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Draytsel DY, Gul S, Sanjel Chhetri A, Masoud H. Opioid Overdose-Induced Diffusion Restriction in the Bilateral Basal Ganglia Revealed on Brain Imaging. Cureus 2024; 16:e59649. [PMID: 38832172 PMCID: PMC11147649 DOI: 10.7759/cureus.59649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2024] [Indexed: 06/05/2024] Open
Abstract
Opioid misuse and addiction have led to an opioid epidemic in the United States, with widespread effects on the healthcare system. Opioid-induced cardiovascular morbidity and mortality effects have been extensively described in past literature; however, neurological effects have been described less frequently. Here, we describe a case of a female patient who presented to our center after being found unresponsive with magnetic resonance imaging (MRI), revealing bilateral basal ganglia diffuse restriction hyperintensities secondary to a diagnosis of opioid overdose. Opioid overdose-induced bilateral basal ganglia diffusion restriction has only been described infrequently in the literature. Recognizing the associated imaging findings as a potential consequence of opioid overdose is important to avoid unnecessary workups for ischemic stroke.
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Affiliation(s)
| | - Sedat Gul
- Neurology, Upstate University Hospital, Syracuse, USA
| | | | - Hesham Masoud
- Neurology, Upstate University Hospital, Syracuse, USA
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Eden CO, Alkhalaileh DS, Pettersson DR, Hunter AJ, Arastu AH. Clinical and neuroradiographic features of fentanyl inhalation-induced leukoencephalopathy. BMJ Case Rep 2024; 17:e258395. [PMID: 38684340 PMCID: PMC11103052 DOI: 10.1136/bcr-2023-258395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 05/02/2024] Open
Abstract
A man in his late 40s with no known past medical history was unresponsive for an unknown period of time. Crushed pills and white residue were found on a nearby table. On presentation he was obtunded and unresponsive to verbal commands but withdrawing to painful stimuli. The initial urine drug screen was negative, but a urine fentanyl screen was subsequently positive with a level of 137.3 ng/mL. MRI of the brain showed reduced diffusivity and fluid attenuated inversion recovery (FLAIR) hyperintensity symmetrically in the bilateral supratentorial white matter, cerebellum and globus pallidus. Alternative diagnoses such as infection were considered, but ultimately the history and workup led to a diagnosis of fentanyl-induced leukoencephalopathy. Three days after admission the patient became able to track, respond to voice and follow basic one-step commands. The patient does not recall the mechanism of inhalation. While there are case reports of heroin-induced leukoencephalopathy following inhaled heroin use and many routes of fentanyl, this is the first reported case of a similar phenomenon due to fentanyl inhalation.
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Affiliation(s)
- Christopher O Eden
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Duna S Alkhalaileh
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - David R Pettersson
- Department of Diagnostic Radiology, Oregon Health & Science University, Portland, OR, USA
| | - Alan J Hunter
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Asad H Arastu
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Newburn G, Condron P, Kwon EE, McGeown JP, Melzer TR, Bydder M, Griffin M, Scadeng M, Potter L, Holdsworth SJ, Cornfeld DM, Bydder GM. Diagnosis of Delayed Post-Hypoxic Leukoencephalopathy (Grinker's Myelinopathy) with MRI Using Divided Subtracted Inversion Recovery (dSIR) Sequences: Time for Reappraisal of the Syndrome? Diagnostics (Basel) 2024; 14:418. [PMID: 38396456 PMCID: PMC10888335 DOI: 10.3390/diagnostics14040418] [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: 12/31/2023] [Revised: 01/25/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Delayed Post-Hypoxic Leukoencephalopathy (DPHL), or Grinker's myelinopathy, is a syndrome in which extensive changes are seen in the white matter of the cerebral hemispheres with MRI weeks or months after a hypoxic episode. T2-weighted spin echo (T2-wSE) and/or T2-Fluid Attenuated Inversion Recovery (T2-FLAIR) images classically show diffuse hyperintensities in white matter which are thought to be near pathognomonic of the condition. The clinical features include Parkinsonism and akinetic mutism. DPHL is generally regarded as a rare condition. Methods and Results: Two cases of DPHL imaged with MRI nine months and two years after probable hypoxic episodes are described. No abnormalities were seen on the T2-FLAIR images with MRI, but very extensive changes were seen in the white matter of the cerebral and cerebellar hemisphere on divided Subtraction Inversion Recovery (dSIR) images. dSIR sequences may produce ten times the contrast of conventional inversion recovery (IR) sequences from small changes in T1. The clinical findings in both cases were of cognitive impairment without Parkinsonism or akinetic mutism. Conclusion: The classic features of DPHL may only represent the severe end of a spectrum of diseases in white matter following global hypoxic injury to the brain. The condition may be much more common than is generally thought but may not be recognized using conventional clinical and MRI criteria for diagnosis. Reappraisal of the syndrome of DPHL to include clinically less severe cases and to encompass recent advances in MRI is advocated.
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Affiliation(s)
- Gil Newburn
- Mātai Medical Research Institute, Tairāwhiti Gisborne 4010, New Zealand; (G.N.); (M.S.); (S.J.H.)
| | - Paul Condron
- Mātai Medical Research Institute, Tairāwhiti Gisborne 4010, New Zealand; (G.N.); (M.S.); (S.J.H.)
- Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences & Centre for Brain Research, University of Auckland, Auckland 1010, New Zealand
| | - Eryn E. Kwon
- Mātai Medical Research Institute, Tairāwhiti Gisborne 4010, New Zealand; (G.N.); (M.S.); (S.J.H.)
- Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences & Centre for Brain Research, University of Auckland, Auckland 1010, New Zealand
| | - Joshua P. McGeown
- Mātai Medical Research Institute, Tairāwhiti Gisborne 4010, New Zealand; (G.N.); (M.S.); (S.J.H.)
| | - Tracy R. Melzer
- Department of Medicine, University of Otago, Christchurch 8011, New Zealand
- New Zealand Brain Research Institute, Christchurch 8011, New Zealand
| | - Mark Bydder
- Mātai Medical Research Institute, Tairāwhiti Gisborne 4010, New Zealand; (G.N.); (M.S.); (S.J.H.)
| | - Mark Griffin
- Mātai Medical Research Institute, Tairāwhiti Gisborne 4010, New Zealand; (G.N.); (M.S.); (S.J.H.)
- Insight Research Services Associated, Gold Coast 4215, Australia
| | - Miriam Scadeng
- Mātai Medical Research Institute, Tairāwhiti Gisborne 4010, New Zealand; (G.N.); (M.S.); (S.J.H.)
- Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences & Centre for Brain Research, University of Auckland, Auckland 1010, New Zealand
| | - Leigh Potter
- Mātai Medical Research Institute, Tairāwhiti Gisborne 4010, New Zealand; (G.N.); (M.S.); (S.J.H.)
| | - Samantha J. Holdsworth
- Mātai Medical Research Institute, Tairāwhiti Gisborne 4010, New Zealand; (G.N.); (M.S.); (S.J.H.)
- Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences & Centre for Brain Research, University of Auckland, Auckland 1010, New Zealand
| | - Daniel M. Cornfeld
- Mātai Medical Research Institute, Tairāwhiti Gisborne 4010, New Zealand; (G.N.); (M.S.); (S.J.H.)
- Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences & Centre for Brain Research, University of Auckland, Auckland 1010, New Zealand
| | - Graeme M. Bydder
- Mātai Medical Research Institute, Tairāwhiti Gisborne 4010, New Zealand; (G.N.); (M.S.); (S.J.H.)
- Department of Radiology, University of California San Diego, San Diego, CA 92093, USA
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Xavier CG, Kuo M, Desai R, Palis H, Regan G, Zhao B, Moe J, Scheuermeyer FX, Gan WQ, Sabeti S, Meilleur L, Buxton JA, Slaunwhite AK. Association between toxic drug events and encephalopathy in British Columbia, Canada: a cross-sectional analysis. Subst Abuse Treat Prev Policy 2023; 18:42. [PMID: 37420239 PMCID: PMC10329314 DOI: 10.1186/s13011-023-00544-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/03/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Encephalopathy can occur from a non-fatal toxic drug event (overdose) which results in a partial or complete loss of oxygen to the brain, or due to long-term substance use issues. It can be categorized as a non-traumatic acquired brain injury or toxic encephalopathy. In the context of the drug toxicity crisis in British Columbia (BC), Canada, measuring the co-occurrence of encephalopathy and drug toxicity is challenging due to lack of standardized screening. We aimed to estimate the prevalence of encephalopathy among people who experienced a toxic drug event and examine the association between toxic drug events and encephalopathy. METHODS Using a 20% random sample of BC residents from administrative health data, we conducted a cross-sectional analysis. Toxic drug events were identified using the BC Provincial Overdose Cohort definition and encephalopathy was identified using ICD codes from hospitalization, emergency department, and primary care records between January 1st 2015 and December 31st 2019. Unadjusted and adjusted log-binomial regression models were employed to estimate the risk of encephalopathy among people who had a toxic drug event compared to people who did not experience a toxic drug event. RESULTS Among people with encephalopathy, 14.6% (n = 54) had one or more drug toxicity events between 2015 and 2019. After adjusting for sex, age, and mental illness, people who experienced drug toxicity were 15.3 times (95% CI = 11.3, 20.7) more likely to have encephalopathy compared to people who did not experience a drug toxicity event. People who were 40 years and older, male, and had a mental illness were at increased risk of encephalopathy. CONCLUSIONS There is a need for collaboration between community members, health care providers, and key stakeholders to develop a standardized approach to define, screen, and detect neurocognitive injury related to drug toxicity.
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Affiliation(s)
- Chloé G Xavier
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
| | - Margot Kuo
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- Overdose Emergency Response Centre, Ministry of Mental Health and Addictions, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Roshni Desai
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Heather Palis
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada
| | - Gemma Regan
- Faculty of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC, Canada
- Woodward Instructional Resource Centre, Vancouver, BC, V6T 1Z3, Canada
| | - Bin Zhao
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Jessica Moe
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- Department of Emergency Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- Department of Emergency Medicine, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Frank X Scheuermeyer
- St Paul's Hospital and the Department of Emergency Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- Centre for Health Evaluation & Outcomes Sciences, St Paul's Hospital, 588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Wen Qi Gan
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Soha Sabeti
- Health Surveillance, First Nations Health Authority, 100 Park Royal S, West Vancouver, BC, V7T 1A2, Canada
| | - Louise Meilleur
- Health Surveillance, First Nations Health Authority, 100 Park Royal S, West Vancouver, BC, V7T 1A2, Canada
| | - Jane A Buxton
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Amanda K Slaunwhite
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada
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