified 51 studies in this review. Drugs of abuse of interest were cocaine (14 studies), MDMA (one study), MA (eight studies), cannabis (23 studies), alcohol (two studies), decongestants (one study), and opioids (two studies). Clinical presentation and stroke presentation were most commonly described features. Thrombectomy outcomes were reported for four patients total (two studies), all with history of cocaine use. Thrombolysis treatment and outcomes were reported for 8851 patients (five studies) with history of cocaine, alcohol, or cannabis. Both treatments were pursued in three patients (three studies). Treatment complications included intracerebral hemorrhage, vasospasm, and cerebral edema.
Conclusion:
Evidence for thrombolytic and thrombectomy treatment in drug users remains limited. Controlled studies are needed to examine complication profile and outcomes following thrombolytic and thrombectomy treatment in this population.
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Haddad YW, Korcari E, Polsinelli GN, Yuchuan D. The effect of cocaine and methamphetamine on saccular aneurysm formation and rupture: A literature review. BRAIN HEMORRHAGES 2021. [DOI: 10.1016/j.hest.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Lappin JM, Darke S. Methamphetamine and heightened risk for early-onset stroke and Parkinson's disease: A review. Exp Neurol 2021; 343:113793. [PMID: 34166684 DOI: 10.1016/j.expneurol.2021.113793] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/09/2021] [Accepted: 06/19/2021] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Methamphetamine users are typically young adults, placing them at risk for significant drug-related harms. Neurological harms include stroke and Parkinson's disease, both of which may develop prematurely in the context of methamphetamine use. MATERIAL AND METHODS We conducted a narrative review examining the evidence first, for stroke under 45 years and second, early onset of Parkinson's disease (PD) and parkinsonism related to methamphetamine use. We summarise epidemiological factors and common clinical features, before examining in detail the underlying pathology and causal mechanisms. RESULTS AND DISCUSSION Methamphetamine use among young people (<45 years) is associated with heightened risk for haemorrhagic stroke. Compared to age-matched all-cause fatal stroke, haemorrhage secondary to aneurysmal rupture is more common among young people with methamphetamine-related stroke and is associated with significantly poorer prognosis. Aetiology is related primarily to both acute and chronic hypertension associated with methamphetamine's sympathomimetic action. Evidence from a variety of sources supports a link between methamphetamine use and increased risk for the development of PD and parkinsonism, and with their early onset in a subset of individuals. Despite this, direct evidence of degeneration of dopaminergic neurons in methamphetamine users has not been demonstrated to date. CONCLUSIONS Stroke and Parkinson's Disease/parkinsonism are neurological harms observed prematurely in methamphetamine users.
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Affiliation(s)
- Julia M Lappin
- National Drug & Alcohol Research Centre, University of New South Wales, NSW, Australia; School of Psychiatry, University of New South Wales, NSW, Australia.
| | - Shane Darke
- National Drug & Alcohol Research Centre, University of New South Wales, NSW, Australia
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Blum K, Cadet JL, Gold MS. Psychostimulant use disorder emphasizing methamphetamine and the opioid -dopamine connection: Digging out of a hypodopaminergic ditch. J Neurol Sci 2021; 420:117252. [PMID: 33279726 DOI: 10.1016/j.jns.2020.117252] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Approved food and drug administration (FDA) medications to treat Psychostimulant Use Disorder (PUD) are needed. Both acute and chronic neurological deficits related to the neurophysiological effects of these powerfully addictive drugs can cause stroke and alterations in mood and cognition. OBJECTIVE This article presents a brief review of the psychiatric and neurobiological sequelae of methamphetamine use disorder, some known neurogenetic associations impacted by psychostimulants, and explores treatment modalities and outcomes. HYPOTHESIS The authors propose that gentle D2 receptor stimulation accomplished via some treatment modalities can induce dopamine release, causing alteration of D2-directed mRNA and thus enhanced function of D2 receptors in the human. This proliferation of D2 receptors, in turn, will induce the attenuation of craving behavior, especially in genetically compromised high-risk populations. DISCUSSION A better understanding of the involvement of molecular neurogenetic opioid, mesolimbic dopamine, and psychostimulant connections in "wanting" supports this hypothesis. While both scientific and, clinical professionals search for an FDA approved treatment for PUD the induction of dopamine homeostasis, via activation of the brain reward circuitry, offers treatment for underlying neurotransmitter functional deficits, potential prophylaxis, and support for recovery efforts. CONCLUSION Dopamine regulation may help people dig out of their hypodopaminergia ditch.
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Affiliation(s)
- Kenneth Blum
- Graduate College, Western University Health Sciences, Pomona, CA, Baltimore, MD, United States of America.
| | - Jean Lud Cadet
- Molecular Neuropsychiatry Research Branch, NIH National Institute on Drug Abuse, United States of America
| | - Mark S Gold
- Department of Psychiatry, Washington University, St Louis, MO, United States of America.
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Noblett D, Hacein-Bey L, Waldau B, Ziegler J, Dahlin B, Chang J. Increased rupture risk in small intracranial aneurysms associated with methamphetamine use. Interv Neuroradiol 2020; 27:75-80. [PMID: 32967503 DOI: 10.1177/1591019920959534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) is the most common cause of nontraumatic SAH. Current guidelines generally recommend observation for unruptured intracranial aneurysms smaller than 7 mm, for those are considered at low risk for spontaneous rupture according to available scoring systems. OBJECTIVE We observed a tendency for SAH in small intracranial aneurysms in patients who are methamphetamine users. A retrospective, single center study to characterize the size and location of ruptured and unruptured intracranial aneurysms in methamphetamine users was performed. MATERIALS AND METHODS Clinical characteristics and patient data were collected via retrospective chart review of patients with intracranial aneurysms and a history of methamphetamine use with a specific focus on aneurysm size and location. RESULTS A total of 62 patients were identified with at least one intracranial aneurysm and a history of methamphetamine use, yielding 73 intracranial aneurysms (n = 73). The mean largest diameter of unruptured aneurysms (n = 44) was 5.1 mm (median 4.5, SD 2.5 mm), smaller than for ruptured aneurysms (n = 29) with a mean diameter of 6.3 mm (median 5.5, SD 2.5 mm). Aneurysms measuring less than 7 mm presented with SAH in 36.5%. With regard to location, 28% (n = 42) of anterior circulation aneurysms less than 7 mm presented with rupture, in contrast to 70% (n = 10) of posterior circulation aneurysms which were found to be ruptured. CONCLUSIONS Methamphetamine use may be considered a significant risk factor for aneurysmal SAH at a smaller aneurysm size than for other patients. These patients may benefit from a lower threshold for intervention and/or aggressive imaging and clinical follow-up.
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Affiliation(s)
- Dylan Noblett
- Department of Radiology, University of California Davis, Sacramento, CA, USA
| | - Lotfi Hacein-Bey
- Department of Radiology, University of California Davis, Sacramento, CA, USA
| | - Ben Waldau
- Department of Neurological Surgery, University of California Davis, Sacramento, CA, USA
| | - Jordan Ziegler
- Department of Radiology, University of California Davis, Sacramento, CA, USA
| | - Brian Dahlin
- Department of Radiology, University of California Davis, Sacramento, CA, USA
| | - Jennifer Chang
- Department of Radiology, University of California Davis, Sacramento, CA, USA
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Yoshida M, Makino Y, Hoshioka Y, Chiba F, Inokuchi G, Torimitsu S, Yamaguchi R, Motomura A, Abe H, Yajima D, Iwase H. Fatal hemorrhage complicated with methamphetamine poisoning and its post-mortem CT features. Forensic Sci Med Pathol 2020; 16:577-585. [PMID: 32852692 DOI: 10.1007/s12024-020-00294-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2020] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to assess the incidence of fatal hemorrhage complicated with methamphetamine (MA) poisoning and to examine the postmortem computed tomography (PMCT) features of fatal intracerebral hemorrhage (ICH) with and without MA poisoning. The study also attempted to determine the differences in PMCT between those two groups. Consecutive medicolegal autopsy data from November 2011 to February 2018 were searched for 3044 cases. First, the incidence and distribution of all cases of nontraumatic fatal hemorrhage with various causes were examined. Second, cases of ICH on the basal ganglia and brain stem were extracted. The PMCT findings were compared with respect to nine parameters: volume of hematoma, ventricular perforation, midline shift distance, aortic calcification, calcification of aortic valve, calcification of coronary artery, cardiothoracic ratio, circumference of ascending aorta, and volume of bladder contents. Of the 3044 cases, 97 were nontraumatic fatal hemorrhage; of these 97 cases, 20 were classified as MA poisoning with 9 ICH cases, and 60 cases were classified as non-MA poisoning with 14 ICH cases. A statistically significant difference in ages was observed between the two groups. On PMCT comparison of ICH, statistically significant differences were evident in the midline shift distance and calcification of the aortic valve. Forensic radiologists should be aware of the possibility of ICH with MA poisoning if fatal hemorrhage is detected on PMCT. Younger age, less calcification of the aortic valve, and a remarkable midline shift may be the keys to recognition.
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Affiliation(s)
- Maiko Yoshida
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba Prefecture, Japan.
| | - Yohsuke Makino
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba Prefecture, Japan.,Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Yumi Hoshioka
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba Prefecture, Japan
| | - Fumiko Chiba
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba Prefecture, Japan.,Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Go Inokuchi
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba Prefecture, Japan
| | - Suguru Torimitsu
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba Prefecture, Japan.,Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Rutsuko Yamaguchi
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba Prefecture, Japan
| | - Ayumi Motomura
- Department of Legal Medicine, International University of Health and Welfare, 4-3, Kozunomori, Narita, Chiba Prefecture, Japan
| | - Hiroko Abe
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba Prefecture, Japan
| | - Daisuke Yajima
- Department of Legal Medicine, International University of Health and Welfare, 4-3, Kozunomori, Narita, Chiba Prefecture, Japan
| | - Hirotaro Iwase
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba Prefecture, Japan.,Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan
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12
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Swor DE, Maas MB, Walia SS, Bissig DP, Liotta EM, Naidech AM, Ng KL. Clinical characteristics and outcomes of methamphetamine-associated intracerebral hemorrhage. Neurology 2019; 93:e1-e7. [PMID: 31142634 DOI: 10.1212/wnl.0000000000007666] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/13/2019] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To compare the clinical characteristics and outcomes of primary intracerebral hemorrhage (ICH) with and without methamphetamine exposure. METHODS We performed a retrospective analysis of patients diagnosed with spontaneous, nontraumatic ICH over a 3-year period between January 2013 and December 2016. Demographics, clinical measures, and outcomes were compared between ICH patients with positive methamphetamine toxicology tests vs those with negative methamphetamine toxicology tests. RESULTS Methamphetamine-positive ICH patients were younger than methamphetamine-negative ICH patients (52 vs 67 years, p < 0.001). Patients with methamphetamine-positive ICH had higher diastolic blood pressure (115 vs 101, p = 0.003), higher mean arterial pressure (144 vs 129, p = 0.01), longer lengths of hospital (18 vs 8 days, p < 0.001) and intensive care unit (ICU) stay (10 vs 5 days, p < 0.001), required more days of IV antihypertensive medications (5 vs 3 days, p = 0.02), and had more subcortical hemorrhages (63% vs 46%, p = 0.05). The methamphetamine-positive group had better premorbid modified Rankin Scale (mRS) scores (p < 0.001) and a greater change in functional ability as measured by mRS at the time of hospital discharge (p = 0.001). In multivariate analyses, methamphetamine use predicted both hospital length of stay (risk ratio [RR] 1.54, confidence interval [CI] 1.39-1.70, p < 0.001) and ICU length of stay (RR 1.36, CI 1.18-1.56, p < 0.001), but did not predict poor outcome (mRS 4-6). CONCLUSIONS Methamphetamine use is associated with earlier age at onset of ICH, longer hospital stays, and greater change in functional ability, but did not predict outcome.
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Affiliation(s)
- Dionne E Swor
- From the Ken and Ruth Davee Department of Neurology (D.E.S., M.B.M., E.M.L., A.M.N.), Northwestern University, Chicago, IL; and Neurology Department (S.S.W., D.P.B., K.L.N.), University of California Davis, Sacramento
| | - Matthew B Maas
- From the Ken and Ruth Davee Department of Neurology (D.E.S., M.B.M., E.M.L., A.M.N.), Northwestern University, Chicago, IL; and Neurology Department (S.S.W., D.P.B., K.L.N.), University of California Davis, Sacramento
| | - Sandeep S Walia
- From the Ken and Ruth Davee Department of Neurology (D.E.S., M.B.M., E.M.L., A.M.N.), Northwestern University, Chicago, IL; and Neurology Department (S.S.W., D.P.B., K.L.N.), University of California Davis, Sacramento
| | - David P Bissig
- From the Ken and Ruth Davee Department of Neurology (D.E.S., M.B.M., E.M.L., A.M.N.), Northwestern University, Chicago, IL; and Neurology Department (S.S.W., D.P.B., K.L.N.), University of California Davis, Sacramento
| | - Eric M Liotta
- From the Ken and Ruth Davee Department of Neurology (D.E.S., M.B.M., E.M.L., A.M.N.), Northwestern University, Chicago, IL; and Neurology Department (S.S.W., D.P.B., K.L.N.), University of California Davis, Sacramento
| | - Andrew M Naidech
- From the Ken and Ruth Davee Department of Neurology (D.E.S., M.B.M., E.M.L., A.M.N.), Northwestern University, Chicago, IL; and Neurology Department (S.S.W., D.P.B., K.L.N.), University of California Davis, Sacramento
| | - Kwan L Ng
- From the Ken and Ruth Davee Department of Neurology (D.E.S., M.B.M., E.M.L., A.M.N.), Northwestern University, Chicago, IL; and Neurology Department (S.S.W., D.P.B., K.L.N.), University of California Davis, Sacramento.
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13
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Stroh GR, Dong F, Ablah E, Ward JG, Haan JM. The Impact of Methamphetamine Use on Trauma Patients at a Level I Trauma Center: A 10-Year Retrospective Review. Am Surg 2018. [DOI: 10.1177/000313481808400329] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The effects of methamphetamines (MAs) on trauma patient outcomes have been evaluated, but with discordant results. The purpose of this study was to identify hospital outcomes associated with MA use after traumatic injury. Retrospective review of adult trauma patients admitted to an American College of Surgeons verified–Level I trauma center who received a urine drug screen (UDS) between January 1, 2004 and December 31, 2013. Logistic regression analysis was used to identify factors associated with mortality. Patients with a negative UDS were used as controls. Among the 2321 patients included, 75.1 per cent were male, 81.9 per cent were white, and the average age was 39. Patients were grouped by UDS results (negative, MA only, other drug plus MA, or other drug without MA). A positive drug screen result of other drug without MA demonstrated a significantly lower risk for mortality, but longer intensive care unit and hospital length of stay, as well as increased ventilator days than negative results. Results of MA only did not alter the risk of mortality. These findings suggest that patients who test positive for MAs are not at an increased risk of in-hospital mortality when compared with patients having a negative drug screen.
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Affiliation(s)
- Gregory R. Stroh
- Department of Surgery, The University of Kansas School of Medicine—Wichita, Wichita, Kansas
| | - Fanglong Dong
- Western University of Health Sciences, Pomona, California
| | - Elizabeth Ablah
- Preventive Medicine and Public Health, The University of Kansas School of Medicine—Wichita, Wichita, Kansas
| | | | - James M. Haan
- Department of Surgery, The University of Kansas School of Medicine—Wichita, Wichita, Kansas
- Department of Trauma Services, Via Christi Hospital Saint Francis, Wichita, Kansas
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14
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Lappin JM, Darke S, Farrell M. Stroke and methamphetamine use in young adults: a review. J Neurol Neurosurg Psychiatry 2017; 88:1079-1091. [PMID: 28835475 DOI: 10.1136/jnnp-2017-316071] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/04/2017] [Accepted: 06/13/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Methamphetamine use and stroke are significant public health problems. Strokes among people aged below 45 years are much less common than in older age groups but have significant mortality and morbidity. Methamphetamine is a putative cause of strokes among younger people. METHODS A review of methamphetamine-related strokes was conducted. Bibliographic databases were searched until February 2017 for articles related to methamphetamine and stroke. Both haemorrhagic and ischaemic strokes were considered. RESULTS Of 370 articles screened, 77 were selected for inclusion. There were 81 haemorrhagic and 17 ischaemic strokes reported in case reports and series. Both types were approximately twice as common in males. Route of administration associated with haemorrhagic stroke was typically oral or injecting, but for ischaemic stroke inhalation was most common. Haemorrhagic stroke was associated with vascular abnormalities in a third of cases. One quarter of individuals completely recovered, and a third died following haemorrhagic stroke. One-fifth completely recovered, and one-fifth died following ischaemic stroke. CONCLUSIONS There is a preponderance of haemorrhagic strokes associated with methamphetamine use in young people, and methamphetamine-related stroke is associated with poor clinical outcomes. Mechanisms of methamphetamine-associated stroke include hypertension, vasculitis, direct vascular toxicity and vasospasm. In a period of rising worldwide methamphetamine use, the incidence of methamphetamine-related stroke will increase, with a consequent increase in the burden of disease contributed by such events.
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Affiliation(s)
- Julia M Lappin
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, New South Wales, Australia
- School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
| | - Shane Darke
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, New South Wales, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, New South Wales, Australia
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15
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Darke S, Lappin J, Kaye S, Duflou J. Clinical Characteristics of Fatal Methamphetamine-related Stroke: A National Study. J Forensic Sci 2017; 63:735-739. [DOI: 10.1111/1556-4029.13620] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 06/30/2017] [Accepted: 07/20/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Shane Darke
- National Drug & Alcohol Research Centre; University of New South Wales; NSW 2052 Australia
| | - Julia Lappin
- National Drug & Alcohol Research Centre; University of New South Wales; NSW 2052 Australia
- School of Psychiatry; University of New South Wales; NSW 2052 Australia
| | - Sharlene Kaye
- National Drug & Alcohol Research Centre; University of New South Wales; NSW 2052 Australia
- Justice Health and Forensic Mental Health Network; NSW Health; PO Box 150, Matraville NSW 2036 Australia
| | - Johan Duflou
- National Drug & Alcohol Research Centre; University of New South Wales; NSW 2052 Australia
- Sydney Medical School; University of Sydney; Sydney NSW 2006 Australia
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16
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Bowyer JF, Sarkar S, Tranter KM, Hanig JP, Miller DB, O'Callaghan JP. Vascular-directed responses of microglia produced by methamphetamine exposure: indirect evidence that microglia are involved in vascular repair? J Neuroinflammation 2016; 13:64. [PMID: 26970737 PMCID: PMC4789274 DOI: 10.1186/s12974-016-0526-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 03/03/2016] [Indexed: 11/24/2022] Open
Abstract
Background Brain microglial activations and damage responses are most commonly associated with neurodegeneration or systemic innate immune system activation. Here, we used histological methods to focus on microglial responses that are directed towards brain vasculature, previously undescribed, after a neurotoxic exposure to methamphetamine. Methods Male rats were given doses of methamphetamine that produce pronounced hyperthermia, hypertension, and toxicity. Identification of microglia and microglia-like cells (pericytes and possibly perivascular cells) was done using immunoreactivity to allograft inflammatory factor 1 (Aif1 a.k.a Iba1) and alpha M integrin (Itgam a.k.a. Cd11b) while vasculature endothelium was identified using rat endothelial cell antigen 1 (RECA-1). Regions of neuronal, axonal, and nerve terminal degeneration were determined using Fluoro-Jade C. Results Dual labeling of vasculature (RECA-1) and microglia (Iba1) showed a strong association of hypertrophied cells surrounding and juxtaposed to vasculature in the septum, medial dorsal hippocampus, piriform cortex, and thalamus. The Iba1 labeling was more pronounced in the cell body while Cd11b more so in the processes of activated microglia. These regions have been previously identified to have vascular leakage after neurotoxic methamphetamine exposure. Dual labeling with Fluoro-Jade C and Iba1 indicated that there was minimal or no evidence of neuronal damage in the septum and hippocampus where many hypertrophied Iba1-labeled cells were found to be associated with vasculature. Although microglial activation around the prominent neurodegeneration was found in the thalamus, there were also many examples of activated microglia associated with vasculature. Conclusions The data implicate microglia, and possibly related cell types, in playing a major role in responding to methamphetamine-induced vascular damage, and possibly repair, in the absence of neurodegeneration. Identifying brain regions with hypertrophied/activated microglial-like cells associated with vasculature has the potential for identifying regions of more subtle examples of vascular damage and BBB compromise. Electronic supplementary material The online version of this article (doi:10.1186/s12974-016-0526-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- John F Bowyer
- Division of Neurotoxicology, National Center for Toxicology/FDA, Jefferson, AR, 72079, USA. .,National Center for Toxicological Research/FDA, 3900 NCTR Road, HFT-132, Jefferson, AR, 72079, USA.
| | - Sumit Sarkar
- Division of Neurotoxicology, National Center for Toxicology/FDA, Jefferson, AR, 72079, USA
| | - Karen M Tranter
- Division of Neurotoxicology, National Center for Toxicology/FDA, Jefferson, AR, 72079, USA
| | - Joseph P Hanig
- Center for Drug Evaluation and Research/FDA, Silver Spring, MD, 20993, USA
| | - Diane B Miller
- Health Effects Laboratory Division, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Morgantown, WV, 26505, USA
| | - James P O'Callaghan
- Health Effects Laboratory Division, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Morgantown, WV, 26505, USA
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17
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Bowyer JF, Hanig JP. Amphetamine- and methamphetamine-induced hyperthermia: Implications of the effects produced in brain vasculature and peripheral organs to forebrain neurotoxicity. Temperature (Austin) 2014; 1:172-82. [PMID: 27626044 PMCID: PMC5008711 DOI: 10.4161/23328940.2014.982049] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 10/22/2014] [Accepted: 10/27/2014] [Indexed: 12/20/2022] Open
Abstract
The adverse effects of amphetamine- (AMPH) and methamphetamine- (METH) induced hyperthermia on vasculature, peripheral organs and peripheral immune system are discussed. Hyperthermia alone does not produce amphetamine-like neurotoxicity but AMPH and METH exposures that do not produce hyperthermia (≥40°C) are minimally neurotoxic. Hyperthermia likely enhances AMPH and METH neurotoxicity directly through disruption of protein function, ion channels and enhanced ROS production. Forebrain neurotoxicity can also be indirectly influenced through the effects of AMPH- and METH- induced hyperthermia on vasculature. The hyperthermia and the hypertension produced by high doses amphetamines are a primary cause of transient breakdowns in the blood-brain barrier (BBB) resulting in concomitant regional neurodegeneration and neuroinflammation in laboratory animals. This BBB breakdown can occur in the amygdala, thalamus, striatum, sensory and motor cortex and hippocampus. Under these conditions, repetitive seizures greatly enhance neurodegeneration in hippocampus, thalamus and amygdala. Even when the BBB is less disrupted, AMPH- or METH- induced hyperthermia effects on brain vasculature may play a role in neurotoxicity. In this case, striatal and cortical vascular function are adversely affected, and even greater ROS, immune and damage responses are seen in the meninges and cortical surface vasculature. Finally, muscle and liver damage and elevated cytokines in blood can result when amphetamines produce hyperthermia. Proteins, from damaged muscle may activate the peripheral immune system and exacerbate liver damage. Liver damage can further increase cytokine levels, immune system activation and increase ammonia levels. These effects could potentially enhance vascular damage and neurotoxicity.
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18
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Bain JA, Dority JS, Cook AM. Subarachnoid hemorrhage in a patient taking phentermine for weight loss. J Am Pharm Assoc (2003) 2014; 54:548-51. [PMID: 25148583 DOI: 10.1331/japha.2014.13226] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To report the case of an angiography-negative subarachnoid hemorrhage (SAH) in association with increased use of the sympathomimetic phentermine. SUMMARY A 45-year-old woman taking phentermine for weight loss presented with the "worst headache of her life," as well as nausea and some confusion. Her prior medical history was largely negative for pathology except for a 20-pack-year history of smoking. RESULTS Upon admission to an inpatient facility, the patient was normotensive with a Glasgow Coma Score of 15. She was found on computed tomography to have a diffuse SAH (Hunt and Hess grade 2, Fisher grade 3). Digital subtraction angiography, performed on hospital day 2, was negative for aneurysm. The patient convalesced in the intensive care unit for 8 days and was treated as a typical patient with SAH (i.e., vasospasm prophylaxis with nimodipine and atorvastatin, ad lib diet with strict attention to fluid balance to maintain euvolemia). A repeat angiographic study on hospital day 8 also did not reveal an aneurysm or other cause for her SAH. She was discharged thereafter with intensive smoking cessation education and counseled to discontinue phentermine. Upon follow-up 6 weeks later, the patient was without complaints or neurologic deficits and had resumed her previous activities and work. CONCLUSION Phentermine is a sympathomimetic agent found commonly in weight-loss products. Sympathomimetics have been linked to the development of hypertension, which can lead to cardiovascular and neurologic hemorrhages. We believe that the SAH in this patient was likely secondary to drug-induced hypertension or vasculopathy from the phentermine.
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19
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Moon K, Albuquerque FC, Mitkov M, Ducruet AF, Wilson DA, Crowley RW, Nakaji P, McDougall CG. Methamphetamine use is an independent predictor of poor outcome after aneurysmal subarachnoid hemorrhage. J Neurointerv Surg 2014; 7:346-50. [PMID: 24780822 DOI: 10.1136/neurintsurg-2014-011161] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 04/03/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND Clinical outcomes of methamphetamine users with aneurysmal subarachnoid hemorrhage (aSAH) are unknown. OBJECTIVE To analyze differences in presentation, in-hospital morbidity, and outcomes between methamphetamine users and non-users. METHODS All 472 patients included in the Barrow Ruptured Aneurysm Trial from 2003 to 2007 were reviewed. Patients with 1- and 3-year follow-up were included in this analysis (n=398). Methamphetamine users were identified as patients who provided a history of methamphetamine use on admission or tested positive on urine toxicology testing. Methamphetamine users were compared with non-users using univariate analysis. Outcomes were then analyzed using multivariate logistic regression models for demographic characteristics, medical comorbidities, radiographic and clinical presentation, and vasospasm. RESULTS Thirty-one patients (7.8%) were identified as methamphetamine users in this cohort. Methamphetamine users were younger than non-users (mean age 42.8 vs 55 years, p<0.001). In multivariate logistic regression models, methamphetamine use was an independent predictor of poor Glasgow Outcome Scale score at both 1 year (OR=5.02; 95% CI 1.03 to 24.48; p<0.05) and 3 years (OR=7.18; 95% CI 1.73 to 29.87; p=0.007). Other independent predictors in this model included older age, clinical vasospasm, diabetes, and aneurysm size. Cocaine and tobacco use were not significantly associated with poor outcome in our cohort. Methamphetamine use was not significantly associated with vasospasm, higher Fisher or Hunt and Hess grade, or intraparenchymal hemorrhage/intraventricular hemorrhage. CONCLUSIONS Methamphetamine users have significantly worse outcomes at 1 and 3 years following aSAH. Further analysis is necessary to understand the pathological response associated with methamphetamine use in this setting.
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Affiliation(s)
- Karam Moon
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mario Mitkov
- School of Medicine, Creighton University, Omaha, Nebraska, USA
| | - Andrew F Ducruet
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - David A Wilson
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - R Webster Crowley
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Peter Nakaji
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Cameron G McDougall
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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