October 10, 2011
43-year-old man with altered level of consciousness and spastic quadriparesis.
Chasing the Dragon (Heroin Leukoencephalopathy)
- Rare toxic spongiform leukoencephalopathy that occurs secondary to the practice of inhaling vapors from heroin that has been heated on a piece of foil aka "chasing the dragon."
- Initial presentation may include ataxia, cerebellar ataxia, and motor restlessness, with variable progression to more severe neurologic symptoms. Can be fatal, with a mortality rate of approximately 25%.
- Often a latent period between exposure and clinical presentation.
- Key Diagnostic Features: Striking symmetric involvement of cerebellar white matter, cerebellar peduncles, brainstem, posterior cerebral white matter, and posterior limbs of the internal capsules. CT demonstrates low attenuation change of these involved structures, with MR demonstrating increased signal on long-TR sequences. No obvious restricted diffusion is seen. MRS demonstrates reduced NAA and increased lactate peaks.
- DDx: PRES
