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Reviews and Overviews   |    
Treatment Advances for Cocaine-Induced Ischemic Stroke: Focus on Dihydropyridine-Class Calcium Channel Antagonists
Bankole A. Johnson, M.D., Ph.D.; Michael D. Devous, Sr., Ph.D.; Pedro Ruiz, M.D.; Nassima Ait-Daoud, M.D.
Am J Psychiatry 2001;158:1191-1198. doi:10.1176/appi.ajp.158.8.1191
Abstract

OBJECTIVE: The authors reviewed the pathogenesis of cocaine-related cerebral ischemia, appraised current knowledge of its sequelae, and assessed the role of putative therapeutic agents, particularly dihydropyridine-class calcium channel antagonists. METHOD: The authors performed an OVID-based literature review of all indexed journals between 1966 and 2000. RESULTS: Cocaine abuse significantly increases the risk of ischemic stroke. The principal mechanism of cocaine-induced cerebral ischemia is vasospasm of large cranial arteries or within the cortical microvasculature. Increased levels of extracellular monoamines, particularly dopamine, mediate vasospasm. Neuroanatomical and labeling studies also have shown that dopamine-innervated neurons may regulate cerebral blood flow. Indeed, dopamine-rich brain regions appear to be relatively specific targets for cocaine-induced cerebral ischemia. Neuroimaging studies show that cocaine-induced hypoperfusion can persist even after 6 months of abstinence. Hypoperfusion can result in deficits on complex and simple psychomotor tasks but perhaps not on memory or attention. Severe cerebral ischemia can directly precipitate neuronal death and degradation, a condition exacerbated by liberation of the excitatory amino acid glutamate. Dihydropyridine-class calcium channel antagonists inhibit cocaine-mediated dopamine release on neurons involved in vasospasm and the control of cortical circulation. Other causes of cerebral ischemia include thrombogenesis and vasculitis. Although antithrombotic agents have potential in alleviating cocaine’s neurotoxic effects, their use may be limited by the risk of spontaneous hemorrhage. CONCLUSIONS: Cocaine abuse can result in stroke, neuroischemia, and cognitive deficits that can persist even after prolonged abstinence. Dihydropyridine-class calcium channel antagonists, such as isradipine, show promise as therapeutic agents for preventing cocaine-induced cerebral ischemia.

Abstract Teaser
Figures in this Article

Cocaine abuse can cause strokes (1, 2). The relative likelihood of developing a stroke in cocaine users may be as much as 14 times greater than that in age-matched non-cocaine-using comparison subjects recruited from the same patient pool (3). Between 25% and 60% of cocaine-induced strokes can be attributed to cerebral ischemia (46). About 80% of the infarcts occur in the regional distribution of the middle cerebral artery (7), typically in young adults without preexisting vascular malformations (6). Nevertheless, increased polysubstance abuse among cocaine addicts has complicated attribution and accurate characterization between amount and duration of cocaine use and its relationship with global and regional hypoperfusion abnormalities (8). Perfusion deficits also can occur in the absence of clinically detectable symptoms in the central nervous system (9, 10) and may persist in abstinent cocaine addicts for 6 months (11) or more (12). Mechanistic processes that underlie cocaine’s site-specific effects on the cerebral vasculature are, therefore, imperfectly understood. Advanced neuroimaging techniques offer a vehicle for elucidating these mechanisms and ascertaining the effectiveness of putative therapeutic agents for treating cerebral ischemia.

Preclinical research suggests that the etiology of cocaine-induced brain ischemia is multifactorial and involves the stimulation of vasospasm (13), platelet aggregation (14), and pathological changes in the cerebral vasculature that can impair cellular oxygenation (14). Within all of these processes, calcium-channel-mediated interactions, particularly with dopamine, play an important role. Dihydropyridine-class calcium channel antagonists, by counteracting cocaine-induced vasospasm, have potential as putative therapeutic agents (15).

This review article is subdivided into three major parts. First, we critically appraise the neurobiology of cocaine-induced cerebral ischemia. Second, we summarize current knowledge on the sequelae of cocaine’s neuroischemic effects. Third, we assess the role of various putative therapeutic agents for treating cocaine-induced cerebral ischemia, with a particular focus on dihydropyridine-class calcium channel antagonists.

Cerebral ischemia is associated with a variety of cocaine’s neurovascular effects. We will review the relative importance of various mechanistic processes attributable to cerebral ischemia.

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Vasospasm

Cocaine, the alkaloid benzoylmethylecgonine, by being highly lipid soluble, traverses the blood-brain barrierrapidly. As in the periphery, cocaine blocks monoamine reuptake, particularly those related to dopamine (7). Cocaine-induced changes in dopamine level are most prominent in mesocorticolimbic neurons (16, 17). Augmentation of mesocorticolimbic dopamine function may be associated with cerebral ischemia by means of two mechanisms. First, dopamine may control local blood flow by inducing vasospasm of smooth muscles lining the cerebral vessels (1821), particularly those of the middle cerebral artery (19). Second, cocaine-induced reductions in cerebral metabolism may lead to feedback down-regulation of blood flow (22). Rapid reperfusion of these previously ischemic areas may, conversely, result in hemorrhage (23).

More recently, the role of dopamine in the regulation of cortical blood flow has been better elucidated. First, my colleagues and I (24) established that cocaine-induced cerebral vasospasm was relatively specific to dopamine-rich brain areas and hypothesized that dopamine pathways play a central role in controlling cerebral blood flow (CBF). Later, Krimer and colleagues (25) provided a mechanistic basis for these findings by showing that dopamine-containing neurons were located adjacent to blood vessels in the frontal lobe and prefrontal cortex. These vessels constricted in response to the perivascular application of dopamine with the maximal calculated reduction of up to 58% of pretreatment flow. Hypothetically, in the living brain, pericytes containing contractile elements located proximal to dopamine nerve endings, which are also responsive to vasoactive substances in the endothelium, may be mechanistically responsible for this process (26, 27). Essential to this process appears to be an initial transmembrane loss of magnesium followed by a rapid rise in intracellular calcium concentration. Severity of the perfusion deficit is, therefore, typically correlated with the relative strength of these neurochemical changes (28). Nevertheless, cocaine’s vasospastic effects can persist beyond its half-life because its major metabolites (benzoylecgonine and norcocaine) also are potent vasoconstrictors (29), and bradykinin-mediated endothelium-dependent relaxation is impaired in chronic cocaine abusers (30, 31).

Although intracortical vessels are preferentially innervated by dopamine, those located extraparenchymally receive their neuronal supply from norepinephrine-containing cells in the superior cervical ganglia (25). Thus, multifactorial mechanisms may be associated with the development and extension of cerebral vasoconstriction. Deep cortical brain regions may be more susceptible to dopamine’s vasospastic effects. In contrast, reductions in CBF subsequent to constriction of large cranial arteries may be more dependent on norepinephrine facilitation (32, 33). The vasospastic effects of serotonin (5-HT), levels of which are also increased by cocaine, also may be greater at large and medium-sized cranial arteries. Cocaine’s vasospastic effects can, therefore, be associated with generalized global reductions in CBF (34).

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Thrombosis

Cocaine-induced cerebral ischemia also can be caused by thrombus formation in the vasculature (29). Chronic cocaine use increases platelet levels, enhances adenosine diphosphate platelet activation, and augments sporadic release of platelet-bound α granules. Platelet activation and aggregation, precursors of thrombus formation, may be mediated by cocaine-induced increases in monoamine levels, particularly of 5-HT. Release of α granules containing growth factors and platelet-specific agglutinating proteins, β thromboglobulin and platelet factor 4, together with enhanced elastase-mediated atherosclerotic damage to the cerebral vasculature, all contribute to cocaine’s thrombogenic potential (35, 36). Thrombus formation also may be facilitated by cocaine-induced cardiomyopathy (14). In vitro studies also have demonstrated cocaine’s ability to facilitate the platelets’ response to arachidonic acid, thereby stimulating thromboxane production and, consequently, their aggregation (3739). Protein C antithrombin III depletion and enhanced prostaglandin release are additional contributors to cocaine’s procoagulant effects (4042). In sum, a gallimaufry of cocaine’s platelet aggregating and cardiomyopathic effects contribute to thrombus formation.

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Vasculitis

Apart from the atherosclerotic changes attributable to chronic cocaine use that contribute to thrombus formation, there also is evidence of other pathological structural alterations in cerebral vasculature. For example, Martinez and co-workers (14) found that long-term cocaine use, due to fluctuations between vasospasm and reperfusion, may result in vessel damage. This vasculitis, not attributable to arteriosclerosis or infection, has also been described by others (2, 42). Chronic cocaine-induced vasculitis exacerbates nonlaminar blood flow and sludging in the vessels. This decreases cellular oxygenation, thereby increasing platelet aggregation and consequent thrombus formation.

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Consequences of Cerebral Ischemia

Cerebral ischemia can result in a variety of quantifiable structural and functional deficits. These deficits contribute to the pathogenesis of cocaine dependence and can impair an addict’s recovery.

Although the focus of this review relates to the quantification of dynamic changes in CBF, it is noteworthy that structural defects also may be a long-term consequence of this abnormality. Ischemic cerebral damage can result in cellular death identifiable by magnetic resonance imaging (MRI). Cocaine-induced cerebral damage appears to have similar hallmarks to other diseases that result in global damage. For instance, as brain cells die, there are generalized atrophic changes with concomitant ventricular enlargement and sulcal widening (42, 43). On a cellular level, ischemia-induced neuronal degeneration is associated with the extracellular leakage of glutamate. This is due to inactivation of the adenosine diphosphate-dependent glutamate reuptake pump, which results in the accumulation of intracellular sodium and consequent neuronal engorgement (44). Glutamate’s neurotoxic effects are potentiated by the long-term influx of intracellular calcium. Excessive intracellular calcium concentration produces direct necrotic cellular changes and promotes the activity of calcium-sensitive proteolytic enzymes. Consequently, apoptotic processes may be triggered prematurely (45). In the aggregate, cerebral ischemia can provoke or potentiate a sequence of events resulting in structural damage due to direct or programmed neuronal cell death.

Functional deficits represented as decreases in cerebral perfusion can exist in the absence of structural damage. These perfusion deficits have mainly been studied using two types of neuroimaging: single photon emission computed tomography (SPECT) and positron emission tomography (PET); however, future studies may make use of developing techniques in functional MRI.

The relationship between chronic cocaine abuse and reported cognitive deficits, hypothetically due to perfusion abnormalities in the striatum (46), remains controversial. Methodological problems, such as small group size, use of published cognitive test norms instead of appropriately matched comparison subjects, differences in population characteristics (e.g., social class, treatment-seeking versus incarcerated status, presence or absence of concomitant drug abuse or dependence, varying lengths of abstinence, and level of care in its verification), have resulted in conflicting findings (47, 48). Generally, controlled studies of cocaine abusers with several months of abstinence support an impairment of response in complex and simple psychomotor tasks (47, 49) and to auditory tones or discrimination tasks (5052) but less consistently demonstrate decrements in memory and attention (47, 48). Future studies of the relationship between cocaine abuse and cognitive dysfunction need to address two current limitations in our knowledge. First, we know of no long-term longitudinal studies charting the relationship between the progression of disease, as identified by neuroimaging studies, and a comprehensive set of standardized cognitive tests. Second, it is important for us in more fully characterizing the relationship between cognitive function and functional brain abnormality to determine how these parameters are affected by whether or not the individual is actively taking cocaine, has recently withdrawn from it, or has entered into a period of prolonged abstinence. Development of accurate methods for characterizing functional changes in CBF, therefore, remains at the cornerstone of quantifying cerebral ischemia and its consequent neuropsychological sequelae.

Neuroimaging studies have provided a vehicle for understanding cocaine’s ischemic effects on the brain. Early studies vary in the reported distribution of regional cerebral blood flow (rCBF) abnormalities found in cocaine users (10, 53, 54); however, these rCBF deficits can be severe (46, 55, 56). Although most abused substances (including cocaine) reduce both global and regional cerebral glucose metabolism during acute use, rCBF can be either increased or decreased, perhaps related to the vasoactive characteristics of particular compounds (57). The distribution of both rCBF and abnormalities in regional cerebral glucose metabolism also depends on whether the individual was currently using the drug, was exposed to cues, had recently withdrawn from cocaine, or was in long-term detoxification (53, 58, 59).

A typical report is that of Holman et al. (60), who studied cocaine abusers with 99mTc-labeled exametazime ([99mTc]hexamethylpropyleneamine oxime) and high-resolution SPECT. Sixteen of 18 cocaine-dependent users had abnormal perfusion characterized primarily as small focal defects involving the infraparietal, temporal and anterofrontal cortex, and basal ganglia (the results of psychometric testing were abnormal in all 18). There was no relationship between the severity of SPECT abnormalities and the mode of cocaine administration or the frequency or length of cocaine use. It is important, however, that these results of global and regional hypoperfusion were consistent with the findings of others (61, 62). Later, Holman and colleagues (58) reported that such findings can be confounded by similar vascular abnormalities observed in HIV-positive and AIDS patients because of the frequent comorbidity of HIV infection and drug abuse.

Pearlson and co-workers (63) advanced these findings in a well-controlled study of acute cocaine dosing. They suggested that cocaine’s ischemic effects were most prominent in dopamine-rich brain regions such as the caudate, inferior cingulate, and frontal areas; however, these site-specific effects could not be established by this experiment because a quantitative approach to SPECT was not employed and the cocaine dose was not manipulated. Pearlson and co-workers (63) also suggested that cocaine-induced reductions in CBF were associated with increased positive subjective mood and abuse liability. These findings differ from those of London and co-workers (54), who, using PET and [18F]fluorodeoxyglucose, did not find an association between regional cerebral glucose metabolism and subjective mood. An advantage of the study of Pearlson and co-workers (63) was that imaging and the peak of cocaine’s behavioral effects were synchronized carefully, thereby increasing the predictive power of the findings. While a detailed description of the relationship between cocaine-induced subjective mood and other (i.e., non-flow-related) aspects of brain function is outside the scope of this review, further studies are clearly needed. Notably, however, this field of inquiry has been advanced by the demonstration that dopamine transporter function may be closely correlated with the expression of cocaine’s subjective effects (64).

More recently, we studied the effects of cocaine on global and rCBF using a novel approach to quantified SPECT (24). In that study, nine cocaine-dependent men and women (six men) with no evidence of structural brain abnormality (verified by an MRI at screening) were intravenously administered low and high doses of cocaine (0.33 mg/kg and 0.65 mg/kg, respectively) or placebo in a double-blind crossover fashion. We established that cocaine administration, compared with placebo, was associated with significant reductions in global and rCBF, which was relatively specific for dopamine-rich brain areas. Also, these CBF reductions were mostly dose dependent (i.e., the high dose led to greater involvement of cortical sites than the low dose), and the areas with greatest deficits were the prefrontal, frontal, temporal, and subcortical gray matter (F1). This study elucidated the site-specific effects of cocaine related to CBF changes and established the utility of this quantified approach to SPECT.

In sum, cocaine abuse, either acute or long-term, is associated with hypoperfusion-related CBF abnormalities. Despite some variance in the literature concerning the anatomical regions most affected, the current evidence suggests that dopamine-rich brain areas are particularly vulnerable. The correlation between regional blood flow reductions in dopamine-rich areas and cocaine abuse was intriguing and, as was later demonstrated, provided strong evidence for a role of cortical dopamine neurons in the regulation of the arteriolar microcirculation. Thus, medications that antagonize these dopamine-mediated effects on CBF offer promise as potential treatments for cocaine-related ischemic stroke.

Until recently, despite the growing epidemic of cocaine-related ischemic stroke, the development of medications specifically targeted at this indication remained in its infancy. The next section describes the potential role of some promising medications aimed at reducing cocaine’s vasospastic, thrombogenic, or neurotoxic effects.

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Antivasospastics

Animal studies support the use of the dihydropyridine-class calcium channel antagonist isradipine for the reversal of cerebral ischemia and the consequent neuronal cell damage (6567). In a landmark study, Sauter and colleagues (68) examined the relative effectiveness of various dihydropyridine-class calcium channel antagonists (i.e., darodipine, nimodipine, nitrendipine, and isradipine) in reducing the ischemic damage produced by occlusion of the middle cerebral artery in the rat. CBF was estimated by using the [14C]iodoantipyrine method for blood flow quantification. In that study, isradipine (2.5 mg/kg given subcutaneously) had the greatest anti-ischemic effect. The dose-related vasodilator response to isradipine was wider than for the other dihydropyridine-class calcium channel antagonists and was correlated with a reduction in infarct size. These antivasospastic effects of isradipine were attributed to the blockade of dopamine release from cortical neurons involved in the control of the cerebral vasculature. In another example, 60 minutes of cerebral ischemia was induced in spontaneously hypertensive male rats by carotid artery occlusion. Hydrogen clearance was used to measure CBF, and in vivo microdialysis was used to quantify extracellular increases in dopamine and glutamate levels. Although the vehicle-treated group experienced 180- and 24-fold increases in extracellular dopamine and glutamate levels, respectively, isradipine significantly reduced the dopamine increase but had no effect on glutamate levels (69). Ooboshi and colleagues (70) confirmed these results. They showed that pretreatment with isradipine (200 μg/ml) did not alter ischemia-induced dopamine release in the striatum but produced a 37% decrease in dopamine levels in the forebrain. Additionally, isradipine significantly reduced forebrain ischemia (i.e., improved blood flow) but had no effect on striatal blood flow. Together, these results suggest that isradipine is a potent cerebral vasodilator with selectivity for dopamine-innervated brain regions.

Most recently, we extended these results to humans using a quantified SPECT approach by demonstrating that isradipine (10 mg given orally) administered 60 min before intravenous cocaine (0.33 mg/kg) prevented both global and regional ischemia in dopamine-rich brain areas (15). This was the first clear demonstration that any medication, including isradipine, could prevent cocaine’s vaso-spastic effects on CBF. One caveat to this study was that there was no condition using isradipine alone. Thus, the relative strength of isradipine’s effectiveness at antagonizing cocaine-induced cerebral ischemia is unknown.

In sum, isradipine appears to be a promising therapeutic medication for the prevention of cocaine-related cerebral ischemia. It is important, however, that we await the results of larger-scale confirmatory neuroimaging studies and the results of clinical testing with the longitudinal evaluation of cerebral perfusion.

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Antithrombogenic Agents

Recently, there has been interest in the use of aspirin to reduce cocaine’s thrombogenic effects. This is predicated on the finding that prostaglandin synthesis, which is enhanced by cocaine (F2), can be blocked by aspirin. Aspirin blocks this process by irreversibly inhibiting the action of cyclo-oxygenase in platelets released from bone marrow. These platelets, derived from the bone marrow, constitute about 15% of the body’s total daily circulation (71, 72). Preliminary results indicate that aspirin (325 mg/day for 4 weeks) may improve CBF in chronic cocaine users; however, the results of a more definitive analysis are awaited (73). Aspirin treatment may, however, increase the risk of spontaneous or uncontrolled bleeding from wounds. Thus, implementation of long-term aspirin treatment for cocaine addicts is impractical, because of their propensity for exposure to high-risk situations. Also, acute aspirin administration is unlikely to result in reversal of cerebral ischemia or substantial CBF improvement in individuals with an evolving ischemic episode of recent onset.

There may be potential for using the potassium-sparing diuretic amiloride for the prevention of ischemia caused by blockade of platelet α granule release in cocaine addicts (73, 74). Again, the results of more definitive studies are awaited. Although the 5-HT2 receptor antagonist ritanserin has demonstrated antiplatelet aggregation properties, its use for this indication in cocaine addicts remains unexplored (75, 76).

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Antineurotoxic Agents

One approach that has been suggested to reduce cocaine’s neurotoxic effects is the use of glutamate antagonists, such as phencyclidine and MK-801. Although these medications should, potentially, reduce the effects of excitatory amino acids released during neuronal degeneration at N-methyl-d-aspartate receptors, their other psychopharmacological effects limit their extensive use in humans. For instance, not only are these medications hallucinogenic, but they can also reduce the seizure threshold. Medications with antiglutamate properties and a more benign side effect profile, such as lamotrigine, or those that facilitate γ-aminobutyric acid neurotransmission, such as gabapentin, may have greater ability to prevent or treat cocaine-induced cerebral ischemia.

Evidence for the use of kappa opiate agonists for preventing ischemia because they modulate glutamate expression is conflicting (77; cf. reference 78). Although decreases in cocaine-induced perfusion abnormalities have been reported with the kappa opiate antagonist buprenorphine, that study’s results were limited by the lack of a placebo control group (59). Furthermore, research is needed to elucidate the role of kappa opiate antagonists in treating cocaine-induced cerebral ischemia.

Cocaine abuse significantly increases the risk of ischemic stroke. Current evidence shows that the genesis of cocaine-related ischemia is multifactorial. Principally, cocaine’s vasospastic effects at large cranial arteries or within the cortical microvasculature are mediated by increased levels of extracellular monoamines, particularly dopamine. Indeed, dopamine-rich brain areas appear to be relatively specific targets for cocaine-induced cerebral ischemia. The development of various neuroimaging tools, particularly PET and SPECT, has greatly advanced our knowledge about cocaine’s global and site-specific effects on CBF. Other mechanistic processes involved with the development of cerebral ischemia include thrombogenesis and vasculitis. Cocaine’s thrombogenic potential is associated with the enhancement of cellular processes that augment platelet aggregation and the enhancement of nonlaminar vascular flow after the development of cardiomyopathy.

Cocaine-induced cerebral ischemia can result in marked hypoperfusion abnormalities. These abnormalities may themselves be associated with deficits in the manipulation of complex and simple psychomotor tasks, but the evidence supporting memory and attentional deficits is less established. Little is known about the pathological development of these hypoperfusion abnormalities, but the prevailing evidence suggests that they persist even after a prolonged period of cocaine abstinence. With repeated cerebral ischemic episodes and subsequent reperfusion, vascular walls are weakened, and the likelihood of hemorrhagic episodes increases. Severe cerebral ischemia can result in direct neuronal death and degradation with the liberation of excitatory amino acids, particularly glutamate, which itself potentiates this process. Antithrombotic agents or medications that can ameliorate cocaine’s neurotoxic effects may have use in preventing or treating cocaine-induced cerebral ischemia. Promising recent data provide strong support for the use of dihydropyridine-class calcium channel antagonists in preventing cocaine-induced vasospasm, the principal cause of cerebral ischemia. Thus, the use of dihydropyridine-class calcium channel antagonists may herald a new vista in the prevention of cocaine-induced cerebral ischemia.

Received Dec. 22, 1999; revision received Nov. 2, 2000; accepted Nov. 10, 2000. From the Departments of Psychiatry and Pharmacology and the Southwest Texas Addiction Research and Technology (START) Center, University of Texas Health Science Center at San Antonio; the Nuclear Medicine Center, University of Texas Southwestern Medical Center, Dallas; and the Department of Psychiatry and Behavioral Sciences, University of Texas Medical School at Houston. Address reprint requests to Dr. Johnson, START Center, 3939 Medical Dr., San Antonio, TX 78229; bjohnson@uthscsa.edu (e-mail). Funded by grants DA-13002-01 and DA-12191 from the National Institute on Drug Abuse.

 
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Figure 1.

Effect of Cocaine on Brain Regional Cerebral Blood Flow (rCBF)a

aParametric images of significant rCBF changes (cocaine versus placebo) from nine subjects studied after administration of placebo, low-dose cocaine (0.33 mg/kg), and high-dose cocaine (0.65 mg/kg) as shown by single photon emission computed tomography (SPECT). Areas of significant change are shown as solid objects overlaid on a model SPECT brain image. Images are oriented with the subject’s left on the viewer’s right. Low-dose cocaine produced rCBF reductions (relative to placebo) in bilateral anterior temporal (perisylvian) sites, in left mesial/anterior temporal sites, and in a right inferior orbital frontal site (Brodmann’s area 11). Additional decreases were observed in superior antero- and posterolateral frontal regions (not shown). Increased rCBF was observed in the brainstem and cerebellum. High-dose cocaine produced more extensive decreases to bilateral anterior temporal (perisylvian) sites and to the right inferior orbital frontal site. New areas of significant rCBF decline (relative to low-dose cocaine) were observed in the inferior cingulate, right mesial temporal lobe (hippocampus), and left inferior/mid temporal lobe (not hippocampus). Furthermore, high-dose cocaine led to increases in left thalamic and left hippocampal sites not seen with low-dose cocaine and to the cerebellar changes seen with low-dose cocaine.

 
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Figure 2.

Thrombosis-Promoting Effects of Cocainea

aPlatelets play an important role in the formation of a thrombus. They undergo three phases: 1) adhesion, 2) secretion, and 3) aggregation. Thromboxane and adenosine diphosphate set up an autocatalytic reaction leading to the buildup of an enlarging platelet aggregate (the primary hemostatic plug). Cocaine enhances thromboxane release, the synthesis of platelets, and thrombus formation.

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Monga M, Chmielowiec S, Andres RL, Troyer LR, Parisi VM: Cocaine alters placental production of thromboxane and prostacyclin. Am J Obstet Gynecol  1994; 171:965-969
[PubMed]
 
Zurbano MJ, Heras M, Rigol M, Roig E, Epelde F, Miranda F, Sanz G, Escolar G, Ordinas A: Cocaine administration enhances platelet reactivity to subendothelial components: studies in a pig model. Eur J Clin Invest  1997; 27:116-120
[PubMed]
 
Cook JL, Randall CL: Cocaine does not affect prostacyclin, thromboxane or prostaglandin E production in human umbilical veins. Drug Alcohol Depend  1996; 41:113-118
[PubMed]
[CrossRef]
 
Isner JM, Chokshi SK: Cocaine and vasospasm (editorial). N Engl J Med 1989; 321:1604-  1606
 
Ohki S, Ogino N, Yamamato S, Hayaishi O: Prostaglandin hydroperoxidase, an integral part of prostaglandin endoperoxide synthetase. J Biol Chem  1979; 254:829-836
[PubMed]
 
Amass L, Nardin R, Mendelson JH, Teoh SK, Woods BT: Quantitative magnetic resonance imaging in heroin- and cocaine-dependent men: a preliminary study. Psychiatry Res  1992; 45:15-23
[PubMed]
[CrossRef]
 
Strock T, Schutle S, Hofmann K, Stoffel W: Structure expression and functional analysis of a Na+-dependent glutamate/aspartate transporter from rat brain. Proc Natl Acad Sci USA 1992; 89:10955-1  0959
 
Berridge MJ, Bootman MD, Lipp P: Calcium—a life and death signal. Nature  1998; 395:645-648
[PubMed]
[CrossRef]
 
Woods SW, O’Malley SS, Martini BL, McDougle CJ, Price LH, Krystal JH, Hoffer PB, Kosten TR: SPECT regional cerebral blood flow and neuropsychological testing in non-demented HIV-positive drug abusers: preliminary results. Prog Neuropsychopharmacol Biol Psychiatry  1991; 15:649-662
[PubMed]
[CrossRef]
 
Robinson J, Heaton R, O’Malley S: Neuropsychological functioning in cocaine abusers with or without alcohol dependence. J Int Neuropsychol Soc  1999; 5:10-19
[PubMed]
 
Horner M: Attentional functioning in abstinent cocaine abusers. Drug Alcohol Depend  1999; 54:19-33
[PubMed]
[CrossRef]
 
O’Malley SS, Gawin FH: Abstinence symptomatology and neuropsychological impairment in chronic cocaine abusers. NIDA Res Monogr  1990; 101:179-190
[PubMed]
 
Roberts LA, Bauer LO: Reaction time during cocaine versus alcohol withdrawal: longitudinal measures of visual and auditory suppression. Psychiatry Res  1993; 46:229-237
[PubMed]
[CrossRef]
 
Bauer LO: Vigilance in recovering cocaine-dependent and alcohol-dependent patients: a prospective study. Addict Behav  1994; 19:599-607
[PubMed]
[CrossRef]
 
Bauer LO: Motoric signs of CNS dysfunction associated with alcohol and cocaine withdrawal. Psychiatry Res  1993; 47:69-77
[PubMed]
[CrossRef]
 
London ED, Cascella NG, Wong DF, Phillips RL, Dannals RF, Links JM, Herning R, Grayson R, Jaffe JH, Wagner HN Jr: Cocaine-induced reduction of glucose utilization in human brain: a study using positron emission tomography and [fluorine 18]-fluorodeoxyglucose. Arch Gen Psychiatry  1990; 47:567-574
[PubMed]
 
London ED, Broussolle EP, Links JM, Wong DF, Cascella NG, Dannals RF, Sano M, Herning R, Snyder FR, Rippetoe LR, Toung TJK, Jaffe JH, Wagner HN Jr: Morphine-induced metabolic changes in human brain: studies with positron emission tomography and [fluorine 18]fluorodeoxyglucose. Arch Gen Psychiatry  1990; 47:73-81
[PubMed]
 
Jenssen R, Olsen TS, Winther BB: Severe non-occlusive ischemic stroke in young heroin addicts. Acta Neurol Scand  1990; 81:354-357
[PubMed]
 
Woods SW: Regional cerebral blood flow imaging with SPECT in psychiatric disease: focus on schizophrenia, anxiety disorders, and substance abuse. J Clin Psychiatry 1992; 53(suppl):20-25
 
Fowler JS, Volkow ND: PET imaging studies in drug abuse. J Toxicol Clin Toxicol  1998; 36:163-174
[PubMed]
[CrossRef]
 
Holman BL, Garada B, Johnson KA, Mendelson J, Hallgring E, Teoh SK, Worth J, Navia B: A comparison of brain perfusion SPECT in cocaine abuse and AIDS dementia complex. J Nucl Med 1992; 33:1312-  1315
 
Holman BL, Mendelson J, Garada B, Teoh SK, Hallgring E, Johnson KA, Mello NK: Regional cerebral blood flow improves with treatment in chronic cocaine polydrug users. J Nucl Med  1993; 34:723-727
[PubMed]
 
Holman BL, Carvalho PA, Mendelson J, Teoh SK, Nardin R, Hallgring E, Hebben N, Johnson KA: Brain perfusion is abnormal in cocaine-dependent polydrug users: a study using technetium-99m-HMPAO and ASPECT. J Nucl Med 1991; 32:1206-  1210
 
Mena I, Giombetti RJ, Miller BL, Garrett K, Villanueva-Meyer J, Mody C, Goldberg MA: Cerebral blood flow changes with acute cocaine intoxication: clinical correlations with SPECT, CT, and MRI. NIDA Res Monogr  1994; 138:161-173
[PubMed]
 
Miller BL, Mena I, Giombetti R, Villanueva-Meyer J, Djenderedjian AH: Neuropsychiatric effects of cocaine: SPECT measurements. J Addict Dis  1992; 11:47-58
 
Pearlson GD, Jeffrey PJ, Harris GJ, Ross CA, Fischman MW, Camargo EE: Correlation of acute cocaine-induced changes in local cerebral blood flow with subjective effects. Am J Psychiatry  1993; 150:495-497
[PubMed]
 
Volkow ND, Wang GJ, Fowler JS, Logan J, Gatley SJ, Hitzemann R, Chen AD, Dewey SL, Pappas N: Decreased striatal dopaminergic responsiveness in detoxified cocaine-dependent subjects. Nature  1997; 386:830-833
[PubMed]
[CrossRef]
 
Sauter A, Rudin M, Wiederhold KH: Reduction of neural damage in irreversible cerebral ischemia by calcium antagonists. Neurochem Pathol  1988; 9:211-236
[PubMed]
 
Sauter A, Rudin M: Calcium antagonists reduce the extent of infarction in rat middle cerebral artery occlusion model as determined by quantitative magnetic resonance imaging. Stroke 1986; 17:1228-  1234
 
Lepakhin VK, Ivleva A, Romashova MF, Udotova SA, Zubovskii LG: [The effect of isradipine on the central and cerebral hemodynamics of patients with circulatory encephalopathy and hypertension.] Eksp Klin Farmakol  1992; 55:24-26 (Russian)
 
Sauter A, Rudin M, Wiederhold KH, Hof RP: Cerebrovascular, biochemical, and cytoprotective effects of isradipine in laboratory animals. Am J Med  1989; 86:134-146
 
Nakane H, Ooboshi H, Ibayashi S, Yao H, Sadoshima S, Fujishima M: Isradipine, a calcium channel blocker, attenuates the ischemia-induced release of dopamine but not glutamate in rats. Neurosci Lett  1995; 188:151-154
[PubMed]
[CrossRef]
 
Ooboshi H, Sadoshima S, Ibayashi S, Yao H, Uchimura H, Fujishima M: Isradipine attenuates the ischemia-induced release of dopamine in the striatum of the rat. Eur J Pharmacol  1993; 233:165-168
[PubMed]
[CrossRef]
 
Patrignani P, Filabozzi P, Patrono C: Selective cumulative inhibition of platelet thromboxane production by low-dose aspirin in healthy subjects. J Clin Invest 1982; 69:1366-  1376
 
Patrignani P, Canete-Soler R: Biosynthesis, characterization and inhibition of leukotriene B4 in human whole blood. Prostaglandins  1987; 33:539-551
[PubMed]
[CrossRef]
 
Kosten TR: Pharmacotherapy of cerebral ischemia in cocaine dependence. Drug Alcohol Depend  1998; 49:133-144
[PubMed]
[CrossRef]
 
Thibonnier M, Bayer AL, Simonson MS, Douglas JG: Effects of amiloride analogues on AVP binding and activation of V1-receptor-expressing cells. Am J Physiol 1992; 262(1, part 1):E76-E86
 
McBride PA, Mann JJ, Nimchinsky E, Cohen ML: Inhibition of serotonin-amplified human platelet aggregation by ketanserin, ritanserin, and the ergoline 5HT2 receptor antagonists-LY53857, sergolexole, and LY237733. Life Sci 1990; 47:2089-  2095
 
Wagner B, Schneider B, Blochl-Daum B, Speiser W, Brenner B, Eichler HG, Lechner K, Kyrle PA: Effect of ritanserin, a 5-hydroxytryptamine2-receptor antagonist, on platelet function and thrombin generation at the site of plug formation in vivo. Clin Pharmacol Ther  1990; 48:419-423
[PubMed]
[CrossRef]
 
McGinty JF: Introduction to the role of excitatory amino acids in the actions of abused drugs: a symposium presented at the 1993 annual meeting of the College on Problems of Drug Dependence. Drug Alcohol Depend  1995; 37:91-94
[PubMed]
[CrossRef]
 
Faden AI: Dynorphin increases extracellular levels of excitatory amino acids in the brain through a non-opioid mechanism. J Neurosci  1992; 12:425-429
[PubMed]
 

Figure 1.

Effect of Cocaine on Brain Regional Cerebral Blood Flow (rCBF)a

aParametric images of significant rCBF changes (cocaine versus placebo) from nine subjects studied after administration of placebo, low-dose cocaine (0.33 mg/kg), and high-dose cocaine (0.65 mg/kg) as shown by single photon emission computed tomography (SPECT). Areas of significant change are shown as solid objects overlaid on a model SPECT brain image. Images are oriented with the subject’s left on the viewer’s right. Low-dose cocaine produced rCBF reductions (relative to placebo) in bilateral anterior temporal (perisylvian) sites, in left mesial/anterior temporal sites, and in a right inferior orbital frontal site (Brodmann’s area 11). Additional decreases were observed in superior antero- and posterolateral frontal regions (not shown). Increased rCBF was observed in the brainstem and cerebellum. High-dose cocaine produced more extensive decreases to bilateral anterior temporal (perisylvian) sites and to the right inferior orbital frontal site. New areas of significant rCBF decline (relative to low-dose cocaine) were observed in the inferior cingulate, right mesial temporal lobe (hippocampus), and left inferior/mid temporal lobe (not hippocampus). Furthermore, high-dose cocaine led to increases in left thalamic and left hippocampal sites not seen with low-dose cocaine and to the cerebellar changes seen with low-dose cocaine.

Figure 2.

Thrombosis-Promoting Effects of Cocainea

aPlatelets play an important role in the formation of a thrombus. They undergo three phases: 1) adhesion, 2) secretion, and 3) aggregation. Thromboxane and adenosine diphosphate set up an autocatalytic reaction leading to the buildup of an enlarging platelet aggregate (the primary hemostatic plug). Cocaine enhances thromboxane release, the synthesis of platelets, and thrombus formation.

+

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[CrossRef]
 
Togna G, Tempesta E, Togna AR, Dolci N, Cebo B, Caprino L: Platelet responsiveness and biosynthesis of thromboxane and prostacyclin in response to in vitro cocaine treatment. Haemostasis  1985; 15:100-107
[PubMed]
 
Monga M, Chmielowiec S, Andres RL, Troyer LR, Parisi VM: Cocaine alters placental production of thromboxane and prostacyclin. Am J Obstet Gynecol  1994; 171:965-969
[PubMed]
 
Zurbano MJ, Heras M, Rigol M, Roig E, Epelde F, Miranda F, Sanz G, Escolar G, Ordinas A: Cocaine administration enhances platelet reactivity to subendothelial components: studies in a pig model. Eur J Clin Invest  1997; 27:116-120
[PubMed]
 
Cook JL, Randall CL: Cocaine does not affect prostacyclin, thromboxane or prostaglandin E production in human umbilical veins. Drug Alcohol Depend  1996; 41:113-118
[PubMed]
[CrossRef]
 
Isner JM, Chokshi SK: Cocaine and vasospasm (editorial). N Engl J Med 1989; 321:1604-  1606
 
Ohki S, Ogino N, Yamamato S, Hayaishi O: Prostaglandin hydroperoxidase, an integral part of prostaglandin endoperoxide synthetase. J Biol Chem  1979; 254:829-836
[PubMed]
 
Amass L, Nardin R, Mendelson JH, Teoh SK, Woods BT: Quantitative magnetic resonance imaging in heroin- and cocaine-dependent men: a preliminary study. Psychiatry Res  1992; 45:15-23
[PubMed]
[CrossRef]
 
Strock T, Schutle S, Hofmann K, Stoffel W: Structure expression and functional analysis of a Na+-dependent glutamate/aspartate transporter from rat brain. Proc Natl Acad Sci USA 1992; 89:10955-1  0959
 
Berridge MJ, Bootman MD, Lipp P: Calcium—a life and death signal. Nature  1998; 395:645-648
[PubMed]
[CrossRef]
 
Woods SW, O’Malley SS, Martini BL, McDougle CJ, Price LH, Krystal JH, Hoffer PB, Kosten TR: SPECT regional cerebral blood flow and neuropsychological testing in non-demented HIV-positive drug abusers: preliminary results. Prog Neuropsychopharmacol Biol Psychiatry  1991; 15:649-662
[PubMed]
[CrossRef]
 
Robinson J, Heaton R, O’Malley S: Neuropsychological functioning in cocaine abusers with or without alcohol dependence. J Int Neuropsychol Soc  1999; 5:10-19
[PubMed]
 
Horner M: Attentional functioning in abstinent cocaine abusers. Drug Alcohol Depend  1999; 54:19-33
[PubMed]
[CrossRef]
 
O’Malley SS, Gawin FH: Abstinence symptomatology and neuropsychological impairment in chronic cocaine abusers. NIDA Res Monogr  1990; 101:179-190
[PubMed]
 
Roberts LA, Bauer LO: Reaction time during cocaine versus alcohol withdrawal: longitudinal measures of visual and auditory suppression. Psychiatry Res  1993; 46:229-237
[PubMed]
[CrossRef]
 
Bauer LO: Vigilance in recovering cocaine-dependent and alcohol-dependent patients: a prospective study. Addict Behav  1994; 19:599-607
[PubMed]
[CrossRef]
 
Bauer LO: Motoric signs of CNS dysfunction associated with alcohol and cocaine withdrawal. Psychiatry Res  1993; 47:69-77
[PubMed]
[CrossRef]
 
London ED, Cascella NG, Wong DF, Phillips RL, Dannals RF, Links JM, Herning R, Grayson R, Jaffe JH, Wagner HN Jr: Cocaine-induced reduction of glucose utilization in human brain: a study using positron emission tomography and [fluorine 18]-fluorodeoxyglucose. Arch Gen Psychiatry  1990; 47:567-574
[PubMed]
 
London ED, Broussolle EP, Links JM, Wong DF, Cascella NG, Dannals RF, Sano M, Herning R, Snyder FR, Rippetoe LR, Toung TJK, Jaffe JH, Wagner HN Jr: Morphine-induced metabolic changes in human brain: studies with positron emission tomography and [fluorine 18]fluorodeoxyglucose. Arch Gen Psychiatry  1990; 47:73-81
[PubMed]
 
Jenssen R, Olsen TS, Winther BB: Severe non-occlusive ischemic stroke in young heroin addicts. Acta Neurol Scand  1990; 81:354-357
[PubMed]
 
Woods SW: Regional cerebral blood flow imaging with SPECT in psychiatric disease: focus on schizophrenia, anxiety disorders, and substance abuse. J Clin Psychiatry 1992; 53(suppl):20-25
 
Fowler JS, Volkow ND: PET imaging studies in drug abuse. J Toxicol Clin Toxicol  1998; 36:163-174
[PubMed]
[CrossRef]
 
Holman BL, Garada B, Johnson KA, Mendelson J, Hallgring E, Teoh SK, Worth J, Navia B: A comparison of brain perfusion SPECT in cocaine abuse and AIDS dementia complex. J Nucl Med 1992; 33:1312-  1315
 
Holman BL, Mendelson J, Garada B, Teoh SK, Hallgring E, Johnson KA, Mello NK: Regional cerebral blood flow improves with treatment in chronic cocaine polydrug users. J Nucl Med  1993; 34:723-727
[PubMed]
 
Holman BL, Carvalho PA, Mendelson J, Teoh SK, Nardin R, Hallgring E, Hebben N, Johnson KA: Brain perfusion is abnormal in cocaine-dependent polydrug users: a study using technetium-99m-HMPAO and ASPECT. J Nucl Med 1991; 32:1206-  1210
 
Mena I, Giombetti RJ, Miller BL, Garrett K, Villanueva-Meyer J, Mody C, Goldberg MA: Cerebral blood flow changes with acute cocaine intoxication: clinical correlations with SPECT, CT, and MRI. NIDA Res Monogr  1994; 138:161-173
[PubMed]
 
Miller BL, Mena I, Giombetti R, Villanueva-Meyer J, Djenderedjian AH: Neuropsychiatric effects of cocaine: SPECT measurements. J Addict Dis  1992; 11:47-58
 
Pearlson GD, Jeffrey PJ, Harris GJ, Ross CA, Fischman MW, Camargo EE: Correlation of acute cocaine-induced changes in local cerebral blood flow with subjective effects. Am J Psychiatry  1993; 150:495-497
[PubMed]
 
Volkow ND, Wang GJ, Fowler JS, Logan J, Gatley SJ, Hitzemann R, Chen AD, Dewey SL, Pappas N: Decreased striatal dopaminergic responsiveness in detoxified cocaine-dependent subjects. Nature  1997; 386:830-833
[PubMed]
[CrossRef]
 
Sauter A, Rudin M, Wiederhold KH: Reduction of neural damage in irreversible cerebral ischemia by calcium antagonists. Neurochem Pathol  1988; 9:211-236
[PubMed]
 
Sauter A, Rudin M: Calcium antagonists reduce the extent of infarction in rat middle cerebral artery occlusion model as determined by quantitative magnetic resonance imaging. Stroke 1986; 17:1228-  1234
 
Lepakhin VK, Ivleva A, Romashova MF, Udotova SA, Zubovskii LG: [The effect of isradipine on the central and cerebral hemodynamics of patients with circulatory encephalopathy and hypertension.] Eksp Klin Farmakol  1992; 55:24-26 (Russian)
 
Sauter A, Rudin M, Wiederhold KH, Hof RP: Cerebrovascular, biochemical, and cytoprotective effects of isradipine in laboratory animals. Am J Med  1989; 86:134-146
 
Nakane H, Ooboshi H, Ibayashi S, Yao H, Sadoshima S, Fujishima M: Isradipine, a calcium channel blocker, attenuates the ischemia-induced release of dopamine but not glutamate in rats. Neurosci Lett  1995; 188:151-154
[PubMed]
[CrossRef]
 
Ooboshi H, Sadoshima S, Ibayashi S, Yao H, Uchimura H, Fujishima M: Isradipine attenuates the ischemia-induced release of dopamine in the striatum of the rat. Eur J Pharmacol  1993; 233:165-168
[PubMed]
[CrossRef]
 
Patrignani P, Filabozzi P, Patrono C: Selective cumulative inhibition of platelet thromboxane production by low-dose aspirin in healthy subjects. J Clin Invest 1982; 69:1366-  1376
 
Patrignani P, Canete-Soler R: Biosynthesis, characterization and inhibition of leukotriene B4 in human whole blood. Prostaglandins  1987; 33:539-551
[PubMed]
[CrossRef]
 
Kosten TR: Pharmacotherapy of cerebral ischemia in cocaine dependence. Drug Alcohol Depend  1998; 49:133-144
[PubMed]
[CrossRef]
 
Thibonnier M, Bayer AL, Simonson MS, Douglas JG: Effects of amiloride analogues on AVP binding and activation of V1-receptor-expressing cells. Am J Physiol 1992; 262(1, part 1):E76-E86
 
McBride PA, Mann JJ, Nimchinsky E, Cohen ML: Inhibition of serotonin-amplified human platelet aggregation by ketanserin, ritanserin, and the ergoline 5HT2 receptor antagonists-LY53857, sergolexole, and LY237733. Life Sci 1990; 47:2089-  2095
 
Wagner B, Schneider B, Blochl-Daum B, Speiser W, Brenner B, Eichler HG, Lechner K, Kyrle PA: Effect of ritanserin, a 5-hydroxytryptamine2-receptor antagonist, on platelet function and thrombin generation at the site of plug formation in vivo. Clin Pharmacol Ther  1990; 48:419-423
[PubMed]
[CrossRef]
 
McGinty JF: Introduction to the role of excitatory amino acids in the actions of abused drugs: a symposium presented at the 1993 annual meeting of the College on Problems of Drug Dependence. Drug Alcohol Depend  1995; 37:91-94
[PubMed]
[CrossRef]
 
Faden AI: Dynorphin increases extracellular levels of excitatory amino acids in the brain through a non-opioid mechanism. J Neurosci  1992; 12:425-429
[PubMed]
 
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