The New Classes of Synthetic Illicit Drugs Can Significantly Harm the Brain: a Neuro Imaging Perspective with Full Review of MRI Findings
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Clinical Radiology & Imaging Journal The New Classes of Synthetic Illicit Drugs Can Significantly Harm the Brain: A Neuro Imaging Perspective with Full Review of MRI Findings Creagh S1*, Warden D2, Latif MA3 and Paydar A4 Review Article 1 Ponce Health Sciences University, Ponce, PR Volume 2 Issue 1 2Diagnostic Radiologist, Florida Hospital-Orlando Received Date: March 31, 2018 3Diagnostic Radiologist, Mount Sinai Medical Center- Miami Beach, FL Published Date: April 25, 2018 4Diagnostic Radiologist, Florida Hospital-Orlando, University of Central Florida College of Medicine, and Florida State University College of Medicine *Corresponding author: Susana Creagh Reyes, Ponce Health Sciences University, 888 Biscayne Blvd, Apt 3809, USA, Tel: 7873613988; Email: [email protected] Abstract Synthetic drugs contain substances that are pharmacologically similar to those found in traditional illicit drugs. Some of the most commonly abused synthetic drugs include synthetic marijuana, bath salts, ecstasy, N-bomb, methamphetamine and anabolic steroids. Many of them share the same chemical properties and physiologic responses with the drugs they mimic and may exaggerate the pathologic response in the brain leading to addiction. These drugs have detrimental (and often irreversible) effects on the brain and primarily affect the central nervous system by two mechanisms: 1) Neural hyper stimulation via increasing activation of certain neurotransmitters (norepinephrine, dopamine, and serotonin), 2) Cause significant reduction in CNS neural connectivity affecting various brain regions such as the basal ganglia, hippocampus, cerebellum, parietal lobe, and globus pallidus. Furthermore these drugs sometimes have severe, life- threatening adverse effects on the human body. A few structural MRI studies have been conducted in synthetic drug abusers to reveal the effects of these drugs on the brain parenchyma. This review article will describe the potential brain imaging findings in synthetic drug abusers as demonstrated by several case reports and the primary literature. Keywords: MRI; Pharmacologically; Pathophysiologic; Cannabinoids; Cathinone; N-methylamphetamine Abbreviations: MRI: Magnetic Resonance Imaging; Methylene Dioxy Pyro Valerone; ADC: Apparent Diffusion THC: Tetra Hydro Cannabinol; OFC: Orbito Frontal Cortex; Coefficient; BOLD: Blood Oxygen Level Dependent; FLAIR: Fluid Attenuation Inversion Recovery; MDPV: MDMA: Methylene Dioxy-Methamphetamine; AAS: Anabolic-Androgenic Steroids. The New Classes of Synthetic Illicit Drugs Can Significantly Harm the Brain: A Neuro Imaging Perspective with Full Review of MRI Findings Clin Radiol Imaging J 2 Clinical Radiology & Imaging Journal Introduction 2012, 11% of American high school seniors disclosed using synthetic marijuana within the last year [1]. Synthetic drugs contain substances that are pharmacologically similar to those found in traditional Synthetic cannabinoids are a combination of herbs and illicit drugs, such as cocaine, methamphetamine, and spices with similar effects as marijuana; however, they marijuana. Some of these synthetic counterparts are can be four times as potent. This drug is usually spread on available in various forms as over the counter herbal material before being smoked, usually in joints or medications and thereby easily accessible to the general pipes. This chemical regulates and binds more strongly to population. These particular over the counter medications the same brain receptors as delta-9-tetra hydro are sold under various names including Jazz, Scooby Snax, cannabinol (THC), the psychoactive component in Spice and Bath Salts, among others. Synthetic drug abuse marijuana, which may account for its stronger and more is a growing epidemic worldwide. Many of these drugs are unpredictable effects. Its psychological effects are addictive stimulants, and their repeated use causes long analogous to those of marijuana including altered term or irreversible damage to dopaminergic, adrenergic perception, paranoia, excessive anxiety, violent behavior and serotonergic pathways in the brain. Some of the most and suicidal thoughts [2]. Previous studies have found commonly abused synthetic drugs include synthetic that chronic marijuana users present with a decreased marijuana, bath salts, ecstasy, N bomb, methamphetamine brain volume in the orbito frontal cortex (OFC), a brain and anabolic steroids. Many of them share the same region that is related to addiction, but otherwise chemical properties and physiologic responses with the demonstrate increased brain connectivity [3]. Yet, limited drugs they mimic and may exaggerate the pathologic research has been performed on the effect of synthetic response in the brain leading to addiction. Furthermore cannabinoids on the brain. Especially, there are few these drugs sometimes have severe, life-threatening records revealing MRI findings in patients under the adverse effects on the human body, including triggering influence of synthetic cannabinoids in the acute setting. seizures, cardiac arrhythmias, acute infarction, and even Few studies available to date have demonstrated sudden death. However, most of these drugs’ abnormal restricted diffusion involving large portions of pathophysiologic and toxic effects have not been well vascular territories or, alternatively, presenting in an studied in the human population, hence resulting in embolic pattern. unknown and unpredictable outcomes. In the meantime, recent advances in medical imaging have made it easy to For instance, a prior case report about two women study the brain parenchyma with great detail. A few (ages 22 and 26) with stroke like symptoms hours after structural MRI studies have been conducted in synthetic having consumed synthetic marijuana demonstrated an drug abusers to reveal the effects of these drugs on the extensive area of acute infarction within the middle brain parenchyma. This review article will describe the cerebral artery vascular territory. Similarly, another study potential brain imaging findings in synthetic drug abusers presenting 19 and 26 year old siblings that had used as demonstrated by several case reports and the primary synthetic cannabis revealed multi-embolic acute infarcts literature. within the middle cerebral artery vascular territory. Yet, a case of a 50 year old male that was found unconscious Objective after synthetic cannabis use the night prior to presentation demonstrated a bilateral symmetric pattern Evaluate the effect of commonly abused new synthetic of abnormal diffusion restriction on MR diffusion imaging drugs on the brain based on abnormal findings detected involving many regions of the brain, not limited to a single by Magnetic Resonance Imaging (MRI). vascular territory. Fluid attenuation inversion recovery (FLAIR) images also showed abnormal hyper intense Discussion signal within the hippocampi, basal ganglia, posterior limbs of the internal capsules, bifrontal cortex, cerebral Synthetic Cannabinoids (Synthetic /Marijuana/ peduncles, posteroinferior cerebellar hemispheres, and Spice K2) the cerebellar vermis (Figures 1 and 2). The fact that this patient did not have other clinical manifestations or On average the US market introduces five synthetic causes of embolic stroke to support these MRI findings drugs every month, which means 60 different names in a may sustain the hypothesis that synthetic marijuana can year. Synthetic marijuana has grown into the second most result in direct neurotoxicity, presumably by affecting commonly abused drug among young males. In fact, in mitochondrial function similar to tetrahydrocannabinol Creagh RS. The New Classes of Synthetic Illicit Drugs Can Significantly Harm the Brain: A Copyright© Creagh RS. Neuro Imaging Perspective with Full Review of MRI Findings. Clin Radiol Imaging J 2018, 2(1): 000116. 3 Clinical Radiology & Imaging Journal (THC) [4]. This pattern is that of a global hypoxic ischemic findings denote how important it is for medical physicians injury. to consider synthetic marijuana intoxication in the differential diagnosis of a first time seizure. Identification Other MRI findings reported in a 24 year old male with of the aforementioned imaging findings can also be a first time seizure after Spice use included diffuse sulcal valuable for early diagnosis of synthetic marijuana FLAIR hyper intensity as well as leptomeningeal toxicity, which has become an increasing issue in the enhancement on post contrast imaging (Figure 3). Such emergency setting [5]. Figure 1: MR images of the brain of a 50 y/o patient following synthetic cannabis use. (A) The basal ganglia and (B) the hippocampi and cerebral peduncles exhibit FLAIR hyper intensities bilaterally. Panels C & D show symmetric restricted diffusion in the basal ganglia bilaterally demonstrating: (C) “hyper intensity on diffusion weighted imaging (DWI) and (D) hypo intensity on the apparent diffusion coefficient (ADC) map” “Courtesy of Sherwani et al., 2015”[4]. Figure 2: DWI images of the brain demonstrate “symmetric pattern of restricted diffusion” that correlated with areas of hyper intensities on FLAIR images (not presented) “Courtesy of Sherwani et al., 2015” [4]. Creagh RS. The New Classes of Synthetic Illicit Drugs Can Significantly Harm the Brain: A Copyright© Creagh RS. Neuro Imaging Perspective with Full Review of MRI Findings. Clin Radiol Imaging J 2018, 2(1): 000116. 4 Clinical Radiology & Imaging Journal Figure 3: Initial T2-weighted MR FLAIR image of the brain demonstrates bilateral sulcal hyper intensity