Neurological complications and pathogenetic therapy for chronic nitrous oxide intoxication (“laughing gas”) in nightclub visitors

Background. Nitrous oxide abuse (“laughing gas”, N2O) is common among young people attending nightclubs. Contrary to popular belief about the safety of N2O, in some cases neurological complications develop due to a deficiency of vitamin B12, the activity of which is blocked by N2O. Purpose of the study – to determine the typology and course of neurological disorders in a group of patients who regularly use “laughing gas”. To note the key diagnostic markers that allow verification of vitamin B12 deficiency induced by nitrous oxide consumption. To describe pathogenetic therapy features and follow-up. Materials and methods. The study included 12 patients (10 men and 2 women) aged 18 to 45 years (average age 29 years) with a diagnosis of B12-deficient myelopolyneuropathy induced by regular use of nitrous oxide. Results. The most common neurological complication of nitrous oxide abuse for more than 1 month was a generalized lesion of the peripheral nerves with acute or subacute distal symmetric sensory or sensorimotor axonal polyneuropathy. In the clinical picture, sensory complaints and disorders prevailed. Paresis developed in half of the cases. A typical neuroimaging symptom characteristic of funicular myelosis was rarely detected (16.7 %). A decrease in B12 vitamin level could most reliably be diagnosed only indirectly, by the presence of hyperhomocysteinemia (91.7 % of cases). In all cases that were followed-up, prolonged therapy with cyanocobalamin led to partial (n = 5; 62.5 %) or complete (n = 3; 37.5 %) regression of neurological symptoms. Conclusion. Caution regarding the use of nitrous oxide should be in all cases of predominantly sensory polyneuropathy with acute or subacute development in young and middle-aged people. A thorough history taking (targeted survey on the fact of nitrous oxide consumption) and diagnostics (testing the level of homocysteine, if possible methylmalonic acid) allow you to not miss a deficiency of vitamin B12, the treatment of the consequences of which with timely verification and adequate correction is quite effective. It is recommended that the level of homocysteine in the blood to be regularly monitored during the treatment (in order to achieve its normalization).

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Metabolic encephalopathy caused by nitrous oxide (‘laughing gas’) induced hyperammonaemia

BMJ Case Reports ◽

10.1136/bcr-2019-232163 ◽

2019 ◽

Vol 12 (11) ◽

pp. e232163

Author(s):

Marissa Ginette Danielle Vive ◽

Galia Valentinova Anguelova ◽

Sjoerd Duim ◽

Herman Marcel André Hofstee

Keyword(s):

Emergency Department ◽

Nitrous Oxide ◽

Altered Mental Status ◽

Vitamin B ◽

Recreational Drug ◽

Metabolic Encephalopathy ◽

Laughing Gas ◽

Catabolic State ◽

Ammonia Degradation

A 26-year-old man presented at the emergency department with confusion and decreased consciousness after several days of vomiting. In the preceding 6 months, he had used a 2-litre tank of nitrous oxide (N2O) weekly. His metabolic encephalopathy was caused by hyperammonaemia which probably resulted from interference of N2O-induced vitamin B12 deficiency with ammonia degradation. A catabolic state might have contributed to the hyperammonaemia in this case. After treatment with vitamin B12 and lactulose, both his consciousness and hyperammonaemia improved. He reported no residual complaints after 3 months of follow-up. Since N2O is increasingly used as a recreational drug, we recommend considering hyperammonaemia as a cause of metabolic encephalopathy in cases of N2O use and altered mental status.

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Acute axonal polyneuropathy with predominant proximal involvement: an uncommon neurological complication of bariatric surgery

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2006000400017 ◽

2006 ◽

Vol 64 (3a) ◽

pp. 609-612 ◽

Cited By ~ 9

Author(s):

Flavia Costa Nunes Machado ◽

Berenice Cataldo Oliveira Valério ◽

Roberto Naun Franco Morgulis ◽

Karlo Faria Nunes ◽

Sílvia Mazzali-Verst

Keyword(s):

Bariatric Surgery ◽

Morbid Obesity ◽

Neurological Complication ◽

Neurological Complications ◽

Gastric Surgery ◽

Lower Limbs ◽

Vitamin Supplementation ◽

Axonal Polyneuropathy ◽

Peripheral Polyneuropathy

Bariatric surgery is frequently indicated in the treatment of morbid obesity. Previously unreported complications have been associated to this surgery; among them, neurological complications have gained attention. We report the case of a 25-year-old man submitted to gastric surgery for treatment of morbid obesity who developed, two months after surgery, acute proximal weakness in lower limbs. The electroneuromyography revealed axonal peripheral polyneuropathy with predominant proximal involvement. After treatment with immunoglobulin and vitamin supplementation, rapid clinical and neurophysiologic recovery was observed. We describe the clinical and electroneuromyographic features of this case, stressing the difficulty of initial diagnosis, particularly in the differential diagnosis with Guillain-Barré syndrome. We discuss the importance of nutritional follow-up and the eventual indication of routine vitamin supplementation in these patients.

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Treatment of posterior circulation fusiform aneurysms

Journal of Neurosurgery ◽

10.3171/2020.4.jns192838 ◽

2020 ◽

pp. 1-7

Author(s):

Ephraim W. Church ◽

Mark G. Bigder ◽

Eric S. Sussman ◽

Santosh E. Gummidipundi ◽

Summer S. Han ◽

...

Keyword(s):

Neurological Complication ◽

Posterior Inferior Cerebellar Artery ◽

Retrospective Chart Review ◽

Neurological Complications ◽

Posterior Circulation ◽

Flow Diversion ◽

Interdisciplinary Treatment ◽

Complication Rates ◽

The Difference

OBJECTIVEPerforator arteries, the absence of an aneurysm discrete neck, and the often-extensive nature of posterior circulation fusiform aneurysms present treatment challenges. There have been advances in microsurgical and endovascular approaches, including flow diversion, and the authors sought to review these treatments in a long-term series at their neurovascular referral center.METHODSThe authors performed a retrospective chart review from 1990 to 2018. Primary outcomes were modified Rankin Scale (mRS) scores and Glasgow Outcome Scale (GOS) scores at follow-up. The authors also examined neurological complication rates. Using regression techniques, they reviewed independent and dependent variables, including presenting features, aneurysm location and size, surgical approach, and pretreatment and posttreatment thrombosis.RESULTSEighty-four patients met the inclusion criteria. Their mean age was 53 years, and 49 (58%) were female. Forty-one (49%) patients presented with subarachnoid hemorrhage. Aneurysms were located on the vertebral artery (VA) or posterior inferior cerebellar artery (PICA) in 50 (60%) patients, basilar artery (BA) or vertebrobasilar junction (VBJ) in 22 (26%), and posterior cerebral artery (PCA) in 12 (14%). Thirty-one (37%) patients were treated with microsurgical and 53 (63%) with endovascular approaches. Six aneurysms were treated with endovascular flow diversion. The authors found moderate disability or better (mRS score ≤ 3) in 85% of the patients at a mean 14-month follow-up. The GOS score was ≥ 4 in 82% of the patients. The overall neurological complication rate was 12%. In the regression analysis, patients with VA or PICA aneurysms had better functional outcomes than the other groups (p < 0.001). Endovascular strategies were associated with better outcomes for BA-VBJ aneurysms (p < 0.01), but microsurgery was associated with better outcomes for VA-PICA and PCA aneurysms (p < 0.05). There were no other significant associations between patient, aneurysm characteristics, or treatment features and neurological complications (p > 0.05). Patients treated with flow diversion had more complications than those who underwent other endovascular and microsurgical strategies, but the difference was not significant in regression models.CONCLUSIONSPosterior circulation fusiform aneurysms remain a challenging aneurysm subtype, but an interdisciplinary treatment approach can result in good outcomes. While flow diversion is a useful addition to the armamentarium, traditional endovascular and microsurgical techniques continue to offer effective options.

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Timing and Spectrum of Neurological Complications After Flow Diverter Implantation for Intracranial Aneurysms

Frontiers in Neurology ◽

10.3389/fneur.2021.590383 ◽

2021 ◽

Vol 12 ◽

Author(s):

Guillaume Charbonnier ◽

Jean-Philippe Desilles ◽

Simon Escalard ◽

Benjamin Maier ◽

Gabriele Ciccio ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Neurological Complication ◽

Neurological Complications ◽

Flow Diverter ◽

Factors Associated ◽

Long Term Follow Up ◽

Ischemic Complications ◽

Ischemic Events

Background and Purpose: The aim of this study was to characterize neurological complications after flow diverter (FD) treatment on a long follow-up cohort and identify predictive factors associated with these complications.Methods: This study was conducted on a monocentric cohort of patients treated for intracranial aneurysms by FD.Results: Between September 2008 and July 2018, 413 patients were treated for 514 aneurysms: 18% of the patients presented with at least one neurological complication during a median follow-up of 446 days (IQR 186–1,210). Sixty-one patients presented with ischemic complications, 13 with hemorrhagic ones and 10 with compressive processes. Among 89 neurological complications 64.5% were peri-operative (occurring within the 30 days following the procedure) and 35.5% were delayed after 1 month.Conclusions: Overall, neurological complications after FD implantation were overrepresented by cerebrovascular ischemic events occurring during the peri-operative period, but also in a delayed manner after 1 year. Long-term follow-up is relevant after aneurysm intervention using FD.

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Hemorrhagic Posterior Reversible Encephalopathy Syndrome: A Rare Neurological Complication of COVID-19 Infection

International Clinical Neuroscience Journal ◽

10.34172/icnj.2021.30 ◽

2021 ◽

Vol 8 (3) ◽

pp. 149-152

Author(s):

Esmaeil KhanMohammadi ◽

Marziyeh Shahrabi ◽

Mohsen Koosha

Keyword(s):

Posterior Reversible Encephalopathy Syndrome ◽

Neurological Complication ◽

Neurological Complications ◽

Convulsive Status Epilepticus ◽

Posterior Reversible Encephalopathy ◽

Cerebrovascular Complication ◽

History Of ◽

Reversible Encephalopathy ◽

Hypertensive Therapy

Neurological complications of COVID-19 are well documented. However, there are limited reports of posterior reversible encephalopathy syndrome (PRES) associated with COVID-19 in the literature. Herein, we described a 21-year-old man with a history of bipolar disease and opioid addiction who was admitted because of COVID-19 infection. He suddenly experienced a convulsive status epilepticus following hypertension crisis. The patient was intubated and underwent antiepileptic and anti-hypertensive therapy. His brain imaging was compatible with PRES. The patient gradually improved and was eventually discharged after 40 days. On the next month follow-up, the patient was able to walk with a cane without a history of seizure. In this report, we aimed to highlight the less common cerebrovascular complication of COVID-19 infection.

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Nitrous oxide myelopathy with functional vitamin B12deficiency

BMJ Case Reports ◽

10.1136/bcr-2018-227439 ◽

2019 ◽

Vol 12 (2) ◽

pp. e227439 ◽

Cited By ~ 4

Author(s):

John Williamson ◽

Saif Huda ◽

Dinesh Damodaran

Keyword(s):

Nitrous Oxide ◽

Male Patient ◽

Neurological Complications ◽

Vitamin B ◽

Blood Tests ◽

Dorsal Columns ◽

Legal High ◽

The Uk ◽

Recreational Use

Recreational use of nitrous oxide as a ‘legal high’ is increasing in the UK. Physicians should be ‘street wise’ to this increasing prevalence and aware of the potential neurological complications which may result from misuse. We describe a 17-year-old male patient who presented to neurology with a severe myelopathy following prolonged recreational use of nitrous oxide. MRI demonstrated characteristic changes affecting the dorsal columns and blood tests demonstrated a ‘functional’ B12 deficiency. Clinical and radiological improvement was noted following initiation of vitamin B12 replacement.

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The dangers of recreational inhalation of nitrous oxide

British Journal of Hospital Medicine ◽

10.12968/hmed.2021.0322 ◽

2021 ◽

pp. 1-8

Author(s):

Joshua Wong ◽

Thevarajah Viyasar ◽

Benjamin Layton ◽

Joshua Lauder

Keyword(s):

Nitrous Oxide ◽

Psychosocial Interventions ◽

Complete Recovery ◽

Clinical Findings ◽

Vitamin B ◽

Alveolar Pressure ◽

Subacute Combined Degeneration ◽

System A ◽

Laughing Gas ◽

The Uk

Nitrous oxide, also known as ‘laughing gas’, is one of the most widely used recreational drugs among teenagers in the UK. Copious inhalation of nitrous oxide may increase intra-alveolar pressure, resulting in barotrauma secondary to alveolar rupture. Pneumomediastinum and subcutaneous emphysema are common clinical findings in nitrous oxide-associated barotrauma. Prolonged nitrous oxide misuse may inactivate vitamin B12 through the alteration of its metabolism, causing demyelination of the central and peripheral nervous system. A spectrum of neurological manifestations has been reported, including peripheral neuropathy, myelopathy and subacute combined degeneration of the spinal cord. Medical therapies and psychosocial interventions aiming at nitrous oxide cessation are important treatment steps to achieve partial or complete recovery from the adverse effects associated with inhalation of nitrous oxide.

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Serum copper decrease and cerebellar atrophy in patients with nitrous oxide-induced subacute combined degeneration: two cases report

BMC Neurology ◽

10.1186/s12883-021-02496-y ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jie Cao ◽

Lusen Ran ◽

Chenchen Liu ◽

Zhijun Li

Keyword(s):

Nitrous Oxide ◽

Neuropsychiatric Symptoms ◽

Neurological Complication ◽

Macrocytic Anemia ◽

Cerebellar Atrophy ◽

Serum Copper ◽

Copper Level ◽

Vitamin B ◽

Subacute Combined Degeneration ◽

First Time

Abstract Background Subacute combined degeneration (SCD) is a neurological complication commonly associated with vitamin B12 deficiency. It can result from nitrous oxide (N2O) abuse and cause neuropsychiatric symptoms. However, there has been no literature regarding alterations of serum copper and cerebellum in SCD patients. Case presentation We reported two cases of young SCD patients with histories of N2O abuse. In these cases, elevated homocysteine, macrocytic anemia, spinal cord abnormalities, and peripheral nerve injuries were detected. In addition, decreased serum copper level and cerebellar atrophy were reported for the first time. The patients’ symptoms improved after withdrawal of N2O exposure and vitamin B12 supplements. Conclusion We reported two SCD cases with serum copper alteration and cerebellar atrophy after N2O abuse for the first time. These might be crucial complements to the diagnosis of SCD.

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Ischaemic Haemorrhagic Stroke in a Child with New Onset Type 1 Diabetes Mellitus

European Endocrinology ◽

10.17925/ee.2018.14.1.59 ◽

2018 ◽

Vol 14 (1) ◽

pp. 59

Author(s):

Noor Shafina Mohd Nor ◽

Choong Yi Fong ◽

Kartini Rahmat ◽

Wan Mun Vanessa Lee ◽

Azriyanti Anuar Zaini ◽

...

Keyword(s):

Neurological Complication ◽

Complete Recovery ◽

Haemorrhagic Stroke ◽

Neurological Status ◽

Neurological Complications ◽

Limb Weakness ◽

Ischaemic Injury ◽

Brain Scans

Cerebral oedema is the most common neurological complication of diabetic ketoacidosis (DKA). However, ischaemic and haemorrhagic brain injury has been reported infrequently. A 10-year old girl who was previously well presented with severe DKA. She was tachycardic with poor peripheral perfusion but normotensive. However, two fast boluses totalling 40 ml/kg normal saline were given. She was transferred to another hospital where she was intubated due to drowsiness. Rehydration fluid (maintenance and 48-hour correction for 7.5% dehydration) was started followed by insulin infusion. She was extubated within 24 hours of admission. Her ketosis resolved soon after and subcutaneous insulin was started. However, about 48 hours after admission, her Glasgow Coma Scale score dropped to 11/15 (E4M5V2) with expressive aphasia and upper motor neuron signs. One dose of mannitol was given. Her symptoms improved gradually and at 26-month follow-up she had a near-complete recovery with only minimal left lower limb weakness. Serial magnetic resonance imaging brain scans showed vascular ischaemic injury at the frontal-parietal watershed regions with haemorrhagic transformation. This case reiterates the importance of monitoring the neurological status of patient’s with DKA closely for possible neurological complications including an ischaemic and haemorrhagic stroke.

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SURGICAL COMPLICATIONS OF PARAPHARYNGEAL SCHWANNOMA: OUR EXPERIENCE

10.36106/ijsr/7621198 ◽

2020 ◽

pp. 1-3

Author(s):

Debabrata Das ◽

Pritha Ghosh ◽

Riya Das ◽

Tanmoy Sarkar

Keyword(s):

Neurological Complication ◽

Tertiary Care ◽

Surgical Excision ◽

Neurological Complications ◽

Neck Mass ◽

Female Ratio ◽

Transcervical Approach ◽

Medical College ◽

Male Female Ratio

Introduction– Tumors of parapharyngeal space are rare. Schwannomas, originating either from Schwann cells or fibroblasts supporting the nerve, are one of the benign neurological tumors occurring in this space. Surgical excision is the mainstay of its management. Transcervical approach is carried out for most of the parapharyngeal schwannomas. This article aims to study the clinical and radiological presentation of parapharyngeal schwannoma and also to study post-operative neurological outcome. Materials and methods – A retrospective study was conducted from June 2018 to November 2019 (1.5 years) at the Department of Otolaryngology, in a tertiary care medical college & hospital. A total of 7 cases of parapharyngeal schwannoma were selected; the clinical, radiological presentation was studied. Post-operative complications were studied within a follow up period of 8 months. Results – The mean age of presentation was 44 years. Male: Female ratio was 5:2. Five patients (71.4%) presented with left sided lesions whereas 2 patients (28.6%) were with right sided lesions. The most common presentation was an asymptomatic palpable neck mass in 4 patients (57.1%). 4 patients (57.1%) had mass arising from vagus nerve, 2 patients (28.6%) had mass arising from sympathetic trunk and one patient (14.3%) had mass arising from hypoglossal nerve. 4 patients (57.1%) had neurological complication in immediate post-operative period, out of which 3 patients (42.8%) improved within 8 months follow up. Conclusion – Most of the parapharyngeal schwannoma presents with asymptomatic slow growing neck and/or oropharyngeal mass. Progressive growth can result in dysphagia. Surgical excision may accompany neurological complications. Outcome of neurological sequelae depends on preserving the anatomical integrity of the nerve from which the tumor arises.

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