By Dr Linxin Li, Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, Oxford University, UK

Mr X was referred to our TIA clinic last month. He is in his late-60s. Although retired, he has remained active in life. He has known history of hypertension, hyperlipidaemia and has smoked 18-20 cigarettes/day for over 40 years.

He presented with two clear-cut transient episodes of right arm weakness. The first event was approximately 2 weeks prior to the clinic appointment when he suddenly noticed that he couldn’t lift the right arm to his face whilst relaxing in the living room. His face or leg was not affected and there was no visual disturbance or speech difficulty. The “dead” arm was back to normally in about five minutes. Then one week prior to the clinic, he had another similar episode when cooking in the kitchen. Again, he suddenly felt that his right arm was weak which resolved in five minutes.

In clinic, his blood pressure was raised at 150/95 mmHg. Neurological exam was unremarkable and he was in sinus rhythm. MRI brain did not show any acute infarct but Carotid Doppler confirmed a stenosis of 60% of the left internal carotid artery at the bifurcation. There was no intracranial stenosis.

So far, all seemed to be straight-forward in terms of aetiology: large artery atherosclerosis in relation to smoking and uncontrolled hypertension/hyperlipidaemia. He was subsequently discharged on standard secondary prevention and was seen by the vascular team with carotid endarterectomy (CEA) scheduled for the following week.

Unfortunately, the story then had a sharp turn.

Two days after being treated in the TIA clinic whilst still waiting for CEA, he presented to the emergency department again with acute onset complete right hand weakness. This time the symptom persisted and considering he is right-handed and is still very active, he was thrombolysed. Mr X recovered well the next day with a normal CT scan. The vascular team was informed about this new admission and came to review him before discharge.

Then, the true story emerged.

It turned out that the most recent episode occurred after a “big party” and on direct questioning, it became apparent that Mr X took cocaine during the party. Moreover, he also used cocaine prior to both of the two initial presentations. Consequently the vascular team felt that the vasoconstriction/spasm associated with the cocaine use was probably contributing more to the recurrent TIAs rather than the <70% smooth stenosis and the CEA was cancelled. Mr X was advised to stop smoking and stop using cocaine. He has not had any recurrence since.

Illicit drug use is normally perceived as behaviour of the young and as a result substance abuse is usually only reserved into a standard history taking for younger patients. However, illicit drug use is reported to be increasing in persons over the age of 65 years in Europe,1 with cocaine and heroin being the two mostly abused substances.2 Whilst this phenomenon is largely under-recognised, it probably reflects the ageing of the general population with people using drugs continuing to do so when they get older and could also be related to the baby boomer generation.3

Numerous case series and cohort studies have suggested a causal link between acute cocaine use and strokes in young adults.4,5 The proposed mechanisms included vasospasm, hypertensive surge causing altered cerebral autoregulation, cerebral vasculitis, enhanced platelet aggregation and cardiac arrhythmia,6 all of which may still be relevant at older ages. It is also possible that with higher frequency of underlying comorbidities at older ages, cocaine as well as other illicit drugs could act as the last straw.

To conclude, it probably no longer holds true that the use of illicit drugs is restricted to the young. As clinicians, we should also increase our awareness of the issue at older ages as it may impact both the diagnosis and the management of our patients.

Sometimes, age doesn’t really matter!

 

Reference

  1. European Monitoring Centre for Drugs and Drug Addiction, Substance Use among Older Adults: A Neglected Problem, 2008 Lisbon, European Monitoring Centre for Drugs and Drug Addiction. 4
  2. Arndt S, Clayton R, Schultz SK. Trends in substance abuse treatment 1998–2008: increasing older adult first-time admissions for illicit drugs. Am J Geriatr Psychiatry. 2011; 19: 704–711.
  3. Beynon CM. Drug use and ageing: older people do take drugs! Age Ageing. 2009; 38: 8-10
  4. de los Ríos F, Kleindorfer DO, Khoury J, et al. Trends in substance abuse preceding stroke among young adults: a population-based study. 2012; 43: 3179–3183.
  5. Cheng YC, Ryan KA, Qadwai SA, et al. Cocaine use and risk of ischemic stroke in young adults. Stroke. 2016; 47: 918-922

Treadwell SD, Robinson TG