Intracerebral haemorrhage caused by drug abuse

Coexisting vascular lesions in reversible cerebral vasoconstriction syndrome

Background

The pathophysiology of reversible cerebral vasoconstriction syndrome (RCVS) is not known. Published cases have documented coexisting cervical artery dissection and unruptured aneurysms, raising the possibility that ultrastructural vessel wall abnormalities underlie the development of vascular lesions as well as RCVS.

Methods

In this retrospective study we compared the frequency of neurovascular abnormalities in 158 consecutive RCVS patients, 44 patients with primary angiitis of the central nervous system (PACNS, positive controls), and 177 non-stroke patients with acute neurological symptoms (non-arteriopathy controls).

Results

Coexisting neurovascular abnormalities were significantly higher ( p < 0.001) in RCVS (23%) as compared to the PACNS (5%) or non-arteriopathy groups (8%). Cervical artery dissections were noted only in the RCVS group (8%, p < 0.001). The RCVS group had more unruptured aneurysms than PACNS (13% vs. 5%, p = 0.099) or non-arteriopathy controls (13% vs. 7%, p = 0.05). Seven RCVS patients also had other vascular malformations (venous anomaly, cavernous malformations, fibromuscular dysplasia). There was no significant association between coexisting vascular abnormalities and brain lesions or discharge clinical outcome in the RCVS group.

Conclusion

The high prevalence and heterogeneous anatomy of coexisting vascular lesions suggest that subtle ultrastructural arterial wall abnormalities may contribute to their development and also predispose to RCVS.

Spontaneous intracerebral hemorrhage: a review

Spontaneous intracerebral hemorrhage (SICH) is a blood clot that arises in the brain parenchyma in the absence of trauma or surgery. This entity accounts for 10 to 15% of all strokes and is associated with a higher mortality rate than either ischemic stroke or subarachnoid hemorrhage. Common causes include hypertension, amyloid angiopathy, coagulopathy, vascular anomalies, tumors, and various drugs. Hypertension, however, remains the single greatest modifiable risk factor for SICH. Computerized tomography scanning is the initial diagnostic modality of choice in SICH, and angiography should be considered in all cases except those involving older patients with preexisting hypertension in thalamic, putaminal, or cerebellar hemorrhage. Medical management includes venous thrombosis prophylaxis, gastric cytoprotection, and aggressive rehabilitation. Anticonvulsant agents should be prescribed in supratentorial SICH, whereas the management of hypertension is controversial.

To date, nine prospective randomized controlled studies have been conducted to compare surgical and medical management of SICH. Although definitive evidence favoring surgical intervention is lacking, there is good theoretical rationale for early surgical intervention. Surgery should be considered in patients with moderate to large lobar or basal ganglia hemorrhages and those suffering progressive neurological deterioration. Elderly patients in whom the Glasgow Coma Scale score is less than 5, those with brainstem hemorrhages, and those with small hemorrhages do not typically benefit from surgery. Patients with cerebellar hemorrhages larger than 3 cm, those with brainstem compression and hydrocephalus, or those exhibiting neurological deterioration should undergo surgical evacuation of the clot. It is hoped that the forthcoming results of the International Surgical Trial in IntraCerebral Hemorrhage will help formulate evidence-based recommendations regarding the role of surgery in SICH.

The health effects of ecstasy: a literature review

Ecstasy (3,4-methylenedioxymethamphetamine, MDMA) is the third most used illicit drug, after cannabis and amphetamines. There has been considerable interest in the adverse effects of use, with particular attention given to a small number of deaths related to ecstasy use, and the neurotoxic effects of MDMA. This paper reviews case reports of adverse effects attributed to ecstasy use, and the findings of animal and human studies, so as to identify the health effects of ecstasy use, and factors contributing to their occurrence. The incidence of serious acute adverse events related to ecstasy is low. It is the unpredictability of those adverse events and the risk of mortality and substantial morbidity that makes the health consequences of ecstasy significant. Hyperthermia and hyponatraemia are the most significant acute adverse effects, and can occur even when MDMA is the only drug used. Ecstasy users should be aware of the importance of controlling body temperature and fluid intake, early signs of adverse effects, and the need to seek medical assistance promptly. Neurotoxicity is potentially the most significant long-term effect of ecstasy. The clinical implications of neurotoxicity are uncertain at this time, but short-term memory impairment may be significant.