Subarachnoid Hemorrhage in Association with Heroin Overdose

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The intravenous use of heroin may cause cardiopulmonary arrest, with the consequence of post-hypoxic encephalopathy and other systemic consequences of hypoxia. Strokes in association with heroin may occur by a number of mechanisms. However, heroin does not elevate blood pressure. Hemorrhages in association with heroin use may be caused by infective arteritis/mycotic aneurysm. We present a case of bilateral diffuse subarachnoid hemorrhage without intraventricular extension, identified on the head CT, in association with heroin use. Such an association has been rarely reported in the literature. It may be underreported due to attribution of the death to heroin overdose

A 39 year old male presented to the hospital status-post cardiac arrest. The patient was found by his mother. He had a syringe in his hand. The patient was reportedly a heroin user but has no other pertinent medical issues. The patient, who lived with his mother, was last seen the night before. The patient’smother, a registered nurse, noted the patient to be unresponsive, with gray skin coloring and with no pulses. His mother administered intranasal naloxone, called 911 and administered cardiopulmonary resuscitation (CPR). The emergency management system (EMS) team reported that the patient was in asystole. The patient was subsequently intubated and was after given one dose of epinephrine. He then had return of spontaneous circulation but remained unconscious with a Glasgow Coma Scale of 3. His initial clinical course was complicated by hypotension with systolic blood pressures in the 50 to 60 mm Hg range. His blood pressure eventually stabilized with the administration of intravenous fluids and vasopressors. The ECG showed normal sinus rhythm with a rate of 81 with a normal axis. An intraventricular conduction delay was noted with a QTc (Bezet) of 497 ms. First troponin was 0.03. The complete blood count revealed a white blood cell count of 14.3x10*3/uL with normal hemoglobin and platelets. 

The basic metabolic panel showed the following: sodium of 141 mmol/L, potassium of 5.6 mmol/L, chloride of 103 mmol/L, CO2 16 mmol/L, BUN of 11 mg/dL and creatinine of 1.73 mg/ dL. The ALT was 245 U/L and the AST was 291 U/L. The lipase was 50. The lactic acid was very elevated at 14.3 mmol/L. The patient’s urine drug screen was positive for opiates only. The alcohol level was negative. Severe acidosis was noted in the ABG with arterial PH of 6.90, [PCO2 of 71, PO2 of 213, HCO3 of 12, BE of -22.6, and measured saturation of 100% on 100% FIO2 . The chest X-ray did not show any infiltrates or pneumothorax and the cardiomediastinal silhouette was normal in size. The endotracheal tube and nasogastric tube were in good positionPrior to the induction of hypothermia, the patient was sent for a CT scan of the head, cervical spine, chest, abdomen and pelvis. Bilateral diffuse subarachnoid hemorrhage without intraventricular extension was identified on the head CT.