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Neuroimaging Features of Heroin Inhalation Toxicity: "Chasing the Dragon"

¹ Department of Radiology, Vancouver Hospital and Health Sciences Centre UBC Site, 2211 Wesbrook Mall, Vancouver, B. C., V6T 2B5 Canada.
² Department of Neurology, Vancouver Hospital and Health Sciences Centre-UBC Site, Vancouver, B. C., V6T 2B5 Canada.

View larger version (121K): [in a new window]   Fig. 1A. —27-year-old man found at home with decreased level of consciousness, aphasia, and spastic quadraparesis. Patient died after seizure 6 weeks after admission and underwent autopsy. Axial CT scan obtained through cerebellum shows symmetric white matter hypodensity with sparing of cortex.

View larger version (127K): [in a new window]   Fig. 1B. —27-year-old man found at home with decreased level of consciousness, aphasia, and spastic quadraparesis. Patient died after seizure 6 weeks after admission and underwent autopsy. Axial CT scan obtained through brain at level of third ventricle shows symmetric white matter hypoattenuation in optic radiations and posterior limbs of internal capsule, simulating dragon's claws.

View larger version (114K): [in a new window]   Fig. 1C. —27-year-old man found at home with decreased level of consciousness, aphasia, and spastic quadraparesis. Patient died after seizure 6 weeks after admission and underwent autopsy. CT scan, obtained cranially relative to A and B, shows more extensive white matter involvement.

View larger version (163K): [in a new window]   Fig. 1D. —27-year-old man found at home with decreased level of consciousness, aphasia, and spastic quadraparesis. Patient died after seizure 6 weeks after admission and underwent autopsy. Axial T2-weighted MR image obtained through posterior fossa shows white matter hyperintensity in cerebellar white matter, sparing cortex and dentate nuclei. Superior, middle, and inferior peduncles were all involved. Note abnormal signal in pons involving corticospinal tracts (white arrow), medial lemnisci, and central tegmental tracts (black arrow). Findings resemble bearded (dentate nuclei) skull.

View larger version (164K): [in a new window]   Fig. 1E. —27-year-old man found at home with decreased level of consciousness, aphasia, and spastic quadraparesis. Patient died after seizure 6 weeks after admission and underwent autopsy. Axial T2-weighted MR image obtained through midbrain shows hyperintensity in medial lemnisci and spinothalamic tracts (arrow), with sparing of adjacent substantia nigra and red nuclei. Image resembles bat staring at viewer.

View larger version (154K): [in a new window]   Fig. 1F. —27-year-old man found at home with decreased level of consciousness, aphasia, and spastic quadraparesis. Patient died after seizure 6 weeks after admission and underwent autopsy. Axial T2-weighted MR image obtained through upper brain reveals extensive signal abnormality tending to preferentially involve posterior white matter. Subcortical white matter (arrows) is spared.

View larger version (159K): [in a new window]   Fig. 2A. —39-year-old man with bradykinesia and ataxia. Axial fluid-attenuated inversion recovery (FLAIR) image shows symmetrically increased signal in cerebellar white matter, peduncles, and pons (white arrow). As in patient shown in Figure 1A,1B,1C,1D,1E,1F,1G,1H, dentate nuclei are spared (black arrow).

View larger version (167K): [in a new window]   Fig. 2B. —39-year-old man with bradykinesia and ataxia. Axial FLAIR image reveals symmetric abnormal signal in optic radiations (short arrow) and posterior limbs of internal capsule (long arrow). Anterior limb of internal capsule was spared in all patients.

View larger version (127K): [in a new window]   Fig. 2C. —39-year-old man with bradykinesia and ataxia. Axial FLAIR image shows characteristic involvement of posterior white matter.

View larger version (113K): [in a new window]   Fig. 3A. —32-year-old man with dysarthria, ataxia, and bradykinesia after inhalation of heroin vapor. Axial CT scan obtained through posterior fossa shows extensive hypodensity in cerebellar hemispheres, with sparing of dentate nuclei, similar to that in patients shown in Figures 1A,1B,1C,1D,1E,1F,1G,1H and 2A,2B,2C.

View larger version (137K): [in a new window]   Fig. 3B. —32-year-old man with dysarthria, ataxia, and bradykinesia after inhalation of heroin vapor. Axial T2-weighted MR image shows symmetric signal hyperintensity in posterior limbs of internal capsule and optic radiations.

View larger version (97K): [in a new window]   Fig. 1G. —27-year-old man found at home with decreased level of consciousness, aphasia, and spastic quadraparesis. Patient died after seizure 6 weeks after admission and underwent autopsy. Low-power photomicrograph of histopathologic specimen shows normal gray matter (white arrow) and subcortical white matter (curved arrow). Extensive spongiform degeneration and vacuole formation are present in deeper white matter (black arrow). (H and E)

View larger version (86K): [in a new window]   Fig. 1H. —27-year-old man found at home with decreased level of consciousness, aphasia, and spastic quadraparesis. Patient died after seizure 6 weeks after admission and underwent autopsy. High-power photomicrograph of histopathologic specimen shows spongiform degeneration and vacuole formation. (H and E)

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