Original Report Our objective was to illustrate the dramatic neuroimag - PDF document

AJR:180, March 2003 Original Report Our objective was to illustrate the dramatic neuroimaging Þndings of toxicleukoencephalopathy caused by heroin vapor inhalation. Symmetric abnormality involving the cerebellar white matter and pos- Downloaded from www.ajronline.org by Welch Medical Library - JHU on 02/04/21 from IP address 162.129.252.226. Copyright ARRS. For personal use only; all rights reserved AJR:180, March 2003Keogh et al. have originated in China in the 1920s andministration in the 1950s in Hong Kong be-cause the drug was cheap but impure. Asmall quantity of powder is placed on alu-minium foil, which is then heated under-neath with a lighter or matches. The heroinliqueÞes into a reddish brown glob, whichmoves around on the foil and emits a whitevapor. The glob or ÒdragonÓ is ÒchasedÓwith the lighter underneath while the vaporis sucked through a straw or pipe. Thismethod of administration avoids the dangersLeukoencephalopathy due to inhalation ofheroin pyrolysate was Þrst described by re-searchers in The Netherlands in 1982 [3]. Clini-cally, the condition has three stages, progressing ABCDEF27-year-old man found at home with decreased level of consciousness, aphasia, and spastic quadraparesis. Patient died after seizure 6 weeks after admission and underwent autopsy.simulating dragonÕs claws.Axial T2-weighted MR image obtained through posterior fossa shows white matter hyperintensity in cerebellar white matter,

sparing cortex and dentate nuclei. Superior,nigra and red nuclei. Image resembles bat staring at viewer. Axial T2-weighted MR image obtained through upper brain reveals extensive signal abnormality tending to preferentially involve posterior white matter. Subcortical white Downloaded from www.ajronline.org by Welch Medical Library - JHU on 02/04/21 from IP address 162.129.252.226. Copyright ARRS. For personal use only; all rights reserved Neuroimaging of Heroin Inhalation Toxicity AJR:180, March 2003 pyramidal and pseudobulbar signs and, in a mi-terized by spasms, hypotonic paresis, andypotonic paresis, anddegeneration occurs, particularly in the cere-generation occurs, particularly in the cere-The MR imaging Þndings reßected this dis-tribution, with symmetric high signal on T2-(Figs. 1 and 2). Involvement of the cerebellumkoencephalopathy such as toluene toxicity orreversible posterior leukoencephalopathy [4,5]. Although sparing of the subcortical whitematter has not been previously described in theimaging literature, it would appear to be typi-cal of this condition. The reason for this strik-ing pattern of involvement is unknown.Kriegstein et al. [2] have shown reduced on proton MR spectroscopyyThe particular chemical that causes heroininhalation toxicity is unknown but is believed 27-year-old man found at home with decreased level of consciousness, aphasia, and spasticPatient died after seizure 6 weeks after admis

sion and underwent autopsy.). (H and E)39-year-old man with bradykinesia and ataxia.Axial ßuid-attenuated inversion recovery (FLAIR) image shows symmetrically increased signal in cerebellar white matter, peduncl Axial FLAIR image reveals symmetric abnormal signal in optic radiations (Axial FLAIR image shows characteristic involvement of posterior white matter. Downloaded from www.ajronline.org by Welch Medical Library - JHU on 02/04/21 from IP address 162.129.252.226. Copyright ARRS. For personal use only; all rights reserved AJR:180, March 2003Keogh et al. to be an occasional impurity that is activatedby heating the drug over the aluminium foil. In our study, all three patients had a deÞ-nite history of chasing the dragon. Within thefollowing month, two additional patients pre-patients were known to smoke crack cocaine,but further details could not be obtained. Onepatient was unresponsive on admission andemergency room after undergoing CT. Theseadditional two patients may also have beendragon chasers, or alternatively, the toxicto heroin or cocaine and is only activated byheating. Unfortunately, samples of the drugswith a number of other effects on the centralnervous system, including hypoxic brain in-jury, transverse myelitis, and brain abscess.however, are nonspeciÞc with regard to cause.Treatment is primarily supportive, although ite, although itIn summary, we presented three dramaticcases of toxic leukoencephalop

athy relatedto heroin vapor inhalation. The condition in-volves the cerebral and cerebellar tracts, withcharacteristic involvement of the cerebellarvariable, nonspeciÞc clinical features, imag-ing, in particular MR imaging, is invaluabletroscopy is not essential for the diagnosis buttion in the future. With changing practices ofdrug use, in part to avoid the risks of IV ad-ministration, further examples of this condi-tion will likely be encountered.AcknowledgmentsWe thank P. ChipperÞeld, T. Hurwitz, andregarding the patients and G. R. W. MooreReferences 1.Filley CM, Kleinschmidt-DeMasters BK. Toxicleukoencephalopathy. 2.Kriegstein AR, Shungu DC, Millar WS, et al. Leu-koencephalopathy and raised brain lactate from her-oin vapor inhalation. Neurology3.Wolters EC, Stam FC, Lousberg RJ, et al. Leukoen-cephalopathy after inhaling heroin pyrolysate. 4.Tan TP, Algra PR, Valk J, Wolters EC. Toxic leu-koencephalopathy after inhalation of poisoned her-oin: MR Þndings. 5.Hedley-Whyte ET. Leukoencephalopathy andraised brain lactate from heroin vapor inhalation.Neurology 32-year-old man with dysarthria, ataxia, and bradykinesia after inhalation of heroin vapor. Axial T2-weighted MR image shows symmetric signal hyperintensity in posterior limbs of internal capsule and Downloaded from www.ajronline.org by Welch Medical Library - JHU on 02/04/21 from IP address 162.129.252.226. Copyright ARRS. For personal use only; all rights reserved