Clinical Characteristics of Fatal Methamphetamine-related Stroke: A National Study

Amphetamine use as a predictor of cardiovascular and cerebrovascular mortality and morbidity: a longitudinal cohort study of criminal justice clients

Introduction

Amphetamine use is an increasing problem, and studies suggest a connection between amphetamine use and cardiovascular and cerebrovascular pathology. However, few long-term studies examine amphetamine users' risk of cardiovascular and cerebrovascular pathology, in comparison to users of other drugs. In addition, in a criminal justice system, illicit drug use and psychiatric comorbidity is common, whereas structured treatment and follow-up is uncommon, and stimulant use is common in this setting. The aim of this study was to investigate the risk of cardiovascular and cerebrovascular morbidity and mortality for intravenous drug users with different drugs as the primary drug, using data from the criminal justice system.

Methods

A cohort of injecting substance users (N = 2,422) was identified in the Swedish criminal justice system through interviews with the Addiction Severity Index (ASI) between January 2001 and August 2006. Data on age, sex, self-reported injection drug, tobacco use, and time in prison or custody were retrieved from the ASI database. The clients were followed in national registers up to 2014 with respect to cardiovascular and cerebrovascular morbidity and mortality. Potential predictors of cardiovascular and cerebrovascular events were investigated.

Result

Self-reported main drug was amphetamine in 51.5% (n = 1,247), polysubstance use in 33% (n = 799), and heroin in 15.5% (n = 376) of the cohort. Total observational time for the entire cohort was 23,911 person-years [median 10.3 years (IQR 9.3-11.2 years)]. The highest incidence rates of both cardiovascular and cerebrovascular events were found among amphetamine users. Bivariate analyses showed a significantly higher percentage of cardiovascular events in amphetamine users compared to other substance users (p < 0.044). Amphetamine was not significantly associated with cardiovascular or cerebrovascular events, compared to the main drug heroin or polysubstance use.

Conclusion

In this study on substance-using criminal justice clients, while the highest incidence rates of both cardiovascular and cerebrovascular events were found among amphetamine-using individuals, the study did not provide evidence of an independent association. The study highlights the need to take co-factors into account, such as comorbidities and socio-economic factors. More studies are needed to distinguish substance-specific pathology from the impact of other unhealthy lifestyle factors among substance-using individuals.

Impact of cannabis abuse on the occurrence of stroke in young people: a systematic review and meta-analysis

Background

The occurrence of stroke in young people has risen significantly. This can easily lead to physical disabilities, swallowing difficulties, and cognitive impairment, among other issues, having a profound impact on families and society. Risk factors for stroke in young people differ from those for traditional stroke, with cannabis abuse emerging as a significant high-risk factor. However, the extent of the impact of cannabis abuse on the occurrence of stroke and the rate of disability in young people remains unclear. To clarify this issue and provide evidence supporting the primary prevention of stroke in young people, this systematic review and meta-analysis summarizes the latest findings from previous studies.

Methods

A systematic search of PubMed, EMBASE, Cochrane Library, and Web of Science databases was conducted until April 2023. The review included observational studies comparing stroke risk estimates between cannabis abusers and non-users.

Results

This review included six observational studies focusing on cannabis abuse, involving 119,284,152 participants. A significant association was found between cannabis abuse and an increased risk of stroke [OR = 1.14, 95% CI (1.08, 1.20)]. However, there was substantial heterogeneity among the studies (I 2 = 89%, p < 0.001). After adjusting for confounders such as smoking and alcohol abuse, we found a stronger association between cannabis abuse and stroke in young adults [OR = 1.21, 95% CI (1.12, 1.29)]. Subgroup analyses revealed no significant difference in stroke risk between ischemic and hemorrhagic strokes (p = 0.43).

Conclusion

The results of our systematic review and meta-analysis showed that cannabis abuse has a more significant effect on the occurrence of stroke in young people; however, it was not possible to distinguish whether cannabis abuse is more likely to cause ischemic or hemorrhagic stroke. Further research is needed to explore the impact of different drug types, dosages, and behaviors on stroke risk.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, Identifier CRD42023443261.

Modeling methamphetamine use disorder in mammals: Sex differences in behavioral, biochemical, and transcriptional consequences

Methamphetamine (METH) is the most commonly misused amphetamine-type stimulant throughout the globe. METH is very rewarding, and its misuse can lead to a diagnosis of METH use disorder (MUD). Although METH use is observed in both sexes, there are, however, reported differences in the clinical manifestations of METH use and its consequences. These observations indicate the need for more research on the long-term sex-dependent consequences of METH taking in both preclinical and clinical settings. In effect, sex is a biological variable that can impact conclusions drawn from various basic and clinical studies. Thus, the present chapter provides a succinct review of the current state of the research on METH and its sex-associated consequences. In addition to behavioral and cognitive aspects of METH use, we discuss METH-induced changes in neurotransmitter systems and structures in the brain. Thus, the book chapter serves to highlight the significance of sex as a critical element that needs to be considered during discussions of novel therapeutic approaches to MUD.

Methamphetamine use increases the risk of cerebral small vessel disease in young patients with acute ischemic stroke

Methamphetamine use causes spikes in blood pressure. Chronic hypertension is a major risk factor for cerebral small vessel disease (cSVD). The aim of this study is to investigate whether methamphetamine use increases the risk of cSVD. Consecutive patients with acute ischemic stroke at our medical center were screened for methamphetamine use and evidence of cSVD on MRI of the brain. Methamphetamine use was identified by self-reported history and/or positive urine drug screen. Propensity score matching was used to select non-methamphetamine controls. Sensitivity analysis was performed to assess the effect of methamphetamine use on cSVD. Among 1369 eligible patients, 61 (4.5%) were identified to have a history of methamphetamine use and/or positive urine drug screen. Compared with the non-methamphetamine group (n = 1306), the patients with methamphetamine abuse were significantly younger (54.5 ± 9.7 vs. 70.5 ± 12.4, p < 0.001), male (78.7% vs. 54.0%, p < 0.001) and White (78.7% vs. 50.4%, p < 0.001). Sensitivity analysis showed that methamphetamine use was associated with increased white matter hyperintensities, lacunes, and total burden of cSVD. The association was independent of age, sex, concomitant cocaine use, hyperlipidemia, acute hypertension, and stroke severity. Our findings suggest that methamphetamine use increases the risk of cSVD in young patients with acute ischemic stroke.

Methamphetamine-related forensic autopsy cases in a Japanese prefecture over a 7-year period: Characteristics of deaths and blood concentrations

Understanding the actual conditions of methamphetamine (MA)-related death is important from the perspectives of criminal justice and public health. In this report, we review 104 cases of MA-related death handled by our departments between January 2014 and December 2020. Based on information from police and autopsy examinations, we classified the cases into the following categories: "accidental intoxication" ("MA only" and "multiple drugs or alcohol"), "fatal disease" ("definitively MA-related," "possibly MA-related," and "unlikely MA-related"), "accident," "suicide," "homicide," and "undetermined." The total number and annual trends for each category and their respective femoral blood concentrations were investigated. "Fatal disease" was the most common category (48 cases), followed by "suicide" (25 cases), "accidental intoxication" (14 cases), and "accident" (11 cases). "Definitively MA-related" in which MA may have played a role in their onset or exacerbation accounted for the majority of "fatal disease": 12 cases of heart disease, 4 cases of aortic dissection, 12 cases of cerebral hemorrhage, and 4 cases of subarachnoid hemorrhage. Cases classified as "definitively MA-related" died with lower femoral blood concentrations of MA compared with "MA only." Cases with "fatal disease" might have been misdiagnosed as "death by natural causes" if a proper autopsy and toxicology examinations were not performed. In death investigations, it is necessary to keep in mind that there are some MA-related deaths, and efforts should be made to increase awareness about the risk of death in using this drug.

Sex differences in methamphetamine use disorder perused from pre-clinical and clinical studies: Potential therapeutic impacts

Methamphetamine (METH) use, and misuse are associated with severe socioeconomic consequences. METH users develop tolerance, lose control over drug taking behaviors, and suffer frequent relapses even during treatment. The clinical course of METH use disorder is influenced by multifactorial METH-induced effects on the central and peripheral nervous systems. Although these METH-induced consequences are observed in humans of all ages, races, and sexes, sexual dimorphism in these outcomes have been observed in both pre-clinical and clinical settings. In this review, we have provided a detailed presentation of the sex differences reported in human and animal studies. We have therefore presented data that identified the influences of sex on METH pharmacokinetics, METH-induced changes in behaviors, cognitive processes, structural changes in the brain, and the effects of the drug on neurotransmitter systems and molecular mechanisms. Finally, we highlighted the potential significance of sex as a critical variable that should be considered when planning the development of new pharmacotherapeutic approaches against MEH use disorder in humans.

Sex-Specific Alterations in Dopamine Metabolism in the Brain after Methamphetamine Self-Administration

Methamphetamine (METH) use disorder affects both sexes, with sex differences occurring in behavioral, structural, and biochemical consequences. The molecular mechanisms underlying these differences are unclear. Herein, we used a rat model to identify potential sex differences in the effects of METH on brain dopaminergic systems. Rats were trained to self-administer METH for 20 days, and a cue-induced drug-seeking test was performed on withdrawal days 3 and 30. Dopamine and its metabolites were measured in the prefrontal cortex (PFC), nucleus accumbens (NAc), dorsal striatum (dSTR), and hippocampus (HIP). Irrespective of conditions, in comparison to females, male rats showed increased 3,4-dihydroxyphenylalanine (DOPA) in the PFC, dSTR, and HIP; increased cys-dopamine in NAc; and increased 3,4-dihydroxyphenylethanol (DOPET) and 3,4-dihydroxyphenylacetic acid (DOPAC) in dSTR. Males also showed METH-associated decreases in DA levels in the HIP but increases in the NAc. Female rats showed METH-associated decreases in DA, DOPAL, and DOPAC levels in the PFC but increases in DOPET and DOPAC levels in the HIP. Both sexes showed METH-associated decreases in NAc DA metabolites. Together, these data document sex differences in METH SA-induced changes in DA metabolism. These observations provide further support for using sex as an essential variable when discussing therapeutic approaches against METH use disorder in humans.

"It's called overamping": experiences of overdose among people who use methamphetamine

BACKGROUND

The USA is experiencing increases in methamphetamine use and methamphetamine-related or attributed deaths. In the current study, we explore qualitative narratives of methamphetamine overdose and strategies used by people who use drugs to reduce the undesirable effects associated with methamphetamine use.

METHODS

We conducted 21 qualitative interviews with people over the age of 18 who reported using methamphetamine in the previous 3 months in Nevada and New Mexico. Interviews were recorded, transcribed, and analyzed using qualitative thematic analysis.

RESULTS

Respondents described a constellation of psychological and physical symptoms that they characterized as "overamping," experienced on a continuum from less to more severe. Reports of acute, fatal methamphetamine overdose were rare. Few reported seeking medical attention for undesirable effects (usually related to psychological effects). General self-care strategies such as sleeping and staying hydrated were discussed.

CONCLUSIONS

When asked directly, our respondents claimed that acute, fatal methamphetamine overdose is rare or even impossible. However, they described a number of undesirable symptoms associated with overconsumption of methamphetamine and had few clinical or harm reduction strategies at their disposal. Addressing this current wave of drug-related deaths will require attention to the multiple factors that structure experiences of methamphetamine "overdose," and a collaborative effort with PWUDs to devise effective harm reduction and treatment strategies.

Methamphetamine and heightened risk for early-onset stroke and Parkinson's disease: A review

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.

Psychostimulant use disorder emphasizing methamphetamine and the opioid -dopamine connection: Digging out of a hypodopaminergic ditch

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.

Fatal hemorrhage complicated with methamphetamine poisoning and its post-mortem CT features

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.

Moyamoya vasculopathy in a young Caucasian woman with significant methamphetamine use

Background

Moyamoya is a rare cerebrovascular disorder seen predominantly in Asian populations. Methamphetamine use is a recognised cause of stroke in young people, but its pathophysiology is not fully understood. The incidence of moyamoya vasculopathy in methamphetamine-associated stroke is unknown due to a lack of sufficient data. We present a rare case of moyamoya syndrome in a young Caucasian woman with methamphetamine-associated stroke.

Case

A 31-year-old Caucasian woman presented with progressive right arm weakness, speech disturbance and seizures on a background of escalating methamphetamine use in the 9 months prior to admission. She did not have a personal or family history of stroke. MRI revealed both embolic and watershed infarcts in bilateral frontal regions and CT angiography showed development of new lenticulostriate collateral vessels. Digital subtraction angiography confirmed steno-occlusive disease of the bilateral anterior circulations and a ‘puff of smoke’ appearance.

Conclusion

In young patients who present with stroke with unclear aetiology, it is important to obtain a thorough substance use history. Moyamoya vasculopathy should be considered when evaluating the pathophysiology of stroke in young people.

Clinical characteristics and outcomes of methamphetamine-associated versus non-methamphetamine intracerebral hemorrhage

Methamphetamine use has emerged as a risk factor for intracerebral hemorrhage (ICH). We aim to investigate the clinical characteristics and outcomes of methamphetamine-associated ICH (Meth-ICH) versus Non-Meth-ICH. Patients with ICH between January 2011 and December 2017 were studied. Meth-ICH and Non-Meth-ICH were defined by history of abuse and urine drug screen (UDS). The clinical features of the 2 groups were explored. Among the 677 consecutive patients, 61 (9.0%) were identified as Meth-ICH and 350 as Non-Meth ICH. Meth-ICH was more common in Hispanics (14.6%) and Whites (10.1%) as compared to Asians (1.2%). Patients with Meth-ICH were more often younger (51.2 vs. 62.2 years, p < 0.001), male (77.0% vs. 61.4.0%, p < 0.05), and smokers (44.3% vs. 13.4%, p < 0.001). Non-Meth-ICH was more likely to have history of hypertension (72.61% v. 59%, p < 0.05) or antithrombotic use (10.9% vs. 1.6%, p < 0.05). There was no significant difference in clinical severity, hospital length of stay (LOS), rate of functional independence (29.5% vs. 25.7%, p = 0.534), or mortality (18.0% vs. 24.6%, p = 0.267) between the 2 groups. Methamphetamine use was not an independent predictor of poor outcome. Despite difference in demographics, Meth-ICH is similar to Non-Meth ICH in hospital course and outcome.

Acute changes in the retina and central retinal artery with methamphetamine

Methamphetamine (METH), an addictive stimulant of neurotransmitters, is associated with cardiovascular and neurological diseases. METH-induced ophthalmic complications are also present but have been insufficiently investigated. The purpose of this study is to investigate the retinal effects of METH. C57BL/6 mice were administrated progressively increasing doses of METH (0-6 mg/kg) by repetitive intraperitoneal injections for 5 days (4 times per day). Retinal degeneration was examined by morphological changes and terminal deoxynucleotidyl transferase deoxyuridine triphosphate nick end labeling (TUNEL) assay. Norepinephrine levels were measured by ELISA, protein expression levels were determined by immunoblot and immunostaining, and gelatinase activity was examined by zymography. The thickness of the retina and the number of nuclei in the inner and outer nuclear layers were decreased by METH. Retinal cell death and astrocyte activation by METH treatment were confirmed by TUNEL assay and glial fibrillary acidic protein expression, respectively. Increased tumor necrosis factor-α protein in the retina and elevated norepinephrine levels in plasma were found in METH-treated mice. Platelet endothelial cell adhesion molecule-1 (PECAM-1) protein expression level was decreased in the retina and central retinal artery (CRA) by METH treatment, along with the endothelial proteoglycans glypican-1 and syndecan-1. Moreover, a regulator of the extracellular matrix, matrix metalloproteinase-14 (MMP-14) in the retina, and MMP-2 and MMP-9 in plasma, were increased by METH treatment. In conclusion, METH administration is involved in retinal degeneration with a vascular loss of PECAM-1 and the glycocalyx in the CRA and retina, and an increase of MMPs.

Clinical characteristics and outcomes of methamphetamine-associated intracerebral hemorrhage

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.

Subarachnoid Mirage: A Case of Pseudosubarachnoid Hemorrhage

A 22-year-old man with a history of intravenous methamphetamine use presented with severe headache for 5 days, was afebrile, and had nuchal rigidity. Computed tomography and magnetic resonance imaging results were interpreted as revealing acute subarachnoid hemorrhage. Twenty-four hours later, he developed acute neurologic deterioration. A lumbar puncture was performed, revealing the presence of Staphylococcus aureus. The false-positive image mimicking blood was potentially a result of an extremely high protein concentration present in the cerebrospinal fluid, provoked by an intense inflammatory reaction leading to disruption of the blood-brain barrier. Pyogenic meningitis is one of the causes of pseudosubarachnoid hemorrhage, or a false diagnosis of subarachnoid hemorrhage, when one does not actually exist.