Methamphetamine Use Tied to Heightened Hemorrhagic Stroke Risk

Pam Harrison

August 25, 2017

Methamphetamine has been linked to a heightened risk for hemorrhagic stroke in young adults, new research shows.

"I am a practicing psychiatrist and I have been surprised by the number of young people I see who use methamphetamine recreationally," Julia Lappin, MD, University of New South Wales, Australia, told Medscape Medical News.

"So it's important for clinicians to explain to young people why they need to inquire about illicit substance use. If young people are able to talk openly about their use, it informs better management of their healthcare as all risks can be considered and appropriate advice and help given when needed," said Dr Lappin.

The findings were published online August 23 in the Journal of Neurology, Neurosurgery and Psychiatry. 

Mortality and Morbidity

Investigators reviewed 77 epidemiologic and case report series to estimate the number of strokes in individuals younger than age 45 years that were potentially attributed to illicit methamphetamine use. The drug, popularly known as speed, ice, or crystal meth, can be swallowed, smoked, injected, or used intranasally.

In the review, 81 hemorrhagic strokes and 17 ischemic strokes could be traced back to illicit methamphetamine use. Both stroke types were about twice as common in men as in women.

The investigators also found that men were more likely to use methamphetamine and to use high doses of the drug, which may explain why they were more likely than their female counterparts to have a stroke.

Hemorrhagic strokes most often occurred after the drug was swallowed or injected. In contrast, ischemic strokes were more likely to occur when methamphetamine was smoked. Still, both types of strokes occurred regardless of the way the drug was used.

For both hemorrhagic and ischemic stroke, headache was the predominant early clinical feature.

In hemorrhagic stroke, headache was often accompanied by vomiting, one-sided weakness, and seizures developing over time, while hypertension was frequently observed in the setting of ischemic stroke.

In hemorrhagic stroke, there were 60 cases of intracranial hemorrhage (ICH) and 32 cases of subarachnoid hemorrhage (SAH). Thirteen patients had evidence of both ICH and SAH.

No vasculature abnormalities were found in approximately half of all cases of hemorrhagic stroke. However, cerebral aneurysm was detected in 17% of cases of hemorrhagic stroke and arteriovenous malformation was detected in 8% of cases.

Other vasculature abnormalities, most frequently beading of the vessel wall or cerebral arteritis, were reported in about a one third of patients with hemorrhagic stroke.

"Haemorrhagic stroke resulted in death in a third of cases," the investigators report.  

A quarter of patients who had a hemorrhagic stroke recovered completely, but residual symptoms, from mild weakness to permanent speech and language difficulties, remained in about 40% of the overall group.

As for those who had an ischemic stroke, 20% died while another 20% recovered completely. The remaining 60% were left with residual impairments, including defects in speech and vision.

"Strikingly High" Rate of Hemorrhagic Stroke

Dr Lappin said it's not clear why the majority of strokes tied to methamphetamine use were hemorrhagic.

"It is well known that methamphetamine increases blood pressure, both transiently, as an acute effect of use, and chronically, leading to accelerated hypertensive changes in many users," she said.

Methamphetamine-induced hypertension could also trigger bleeding in vessels, causing a hemorrhagic stroke, especially if preexisting vascular abnormalities are present, she added.

Whatever the mechanism, the 80% of methamphetamine-related strokes identified in the review were hemorrhagic is "strikingly high" compared with hemorrhagic stroke rates of 40% to 55% in the general population younger than 45 years of age.  

"To discourage young people from using substances is difficult because the reasons behind drug use are complex," Dr Lappin said.

"So it's important for clinicians to understand the drivers of drug use for the individual and to try to offer support across multiple domains in their life: for example, social and family support, mental health issues, unemployment, and social exclusion."

While advising young people about the risks associated with illicit substance use in the short and long term may be valuable, "for many, knowledge of these risks won't lead to cessation," Dr Lappin cautioned.

Plausible Biological Mechanism?

Commenting on the study for Medscape Medical News, Karen Curtin, PhD, associate professor of medicine, University of Utah School of Medicine, Salt Lake City, said the finding that illicit methamphetamine use is linked to largely hemorrhagic stroke was not that surprising and that the suggested biological mechanism posited by the investigators seems plausible.

"In absolute terms, the risk of [hemorrhagic stroke] in a methamphetamine-using population is low. But relative to the population at large, there is an adverse impact that seems to be associated with its use," she said.

As reported by Medscape Medical News. Dr Curtin and colleagues previously found that methamphetamine or its metabolite amphetamine increased the risk for Parkinson's disease (PD) by almost threefold compared with nonusers, The median age at PD onset in that cohort study of Utah residents was 50 years for women and 45 years for men.

Anecdotally, Dr Curtin has also observed that methamphetamine is often used by women following weight gain after pregnancy. This is often called the "Jenny Crank diet" because "crank" is slang for methamphetamine.

She also noted that, unlike in the eastern part of the United States, methamphetamine has long been the "drug of choice" in the western parts of the country. It was often made in basement laboratories in Utah, but more recently the drug is being made in Mexico.

"Other than the recent rash of the opioid epidemic and deaths, methamphetamine has long been the scourge of the intermountain west. My understanding is that it's the worst addiction there is because even after a single use of the drug, it changes the brain and there is no way to reverse the changes," said Dr Curtin.

"So I agree with the study authors that physicians need to be telling patients why they are asking about illicit methamphetamine use, and at least give patients information about the drug for their consideration," she said.

The authors and Dr Curtin have disclosed no relevant financial relationships.

J Neurol Neurosurg Psychiatry. Published online August 23, 2017. Abstract

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