Neurologic Effects of Cocaine Workup

  • Author: Pinky Agarwal, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA   more...
 
Updated: Mar 8, 2011
 

Laboratory Studies

Lab tests should be ordered on the basis of patient presentation. Indications for ordering labs are as follows:

  • Diagnosis of cocaine use
    • Urine drug screen: Qualitative drug screens usually test for the inactive cocaine metabolite, benzoylecgonine, which may be present for as long as 36 hours after a single use. Metabolites can be demonstrated in the urine within 5 minutes after intravenous administration. With long-term use, urine metabolites may be detected for as long as 3 weeks after discontinuation of the drug. Urine drug screen in the neonate also can be used to detect possible in utero exposure to cocaine. The persistence of benzoylecgonine, which can be detected in the neonate's urine for as long as 4 days, is due to slow metabolism, probably related to immaturity or relative deficiency of plasma cholinesterases in the newborn.
    • Serum level of cocaine: This can be determined but has not been found to be useful clinically because of the rapid metabolism and short half-life of the drug.
  • Diagnosis of neurological complications: Tests used for diagnosing neurological complications include antinuclear antibody (ANA), creatine kinase (CK), CT scan, brain MRI, magnetic resonance angiography (MRA) of neck and intracranial vessels, 4-vessel angiogram, echocardiogram (transthoracic, transesophageal), positron emission tomography (PET), and single-photon emission computed tomography (SPECT).
  • CK: Urine should be evaluated routinely for the presence of myoglobin. Of patients with cocaine-induced rhabdomyolysis, 75% have a positive urine dipstick result for the orthotolidine reaction for heme, 67% yield positive findings for urine protein, and many manifest microscopic hematuria.
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Imaging Studies

  • CT scan of brain: Focal neurological deficits or alterations in mental status are indications for performing CT scan of the brain. With long-term cocaine use, significant cerebral atrophy, enlarged lateral ventricles, and widened sylvian fissures may be seen. CT scan also reveals intracerebral hemorrhage.
  • MRI of brain: MRI of newborns exposed to cocaine in utero may reveal evidence of cortical infarction, major congenital malformations, and mainly midline CNS abnormalities. Prenatal cocaine exposure reveals subtle microstructural changes on diffusion tensor imaging, suggesting less mature development of frontal white matter pathways.[7]
  • MRA of brain and intracranial vessels: MRA is indicated in patients with ischemic stroke or subarachnoid hemorrhage. MRA may show evidence of vasculitis or aneurysm; venous phase may show evidence of venous thrombosis.
  • Four-vessel angiogram: This study is indicated in patients with a history of cocaine abuse and presenting with intracerebral hemorrhage, especially subarachnoid hemorrhage. Angiogram may show underlying vascular abnormalities. Berry aneurysms of the circle of Willis are a common finding. Arteriovenous (AV) malformations or tumor may be seen as well. Rarely, superior sagittal sinus thrombosis with hemorrhagic venous infarction, dural AV fistula, rupture of multiple mycotic aneurysms, and large-vessel thrombosis have been described. Angiographic beading can be seen in patients with vasculitis.
  • Neuroradiological study of newborns born to mothers who had used cocaine during pregnancy may reveal periventricular leukomalacia or holoprosencephaly. Evidence of intracerebral, intraventricular or subarachnoid hemorrhage may be observed. Sonography, CT scan, and MRI revealed cortical infarcts and midline congenital malformations in 15% of infants exposed to cocaine in utero.
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Other Tests

  • ECG: Perform ECG if patient has chest pain.
  • EEG: Perform EEG in patients with seizures and a history of cocaine use. Habitual cocaine use can be associated with diffuse slowing on EEG. Focal abnormalities in the form of spikes or slowing can be seen in patients with focal seizures or intracerebral complications.
  • Transthoracic and transesophageal echocardiogram: Perform transthoracic and transesophageal echocardiogram in patients with embolic stroke caused by cocaine use. These studies may show evidence of vegetations in patients with infective endocarditis.
  • PET and SPECT: These studies may provide additional information in long-term cocaine users presenting with neuropsychiatric manifestations. Cerebral blood flow is reduced in habitual cocaine abusers, and abnormalities are most marked in the prefrontal cortex. Some investigators using PET have found reduced glucose metabolism over the entire cerebral cortex, thalamus, and midbrain. SPECT with iodine-123 isopropyl iodoamphetamine (IMP) revealed irregularly reduced cerebral perfusion even among asymptomatic social cocaine users who had normal findings on CT scans. In cocaine-dependent polydrug users (many of whom also used opioids and/or ethanol), some authors have found abnormal cerebral perfusion that primarily involved parietal, temporal, frontal, and basal ganglia.[8]
  • Ophthalmoscopic examinations and fundus photography of the retinas of cocaine addicts have revealed increased retinal arterial branching angle and venular caliber.[9]
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Contributor Information and Disclosures
Author

Pinky Agarwal, MD  Clinical Assistant Professor, Department of Neurology, University of Washington; Attending Neurologist, Booth Gardner Parkinson's Care Center, Kirkland, WA

Pinky Agarwal, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, and Movement Disorders Society

Disclosure: Nothing to disclose.

Coauthor(s)

Souvik Sen, MD, MPH, MS, FAHA  Professor and Chair, Department of Neurology, University of South Carolina School of Medicine

Souvik Sen, MD, MPH, MS, FAHA is a member of the following medical societies: American Academy of Neurology, American Heart Association, and Association for Patient Oriented Research

Disclosure: NINDS Grant/research funds Research project; BMS/Sanofi Aventis Honoraria Speaking and teaching; Boehringer Ingelheim Honoraria Speaking and teaching

Specialty Editor Board

Edward L Hogan, MD  Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina

Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Neurological Association, American Society for Biochemistry and Molecular Biology, Phi Beta Kappa, Sigma Xi, Society for Neuroscience, and Southern Clinical Neurological Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Richard J Caselli, MD  Professor, Department of Neurology, Mayo Medical School, Rochester, MN; Chair, Department of Neurology, Mayo Clinic of Scottsdale

Richard J Caselli, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Neurological Association, and Sigma Xi

Disclosure: Nothing to disclose.

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Chief Editor

Stephen A Berman, MD, PhD, MBA  Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

References

  1. Freud S. Uber Coca.Neu durchgesehener und vermehrter Separat-Abdruck aus dem Centralblatt fur die gesamte Therapie, II. Vienna: Verlag von Moritz Perles; 1884-1885:289-314.

  2. elSohly MA, Brenneisen R, Jones AB. Coca paste: chemical analysis and smoking experiments. J Forensic Sci. Jan 1991;36(1):93-103. [Medline].

  3. Pozzi M, Roccatagliata D, Sterzi R. Drug abuse and intracranial hemorrhage. Neurol Sci. Sep 2008;29 Suppl 2:S269-70. [Medline].

  4. Harzke AJ, Williams ML, Bowen AM. Binge Use of Crack Cocaine and Sexual Risk Behaviors Among African-American, HIV-Positive Users. AIDS Behav. Aug 30 2008;[Medline].

  5. Grov C, Kelly BC, Parsons JT. Polydrug use among club-going young adults recruited through time-space sampling. Subst Use Misuse. 2009;44(6):848-64. [Medline].

  6. Zagnoni PG, Albano C. Psychostimulants and epilepsy. Epilepsia. 2002;43 Suppl 2:28-31. [Medline].

  7. Warner TD, Behnke M, Eyler FD, et al. Diffusion tensor imaging of frontal white matter and executive functioning in cocaine-exposed children. Pediatrics. 2006;118(5):2014-24. [Medline].

  8. Tumeh SS, Nagel JS, English RJ, Holman BL. Cerebral abnormalities in cocaine abusers: demonstration by SPECT perfusion brain scintigraphy. Work in progress. Radiology. Sep 1990;176(3):821-4. [Medline].

  9. Leung IY, Lai S, Ren S, Kempen J, Klein R, Tso MO, et al. Early retinal vascular abnormalities in African-American cocaine users. Am J Ophthalmol. July/2008;146(4):612-619. [Medline]. [Full Text].

  10. Nejtek VA, Avila M, Chen LA, Zielinski T, Djokovic M, Podawiltz A, et al. Do atypical antipsychotics effectively treat co-occurring bipolar disorder and stimulant dependence? A randomized, double-blind trial. J Clin Psychiatry. Aug/2008;69(8):1257-66. [Medline]. [Full Text].

  11. Shoptaw S, Heinzerling KG, Rotheram-Fuller E, Kao UH, Wang PC, Bholat MA, et al. Bupropion hydrochloride versus placebo, in combination with cognitive behavioral therapy, for the treatment of cocaine abuse/dependence. J Addict Dis. 2008;27(1):13-23. [Medline].

  12. Dattilo PB, Hailpern SM, Fearon K, Sohal D, Nordin C. Beta-blockers are associated with reduced risk of myocardial infarction after cocaine use. Ann Emerg Med. Feb2008;51(2):117-25. [Medline].

  13. McCord J, Jneid H, Hollander JE, de Lemos JA, Cercek B, Hsue P. Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation. Apr 8 2008;117(14):1897-907. [Medline].

  14. [Best Evidence] Martell BA, Orson FM, Poling J, Mitchell E, Rossen RD, Gardner T, et al. Cocaine vaccine for the treatment of cocaine dependence in methadone-maintained patients: a randomized, double-blind, placebo-controlled efficacy trial. Arch Gen Psychiatry. Oct 2009;66(10):1116-23. [Medline].

  15. Lason W. Neurochemical and pharmacological aspects of cocaine-induced seizures. Pol J Pharmacol. Jan-Feb 2001;53(1):57-60. [Medline].

  16. Zhou W, Lin PH, Bush RL, et al. Acute arterial thrombosis associated with cocaine abuse. J Vasc Surg. Aug 2004;40(2):291-5. [Medline].

  17. Brody SL, Slovis CM, Wrenn KD. Cocaine-related medical problems: consecutive series of 233 patients. Am J Med. Apr 1990;88(4):325-31. [Medline].

  18. Amin M, Gabelman G, Karpel J, Buttrick P. Acute myocardial infarction and chest pain syndromes after cocaine use. Am J Cardiol. Dec 15 1990;66(20):1434-7. [Medline].

  19. McCord J, Jneid H, Hollander JE, de Lemos JA, Cercek B, Hsue P. Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation. Apr 8 2008;117(14):1897-907. [Medline].

  20. Chang AM, Walsh KM, Shofer FS, et al. Relationship Between Cocaine Use and Coronary Artery Disease in Patients With Symptoms Consistent With an Acute Coronary Syndrome. Acad Emerg Med. Dec 23 2010;[Medline].

  21. MacDonald S, Mann R, Chipman M, Pakula B, Erickson P, Hathaway A, et al. Driving behavior under the influence of cannabis or cocaine. Traffic Inj Prev. 2008;9(3):190-4. [Medline].

  22. Bendersky M, Bennett D, Lewis M. Aggression at Age 5 as a Function of Prenatal Exposure to Cocaine, Gender, and Environmental Risk. J Pediatr Psychol. Apr 12 2005;[Medline].

  23. Brewer JD, Meves A, Bostwick JM, Hamacher KL, Pittelkow MR. Cocaine abuse: dermatologic manifestations and therapeutic approaches. J Am Acad Dermatol. Sep 2008;59(3):483-7. [Medline].

  24. Brown E, Prager J, Lee HY, Ramsey RG. CNS complications of cocaine abuse: prevalence, pathophysiology, and neuroradiology. AJR Am J Roentgenol. Jul 1992;159(1):137-47. [Medline].

  25. Brust JC. Clinical, radiological, and pathological aspects of cerebrovascular disease associated with drug abuse. Stroke. Dec 1993;24(12 Suppl):I129-33; discussion I134-5. [Medline].

  26. Chasnoff IJ, Bussey ME, Savich R, Stack CM. Perinatal cerebral infarction and maternal cocaine use. J Pediatr. Mar 1986;108(3):456-9. [Medline].

  27. Dackis CA, Kampman KM, Lynch KG, et al. A double-blind, placebo-controlled trial of modafinil for cocaine dependence. Neuropsychopharmacology. Jan 2005;30(1):205-11. [Medline].

  28. Fiellin DA, Pantalon MV, Chawarski MC, et al. Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence. N Engl J Med. Jul 27 2006;355(4):365-74. [Medline].

  29. Gillman MA, Lichtigfeld FJ, Harker N. Psychotropic analgesic nitrous oxide for acute cocaine withdrawal in man. 1: Int J Neurosci. 2006;116(7):847-57. [Medline].

  30. Green RM, Kelly KM, Gabrielsen T, et al. Multiple intracerebral hemorrhages after smoking "crack" cocaine. Stroke. Jun 1990;21(6):957-62. [Medline].

  31. Halkitis PN, Palamar JJ. Multivariate modeling of club drug use initiation among gay and bisexual men. Subst Use Misuse. 2008;43(7):871-9. [Medline].

  32. Hayaki J, Anderson B, Stein M. Sexual risk behaviors among substance users: relationship to impulsivity. Psychol Addict Behav. 2006;20(3):328-32. [Medline].

  33. Jacobs IG, Roszler MH, Kelly JK, et al. Cocaine abuse: neurovascular complications. Radiology. Jan 1989;170(1 Pt 1):223-7. [Medline].

  34. Kaku DA, Lowenstein DH. Emergence of recreational drug abuse as a major risk factor for stroke in young adults. Ann Intern Med. Dec 1 1990;113(11):821-7. [Medline].

  35. Kaye BR, Fainstat M. Cerebral vasculitis associated with cocaine abuse. JAMA. Oct 16 1987;258(15):2104-6. [Medline].

  36. Killam AL. Cardiovascular and thrombosis pathology associated with cocaine use. Hematol Oncol Clin North Am. Dec 1993;7(6):1143-51. [Medline].

  37. Klonoff DC, Andrews BT, Obana WG. Stroke associated with cocaine use. Arch Neurol. Sep 1989;46(9):989-93. [Medline].

  38. Krendel DA, Ditter SM, Frankel MR, Ross WK. Biopsy-proven cerebral vasculitis associated with cocaine abuse. Neurology. Jul 1990;40(7):1092-4. [Medline].

  39. Levine SR, Brust JC, Futrell N, et al. A comparative study of the cerebrovascular complications of cocaine: alkaloidal versus hydrochloride--a review. Neurology. Aug 1991;41(8):1173-7. [Medline].

  40. Mody CK, Miller BL, McIntyre HB, et al. Neurologic complications of cocaine abuse. Neurology. Aug 1988;38(8):1189-93. [Medline].

  41. Nalls G, Disher A, Daryabagi J, et al. Subcortical cerebral hemorrhages associated with cocaine abuse: CT and MR findings. J Comput Assist Tomogr. Jan-Feb 1989;13(1):1-5. [Medline].

  42. Nolte KB, Brass LM, Fletterick CF. Intracranial hemorrhage associated with cocaine abuse: a prospective autopsy study. Neurology. May 1996;46(5):1291-6. [Medline].

  43. Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol. 2006;108(4):1005-16.

  44. Pascual-Leone A, Dhuna A, Altafullah I, Anderson DC. Cocaine-induced seizures. Neurology. Mar 1990;40(3 Pt 1):404-7. [Medline].

  45. Rivero M, Karlic A, Navaneethan SD, Singh S. Possible cocaine-induced acute renal failure without rhabdomyolysis. J Nephrol. Jan-Feb;. 2006;19(1):108-10. [Medline].

  46. Rohsenow DJ, Monti PM, Martin RA, et al. Motivational enhancement and coping skills training for cocaine abusers: effects on substance use outcomes. Addiction. Jul 2004;99(7):862-74. [Medline].

  47. Roth ME, Carroll ME. Sex differences in the escalation of intravenous cocaine intake following long- or short-access to cocaine self-administration. Pharmacol Biochem Behav. Jun 2004;78(2):199-207. [Medline].

  48. Sanchez-Ramos JR. Psychostimulants. Neurol Clin. Aug 1993;11(3):535-53. [Medline].

  49. Sen S, Silliman SL, Braitman LE. Vascular risk factors in cocaine users with stroke. J Stroke Cerebrovasc Dis. 1999;8(4):254-258.

  50. Sloan MA, Kittner SJ, Rigamonti D, Price TR. Occurrence of stroke associated with use/abuse of drugs. Neurology. Sep 1991;41(9):1358-64. [Medline].

  51. Sofuoglu M, Kosten TR. Novel approaches to the treatment of cocaine addiction. CNS Drugs. 2005;19(1):13-25. [Medline].

 
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