Acute Leukoencephalopathy after Inhalation of a Single Dose of Heroin

Abstract

We describe extended and repeat magnetic resonance (MR) examinations in the case of a 16-year-old male who developed acute left-sided sensorimotor hemiplegia after a single dose of inhaled heroin. MRI revealed symmetrical hyperintense signals in T₂-weighted images and massive diffusion disorders in the diffusion weighted images predominantly in parieto-occipital subcortical white matter and both ventral globi pallidi with preservation of U fibers and no brain oedema. MR spectroscopy data were compatible with combined hypoxic and mitochondrial damage resulting in axonal injury without demyelination. Normal values and variations had been obtained from spectra of five age-matched subjects. This is the first reported MR follow-up study of leukoencephalopathy occurring acutely after a first inhaled dose of heroin. We postulate that toxic spongiform leukoencephalopathy in heroin addicts may be the outcome of a complex mechanism directly triggered by heroin and causing mitochondrial as well as hypoxic injury in specific and limited areas of white matter.

Key words

Leukoencephalopathy - inhaled heroin - MRI - magnetic resonance spectroscopy

References

• 1 Chang Y J, Tsai C H, Chen C J. Leukoencephalopathy after inhalation of heroin vapor.  J Formos Med Assoc. 1997;  96 758-760
• 2 Chen C Y, Lee K W, Lee C C, Chin S C, Chung H W, Zimmerman R A. Heroin-induced spongiform leukoencephalopathy: value of diffusion MR imaging.  J Comput Assist Tomogr. 2000;  24 735-737
• 3 Häussinger D, Laubenberger J, vom Dahl S, Ernst T, Bayer S, Langer M. et al . Proton magnetic resonance spectroscopy studies on human brain myo-inositol in hypo-osmolarity and hepatic encephalopathy.  Gastroenterology. 1994;  107 1475-1480
• 4 Hofmann L, Slotboom J, Jung B, Maloca P, Boesch C, Kreis R. Quantitative ¹H-magnetic resonance spectroscopy of human brain: Influence of composition and parameterization of the basis set in linear combination model fitting.  Magn Reson Med. 2002;  48 440-453
• 5 Hungerbuehler H, Waespe W. Leukoenzephalopathie nach Inhalation von Heroin-Pyrolysat.  Schweiz Med Wochenschr. 1990;  120 1801-1805
• 6 Kreis R. Quantitative localized ¹H-MR spectroscopy for clinical use.  Prog NMR Spectroscopy. 1997;  31 155-195
• 7 Kreis R, Arcinue E, Ernst T, Shonk T K, Flores R, Ross B D. Hypoxic encephalopathy after near-drowning studied by quantitative ¹H-magnetic resonance spectroscopy: Metabolic changes and their prognostic value.  J Clin Invest. 1996;  97 1142-1154
• 8 Kriegstein A R, Shungu D C, Millar W S, Armitage B A, Brust J C, Chillrud S. et al . Leukoencephalopathy and raised brain lactate from heroin vapor inhalation.  Neurology. 1999;  53 1765-1773
• 9 O'Donnell P, Buxton P J, Pitkin A, Jarvis L J. The magnetic resonance imaging appearances of the brain in acute carbon monoxide poisoning.  Clin Radiol. 2000;  55 273-80
• 10 Provencher S W. Estimation of metabolite concentration from localized in vivo proton NMR spectra.  Magn Reson Med. 1993;  30 672-679
• 11 Roulet Perez E, Maeder P, Rivier L, Deonna T. Toxic leukoencephalopathy after heroin ingestion in a 2 œ-year-old child.  Lancet. 1992;  340 729
• 12 Tan P, Algra P R, Valk Jaap, Wolters E C. Toxic leukoencephalopathy after inhalation of poisoned heroin: MR Findings.  AJNR. 1994;  15 175-178
• 13 Weber W, Henkes H, Moller P, Bade K, Kuhne D. Toxic spongiform leukoencephalopathy after inhaling heroin vapor.  Eur Radiol. 1998;  8 749-755
• 14 Wilichowski E, Pouwels P J, Frahm J, Hanefeld F. Quantitative proton magnetic resonance spectroscopy of cerebral metabolic disturbances in patients with MELAS.  Neuropediatrics. 1999;  30 256-63
• 15 Wolters E C, van Wijngaarden G K, Stam F C, Rengelink H, Lousberg R J, Schipper M EI. et al . Leucoencephalopathy after inhaling heroin pyrolysate.  Lancet. 1982;  ii 1233-1237