Massive intracerebral hemorrhage following methamphetamine poisoning in a man: A case report

Abstract

Introduction and importance

Methamphetamine (MAP) is a highly addictive stimulant known to have detrimental effects on the brain and various physiological systems, including an elevation in heart rate and blood pressure. Additionally, MAP use has been linked to the development of intracerebral hemorrhage (ICH), a serious and potentially fatal condition that is notably prevalent among young individuals.

Case presentation

We present the case of a 42-year-old man who suffered a massive ICH due to hypertension resulting from MAP poisoning. The patient presented with symptoms of nausea, vomiting, and blurred vision for around two hours following the accidental inhalation of MAP. However, his condition was significantly improved through the implementation of neurosurgical intervention.

Clinical discussion

In recent years, the misuse of MAP among young adults has raised concerns about its association with ICH. ICH is a type of stroke where a blood vessel in the brain ruptures due to high blood pressure, causing bleeding. This medical emergency can lead to various symptoms, such as severe headaches, loss of consciousness, and paralysis. ICH is indeed a serious and life-threatening condition that necessitates prompt medical attention. It can also lead to long-term adverse effects for the individual affected.

Conclusions

The association with ICH and MAP abuse among young adults is a substantial public health issue. To gain a comprehensive understanding of the mechanisms underlying MAP abuse-induced elevation of ICH risk, further exploration is necessary.

Highlights

• •Methamphetamine is a highly addictive stimulant that has severe consequences on the brain and other physiological systems.
• •One of the effects of MAP is an increase in heart rate and blood pressure.
• •MAP use has been linked to the development of intracerebral hemorrhage (ICH).
• •ICH is indeed a serious and life-threatening condition that necessitates prompt medical attention.

1. Introduction

Methamphetamine (MAP) is a sympathomimetic agent that acts indirectly by enhancing neurotransmission through the production of biogenic amines like dopamine, serotonin, noradrenaline, and adrenaline [1]. MAP is commonly referred to as “ice,” “crack,” “speed,” or “glass,” and can be absorbed in several ways, including oral ingestion, injection, and inhalation, all of which can lead to severe poisoning [2]. In addition to causing an increase in heart rate and blood pressure, MAP also leads to heightened alertness and loss of appetite [3]. One serious condition associated with MAP use, especially among young individuals, is stroke [4].

MAP has an effect on the brain by causing an elevation in dopamine release from the vesicular storage and facilitating augmented extracellular dopamine levels through reverse transport [5]. The drug also affects serotonergic, glutamatergic, and nor-adrenergic neurotransmission by interacting with specific transporters like 5-HT transporters, N-Methyl-d-aspartate transporters, and monoamine transporters [5]. Notably, the cardiovascular and neurological systems are the most vulnerable to MAP poisoning.

Intracerebral hemorrhage (ICH) is a significant cause of stroke and has been identified as the second most common form of stroke. ICH presents with a high mortality rate [6]. The association with mean arterial pressure and ischemic and hemorrhagic stroke, including subarachnoid hemorrhage and ICH, has been investigated in prior studies [[7], [8], [9], [10]]. While hypertension remains the leading cause of ICH across all age groups, in younger adults, arteriovenous malformation, ruptured saccular aneurysm, and sympathomimetic drug usage are the primary factors [11,12]. This report describes the case of a 42-year-old male who suffered from massive ICH as a result of hypertension caused by MAP poisoning. The patient underwent a neurosurgical procedure that resulted in improvements to his condition. The work has been reported in line with the SCARE 2023 criteria [13].

2. Presentation of case

A 42-year-old male without underlying disease was brought to the emergency room of a hospital located in northern Iran. The patient presented with symptoms of nausea, vomiting, and blurred vision for around two hours following the accidental inhalation of MAP. It is important to note that prior to this incident, the patient did not have a history of substance use, anticoagulants, anti-platelets, trauma, hypertension, or cardiovascular disease. Upon arrival at the emergency department, the patient's Glasgow coma scale was measured to be 8 out of 15, blood pressure was 240/130 mmHg, heart rate was 110 beats per minute, respiratory rate was noted to be 20 breaths per minute, his temperature was measured to be 36.8 °C, and his blood oxygen saturation level was recorded as 97 % on room air.

Upon physical examination, the patient's level of consciousness had decreased and anisocoria of the pupils, prompting immediate intubation and move to the intensive care unit (ICU). The oral cavity examination revealed no lesions, including dental changes or gingivitis. Additionally, sonography of the internal abdominal and pelvic viscera revealed no abnormalities. A brain computed tomography (CT) scan subsequently revealed the presence of a massive ICH and intraventricular hemorrhage (IVH) (Fig. 1). Following consultation with a neurosurgeon, the patient was then transferred to the operation room for further intervention.

Fig. 1.

A brain computed tomography scan subsequently revealed the presence of a massive ICH and IVH.

After positioning the patient in the operation room with the head of the bed elevated at a 45-degree angle in the supine position and administering general anesthesia, sterile preparation, and draping were conducted for a twist-drill craniotomy. Burr holes were then created on both sides of the skull at Kocher's point. The pia and dura were penetrated using a scalpel, and an external ventricular drain catheter was inserted into the ventricles. Upon visualization of cerebrospinal fluid flow after removing the catheter stylet, the proximal and distal tubes were connected to an external drainage system. The skin was closed with sutures, and the patient was transferred to the recovery area.

Additionally, during the preliminary examinations, it was determined through the use of gas chromatography and mass spectrometry (GC–MS) on urine samples that metabolites of MAP and amphetamine were present. It was confirmed that co-intoxicants were not a factor following a comprehensive urine screening test utilizing GC–MS technology. The levels of MAP and amphetamine in the serum were measured to be 950 ng/ml and 84 ng/ml, respectively. The results of his laboratory findings are shown in Table 1. With the exception of an elevated serum creatinine level on the first day, which returned to normal in the following days, all other laboratory tests and urinary analysis showed no changes. The electrocardiogram revealed no abnormalities, except for sinus tachycardia.

Table 1.

The results of laboratory tests performed during hospitalization.

Parameter	Results	Normal range
BS	162	<200 mg/dl
BUN	13	6–24 mg/dl
Cr	1.3	0.6–1.2 mg/dl
Na	142	135–145 mEq/l
K	3.6	3.5–5.5 mEq/l
Ca	9.3	8.5–10.5 mg/dl
Mg	1.6	1.5–2.6 mEq/l
HB	13.6	14–16 g/dl
pH	7.39	–
HCO3	24.4	mEq/l
PCO2	40.9	mmHg
AST	39	<35 IU/l
ALT	16	<35 IU/l
ALP	250	80–306 IU/l
PT	12.5	10.5–11 Sec
PTT	37	25–35 Sec
INR	1.5	1–1.3 Ratio

Abbreviations: Cr: creatinine, BUN: blood urea nitrogen, BS: blood sugar, HB: hemoglobin, K: potassium, Na: sodium, Ca: calcium, Mg: magnesium, AST: aspartate aminotransferase, ALT: alanine aminotransferase, ALP: alkaline phosphatase, PH: potential of hydrogen, PCO₂: pressure of carbon dioxide, HCO₃: bicarbonate, PT: prothrombin time, PTT: partial thromboplastin time, INR: international normalised ratio.

The patient in the ICU was treated using a phenytoin ampule with a dosage of 750 mg stat, followed by 150 mg three times daily. Other medicines that were administered include dexamethasone at 8 mg three times daily, manitol serum, vancomycin at 1 g twice a day, meropenem at 1 g twice daily, and levetiracetam at 500 mg twice daily. As the patient's hypertension was well managed, there was no need to prescribe antihypertensive drugs. Additionally, during hospitalization, there were no clinical features to suggest the presence of chronic hypertension or MAP withdrawal in the patient.

A CT-angiogram was conducted on the patient; however, it did not reveal any evidence of arterio-ventricular malformation (AVM) or brain aneurysm (Fig. 2). The patient was extubated after five days, and ten days later, he was moved to the neurosurgery ward. Finally, the patient was discharged from the hospital in good general condition after three weeks (Fig. 3). Postoperatively, the patient was monitored for three months and made a full functional recovery.

Fig. 2.

A CT-angiogram did not reveal any evidence of AVM or brain aneurysm.

Fig. 3.

The CT scan shows absorption of ICH, IVH and improvement of the patient.

Written informed consent was obtained from the patient's parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. This study was conducted according to the Declaration of Helsinki Principles. The study is registered with the research registry, and the UIN is research registry 9933 https://www.researchregistry.com/browse-the-registry?__cf_chl_tk=5Ouzznv6GEvfnTQwgn14aPYg02xz7Oe7gCKxxCO4i10-1705649417-0-gaNycGzNDdA#home/.

3. Discussion

In recent years, there has been a growing concern regarding the correlation between ICH and the misuse of MAP among young adults [9]. This highly addictive stimulant is known to have severe consequences on the brain and other physiological systems [1]. Due to its association with various negative health outcomes, including ICH, the abuse of MAP has become a significant public health issue [14].

ICH pertains to a type of stroke that occurs when a blood artery within the brain ruptures and causes bleeding. This medical emergency can lead to various symptoms, such as severe headaches, loss of consciousness, and paralysis. ICH is a life-threatening condition that requires immediate medical care and can have long-term effects for the affected individual [15]. Current research indicates a substantial relationship between MAP abuse and ICH in young adults [9,16,17,and]. MAP usage is strongly linked to haemorrhagic stroke in 18–44-year-olds [8]. The use of MAP can cause hypertension and tachycardia, which may lead to intracranial hemorrhaging, even in the absence of underlying cerebrovascular disease. This was experienced in our case [18,19]. MAP can also result in vasoconstriction, pulmonary hypertension, coronary artery disease, cardiac arrhythmias, and cardiomyopathy, all of which may ultimately contribute to the occurrence of a stroke [18].

The preliminary signs of a stroke resulting from MAP usage are similar to those of a stroke caused by other factors. These symptoms include a severe headache, nausea, vomiting, confusion, and possibly motor or sensory impairments that can emerge several hours after taking the substance. The degree and location of a stroke might have an effect on the symptoms that manifest [16].

It is important to note that the administration of MAP through any route carries a risk of stroke. This risk is particularly significant in cases where substances are injected intravenously, as this can cause stroke through bacterial endocarditis or embolism [9]. Rectal administration of drugs, known colloquially as “boofing” or “butt chugging”, is not a common method of abuse. However, it should be noted that the extensive blood vessel system in the rectum can lead to immediate feelings of well-being, along with vasoconstriction that may result in mesenteric ischemia and subsequent colostomy, or even death [20].

The study by Lappin et al. revealed that haemorrhagic and ischemic strokes are roughly twice as prevalent in men. Haemorrhagic strokes were predominantly linked to oral or injectable MAP use, while inhalation was the primary route associated with ischemic strokes. The research findings indicated that MAP-induced strokes are linked to negative clinical consequences, with a higher incidence of haemorrhagic strokes in young individuals. Factors like hypertension, vasculitis, direct vasotoxicity, and vasospasm play a role in MAP-related cerebral strokes [9]. In our case, the stroke was caused by inhaling MAP and it was a haemorrhagic stroke. Additionally, the follow-up did not reveal any cerebrovascular sequelae.

In their publication, Rouhani et al. detailed a case of MAP poisoning in a male prisoner who had ingested MAP packages. The rupture of these packages resulted in symptoms such as restlessness, tachycardia, and hypertension. However, the aforementioned symptoms improved following a laparotomy procedure [2]. Joo-Young et al., reported a case of ICH predominantly affecting the right frontal lobe, coupled with IVH, in a 33-year-old previously healthy male who had been consuming MAP chronically. The patient had no history of medical conditions or trauma, and was brought to the emergency department with complaints of dyspnea and vomiting. Unfortunately, the patient expired just one hour after being admitted [21].

According to Zhu et al.'s study, MAP use is a risk factor for ICH. The study compared the clinical features and outcomes of MAP-associated ICH (MAP-ICH) versus non-MAP-ICH cases. The results showed that patients with MAP-ICH were more likely to be younger, male, and smokers. Conversely, non-MAP-ICH cases were more likely to have a history of hypertension or anticoagulant use. However, there was no significant difference in clinical severity, length of hospitalization, rates of functional independence, or mortality between the two groups [17].

McGee et al., described a healthy 31-year-old male who had a history of MAP abuse who developed slurred speech, a severe headache, and left-sided hemiparesis after inhaling MAP and died a few hours later. The autopsy revealed a bilateral subarachnoid hemorrhage with a prominent intralobar hemorrhage located in the right frontal cerebral hemisphere. However, no evidence of vasculitis, infarction, IVH, or ruptured aneurysm was observed [22].

According to Miyashita et al.'s report, a fatal case of pontine hemorrhage related to MAP abuse was autopsied. The autopsy revealed no severe trauma leading to death, and macroscopically, no vascular abnormalities such as aneurysms or malformations were observed. However, in the sections of the brain stem, a massive hematoma occupied the central area of the pons. The drug screening test was weakly positive for amphetamines, and in the blood sample, MAP was quantitatively detected at concentrations of 0.4 mg/l by GC–MS. The authors concluded that the pontine hemorrhage appeared to have resulted from MAP-induced angiitis, with an acute elevation of blood pressure after MAP abuse [23]. Fortunately, our patient did not die, and the CT angiography did not reveal any evidence of AVM or brain aneurysm. The blood concentrations of MAP and amphetamine, as measured by GC–MS technology, were 950 ng/ml and 84 ng/ml, respectively.

The management of acute MAP poisoning is primarily supportive. Activated charcoal may be administered if methamphetamine is ingested orally. Benzodiazepines like IV diazepam 10 mg can be used for seizures or agitation, while antipsychotics such as haloperidol may be necessary for patients experiencing paranoia or psychosis. In addition to managing agitation, external cooling methods may be needed for hyperthermia. If the patient's blood pressure remains elevated despite controlling agitation, α-adrenergic antagonist drugs like phentolamine and vasodilators such as nitroprusside may be recommended [24].

The considerable incidence of MAP abuse in young adults has raised significant apprehensions regarding the correlation between this drug and ICH, thus posing a substantial public health concern. In order to tackle this issue proactively, it is imperative for healthcare providers and policymakers to collaborate and devise efficacious approaches aimed at preventing and treating MAP abuse among young adults.

4. Conclusion

The correlation between ICH and MAP abuse among young adults is a substantial public health issue. To gain a comprehensive understanding of the mechanisms underlying MAP abuse-induced elevation of ICH risk, further exploration is necessary. In addition, effective prevention and treatment approaches need to be developed. Nonetheless, it is evident that immediate measures are required to address this problem and safeguard the health and welfare of young adults who are susceptible to MAP abuse and its related complications. It is imperative for clinicians to be mindful of the possibility of ICH in cases where young adult patients with a history of MAP abuse exhibit symptoms.

Patient (parent's) consent

Written informed consent was obtained from the patient's parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval for this study (No: IR.MAZUMS.REC.1399.7850) was provided by the Mazandaran University of Medical Science Ethical Committee on 29 July 2020 and was carried out in accordance with the Helsinki Declaration Principles.

Funding

None.

Guarantor

Elham Sadat Banimostafavi.

Research registration number

9933.

CRediT authorship contribution statement

ZZ and AMT involved in the clarification and collecting of data and writing of the manuscript draft. ESB and AM involved in editing of the manuscript. ZZ is responsible for presenting data and submitting the manuscript. All authors reviewed and approved the final version of the manuscript.

Declaration of competing interest

The authors declare that they have no conflicts of interest.

Data availability statement

The data are available with the correspondence author and can be achieved on request.