"Chasing the dragon"--imaging of heroin inhalation leukoencephalopathy

"Chasing the dragon" refers to the inhalation of heroin pyrolysate vapors produced when the freebase form of heroin is heated. Inhalation of these vapors can result in a rare toxic spongiform leukoencephalopathy. The patients may progress through 3 defined clinical stages, with one-quarter reaching the terminal stage, which invariably leads to death. Imaging and, in particular, magnetic resonance imaging (MRI) demonstrates white matter findings that are felt to be specific for this entity and essential in its early diagnosis. We present the typical imaging findings in a pictorial essay format, using images taken from 9 patients who presented within an 18-month period at UBC-affiliated hospitals. These findings include low computed tomography (CT) attenuation and high T2 MRI signal most commonly in the posterior cerebral and cerebellar white matter, cerebellar peduncles, splenium of the corpus callosum, and posterior limb of the internal capsules. In addition, there is often selective, symmetric involvement of the corticospinal tract, the medial lemniscus, and the tractus solitarius. We also present the variable diffusion-weighted imaging and apparent diffusion coefficient findings from 4 of our patients, which to our knowledge, have not been described in the literature.