Drug abuse is a worldwide problem responsible for a considerable number of deaths, functional dependence, and healthcare costs. Use continues to rise throughout the world and synthetic drugs have been added to the repertoire alongside cocaine, heroin, and methamphetamine. The acute intoxicating effects on the brain are well known; however, an understanding of the neurological complications is important in the acute period to guide workup and treatment. This panel is in the SMACC Brain pre-conference workshop will review neurological complications of intravenous drugs including endocarditis and the resultant septic emboli and stroke, intracerebral hemorrhages, and aneurysms. We will also dive into the less well-known neurological sequelae of other drugs including some not-so-uncommon zebras.

1. BRAIN ON DRUGS:
Chasing Dragons &
Other Demons
Rhonda Cadena, MD
University of North Carolina
Neurocritical Care/Emergency Medicine

2. I have no disclosures

3. Drugs
Opiates
Cannabis
Amphetamines
Cocaine
4.3 billion users
38 million abusers
21 million IVDU
Cannabis
Opiates
Cannabis
Amphetamines
Others

4. US Drug Overdose Deaths (1999-2017)
Prescription Opioids
Heroin
Cocaine
Benzodiazepines
Psychostimulants (Including
Methamphetamine)
CDC, Dec 2018

5. Aside from death, drugs may also have
neurological complications that may leave
the user with long term neurological
sequelae
Since these are young users, a significant
financial burden to families and the society

6. IVDU and Neurological
Complications of Endocarditis

8. DWI ADC
ICH

10. Neurological complications
> 56% stroke, 20% encephalopathy, 18% hemorrhage,
5% meningitis/abscess
> Mostly occurred before treatment or within first 2 weeks
> Worsen mortality
Embolic events
> 80% of cerebral emboli are clinically silent
> Clinically apparent in 10-35% of patients with left-sided infective
endocarditis
Alteplase contraindicated if stroke due to endocarditis is
suspected (but endovascular is not)
Garcia-Cabrere et al. Circulation. 2013

11. Cerebral hemorrhage
> Primary hemorrhages
> Hemorrhagic conversion of embolic stroke
> Rupture of infective (mycotic) aneurysm
Mycotic/infective aneurysms
> 1/5 of embolic events develop aneurysm
> Typically more distal
> Resolve with antibiotics
> Surgery or endovascular treatment to obliterate vessel if severe or re-rupture

12. Treatment
>Resuscitation and stabilization of multiorgan failure
>Treatment of ICP
>Neuro specific treatment (ICH,AIS,SAH)
Broad spectrum antibiotics
>Vancomycin, cefepime, aminoglycoside
Neurosurgical evaluation
>Medical vs surgical vs endovascular

13. Other Drugs

14. Infection
Hemorrhage (ICH/SAH)
Infarct
Encephalopathy
Seizures
Vasculitis
PRES
Movement disorders
Variations due to dose, route,
additives, polysubstance
interaction, and co-morbidities

15. COCAINE
SAH/ICH
>50% have underlying vascular abnormality
>Acute rise in blood pressure
ISCHEMIC STROKE
>Vasoconstriction, vasospasm, or vasculitis
>Accelerated atherosclerosis
>Pro-thrombotic
SEIZURES
>Occur shortly after use

16. MOVEMENT DISORDERS “Crack Dancing”

17. AMPHETAMINE (methamphetamine/MDMA)
INTRACEREBRAL HEMORRHAGE
>Underlying vascular abnormalities
ISCHEMIC STROKE
>Vasoconstriction
PRES
>Reversible
Movement disorders
>Tremors, restless legs, punding
Mobius 2014

18. METHCATHINONE (ephedrone, cat, jeff)
Ataxia, postural disturbances, dysarthria,
facial and lower extremity dystonia,
bradykinesia
>Permanent if used for more than 6 months
Parkinsonism
>Manganese intoxication in IV ephedrone

19. HEROIN
ISCHEMIC STROKE
>Vasospasm, vasculitis
>Additives and embolism
TOXIC LEUKOENCEPHALOPATHY
>Impurities from heating the aluminum foil
>Cerebellar and extrapyramidal signs
(dystonia, akathisia, parkinsonism)
INFECTION
>Intravenous
Offiah, Clin Rad 2007

20. SYNTHETIC OPIOIDS
LEUKOENCEPHALOPATHY
>Acute use or chronic users

21. SYNTHETIC CANNABINOIDS (SPICE)
ISCHEMIC STROKES
>Symmetric
SEIZURES
>Treatment with benzodiazepines
MRI leptomeningeal enhancement
>Reversible
Serwani, 2015

22. ALOCOHOLISM
INTRACEREBRAL HEMORRHAGE
>Due to falls
SEIZURES
>Use or withdrawal
VITAMIN DEFICIENCY
>Wernicke’s encephalopathy