Case study 23 - Methamphetamine is a sympathomimetic amine, which has stimulant, euphoric, and hallucinogenic effects. From 2015 to 2018, an estimated 1.6 million US adults had reported annual methamphetamine use, and 22.3% had reported injecting methamphetamine within the past year. A total of 52.9% had a methamphetamine use disorder. Methamphetamine has increased lipophilicity, which enables it to easily pass through the blood-brain barrier. It is an indirect neurotransmitter that embeds itself into cytoplasmic vesicles where it displaces epinephrine, norepinephrine, dopamine, and serotonin into the cytosol. As these concentrations rise within the cell, the neurotransmitters diffuse out of the neuron and synapse with the postsynaptic receptors, resulting in a surge of adrenergic stimulation. These stimulated adrenergic receptors cause hypertension, tachycardia, hyperthermia, and vasospasm, which may be hard to differentiate from more-critical complications that methamphetamine can cause.

Methamphetamine, cocaine, and ecstasy are known as “designer drugs.” They are quickly replacing traditional causes of intracranial hemorrhage in young adults. These hemorrhages occur because of uncontrolled hypertension, vasospasm, and in some cases—especially with methamphetamine and cocaine use—underlying vascular malformations like aneurysms. Therefore, a CT scan of the head should be part of the workup in young adults with methamphetamine use and behavioral changes.

The onset of action occurs within seconds after smoking or injecting the drug, and its peak plasma concentrations are reached 30 minutes after IV or intramuscular administration and up to 2 to 3 hours after ingestion. The plasma half-life is 12 to 34 hours, although the duration can persist longer when renal or hepatic insufficiency is present or in individuals with binge use, given that the breakdown of methamphetamine results in active metabolites that can stack in the system.

Conclusion. From a neurological standpoint, acute methamphetamine use can cause agitation, delirium, and paranoia. However, cerebrovascular disorders contribute to morbidity, disability, and fatality associated with illicit drug use and should not be missed. A fatal complication from using methamphetamine or other designer drugs are brain bleeds, including intracranial hemorrhage, subarachnoid hemorrhage, and subdural hemorrhage, as well as underlying ischemia resulting in stroke.

In the past, these sequalae were thought to be solely caused by uncontrolled hypertension and vasospasm, as in our patient’s case. We now know that many patients have vascular anomalies as well. Illicitly misused neurostimulants predispose patients to aneurysmal formation with reported rupture at a younger age and with much smaller sized aneurysms.4 Therefore, in addition to conducting a CT scan of the head to rule in brain bleed, patients should also undergo a CT angiography scan if a bleed is found on the CT scan.

Causes of intracranial bleeds include disruption to the blood-brain barrier, changes in cerebral perfusion representing neural toxicity from excess neurotransmitters in the brain, and depletion of dopamine and serotonin; in chronic users, cortical grey and white matter loss is also seen. #brain #stroke #neurosurgery #emt #paramedic #firstresponders #emergency #ernurse #mentalhealthawareness #mentalhealthmatters #mentalhealth

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