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The clinical manifestations encompassed cerebellar and bulbar dysfunction, coupled with motor impairment and altered consciousness. This article aims to provide insights into the clinical and radiological aspects of HLE, emphasizing the diagnostic significance of radiological findings. The gold standard examination for diagnosis is MRI, crucial due to the difficulties in obtaining histological confirmation for this rare condition. Heroin-induced leukoencephalopathy HLE is a rare form of toxic encephalopathy that involves damage to the white matter, particularly the myelin, caused by heroin consumption. This condition is almost exclusively encountered when the patient inhale fumes resulting from heating the drug on tin-foil. The exact cause and pathophysiology of these lesions are still poorly understood to this day. Several hypotheses have been proposed, but the exact pathogenic agent remains unidentified. The clinical presentation typically includes signs of cerebellar and bulbar dysfunction that may be associated with motor impairment and altered consciousness. We present the case of a year-old polydrug user in whom HLE was diagnosed following hospitalization for a rapidly progressive flaccid tetraplegia and aphasia. This article aims to present a typical case from both clinical and radiological perspectives, and to highlight the radiological findings that contribute to the diagnosis. A year-old male patient, with a history of polydrug use, was admitted to our hospital for management of ataxia, rapidly progressive flaccid paraplegia and aphasia. Obtaining information from the patient and family was challenging, there was a history of chronic toxic substance abuse, including solvents such as toluene and n-hexane; however, heroin use was not initially reported. No fever or sensory impairment was noted. MRI was performed to rule out an infectious disease within the central nervous system and potentially confirm the diagnosis of toxic encephalopathy. It revealed bilateral hemispheric signal abnormalities, hypointense on the T1-weighted sequence, and hyperintense on T2-weighted and FLAIR images Figure 1. Involvement of the posterior limb of the internal capsule extending to the corticospinal tract of the pons and symmetric involvement of the middle cerebellar peduncles MCP sign was also noted Figure 2. The lesions also showed peripheral restrictive areas observed on the diffusion sequence and apparent diffusion coefficient ADC cartography Figure 3. No pathological enhancement or signs of intracranial infection were observed. MR spectroscopy was not performed for this patient. Axial T2-weighted slices passing through the thalamus and the posterior cranial fossa, demonstrate involvement of the posterior limb of the internal capsule arrow and the middle cerebellar peduncle sign or MCP sign arrowhead. DWI images at two different levels illustrating diffusion restriction scattered within the white matter lesions A, B , confirmed on the ADC cartography C. The absence of heroin detection in the toxicology tests is most likely explained by the delayed timing of the test. Upon admission, the patient was initially placed on empirical antibiotic therapy which was later discontinued after encephalitis was ruled out. Over the next few days following the diagnosis, the patient received symptomatic treatment aimed at alleviating his symptoms; however, his condition continued to worsen. On day 22 after his hospitalization, he experienced status epilepticus and remained in an altered state of consciousness thereafter. He passed away 3 days later. Toxic leukoencephalopathy is a condition encompassing various non-specific neurological manifestations resulting from white matter lesions, due to the consumption of different toxic agents chemotherapeutic drugs, immunosuppressants, environmental toxins, recreational drugs, etc. We distinguish 2 forms: the most frequent one being the chronic form typically revealed by insidious manifestations, and the relatively rare and more severe one being the acute form. The drug is typically placed on a piece of aluminium foil and heated from underneath using a match or a lighter. The powder transforms into a reddish-brown gelatinous substance, releasing white fumes that are inhaled using a straw or similar device. First described in in a Dutch cohort, the clinical signs and their severity can vary, mild cases primarily present with cerebellar and bulbar involvement, including dysarthria and ataxia, accompanied by motor signs such as hyporeflexia, muscle weakness, and spasticity. The diagnosis should be suspected in a patient known to be a heroin user and presenting with acute neurological signs in the absence of other infectious or toxic causes mimicking similar symptoms. Definitive diagnosis requires anatomopathological examination of brain samples, which is rarely performed in practice. Imaging plays a crucial role in HLE diagnosis, given the challenges in obtaining histological confirmation. MRI is the gold standard examination, and although there are no pathognomonic signs, the lesions pattern is often highly suggestive. The lesions will usually show scattered hyperintensities on diffusion-weighted imaging and low ADC, This reflects the demyelinating nature of the lesions. Specific features include: 1 , 3. A vacuolated appearance of the lesions, representing the presence of fluid-filled cyst-like formations between nerve fibres, particularly well visualized on T2-weighted sequences as shown in Figure 1. Bilateral and symmetrical involvement of the posterior limbs of the internal capsule extending to the corticospinal tract. Butterfly-shaped symmetrical involvement of the middle cerebellar peduncles. Spectroscopy findings are non-specific and typically show a reduction in N-acetylaspartate and choline, as well as an increase in lactate levels. The differential diagnosis is typically made with other toxic encephalopathies, but the presence of a history of heroin inhalation along with typical imaging findings as described above is usually sufficient to establish the diagnosis. Management primarily focuses on symptomatic treatment, although supplementation with certain molecules such as coenzyme Q10, vitamin E, and vitamin C has shown some benefits in some patients. The prognosis varies depending on the severity of white matter involvement and clinical manifestations. In moderate cases, mortality is lower, but long-term neurological sequelae are common. Although rare, heroin-induced leukoencephalopathy should be considered in polydrug users. A detailed medical history should be obtained to determine potential heroin consumption and the method of administration. MRI plays a crucial role in diagnosis due to the difficulty of histological confirmation. Radiological findings are not specific; however, a pattern of bilateral signal abnormalities sparing U fibres, middle cerebellar peduncles sign, involvement of the posterior limb of the internal capsule, together with a favourable clinical presentation, strongly suggests the diagnosis. Mimicking a psychiatric disorder: heroin-induced leukoencephalopathy. Google Scholar. Heroin-induced leukoencephalopathy. Singh R , Saini M. Singapore Med J. Inhalational heroin use and leukoencephalopathy: a case report. Heroin-induced leukoencephalopathy leading to locked-in syndrome: a case report. Fatal toxic leukoencephalopathy: clinical, radiological, and necropsy findings in two patients. J Neurol Neurosurg Psychiatry. Chasing the wrong dragon: a new presentation of heroin-induced toxic leukoencephalopathy mimicking anoxic brain injury. J Intensive Care Soc. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Advertisement intended for healthcare professionals. Sign in through your institution. British Institute of Radiology Journals. AI and Machine Learning. Head and Neck. Medical Physics: Radiotherapy. Medical Physics: Diagnostic. Musculoskeletal and Soft Tissue. Nuclear Medicine and Molecular Imaging. Obstetrics and Gynaecology. Radiation Protection. Radiotherapy and Oncology. Respiratory and Chest. Browse all content Browse content in. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents Abstract. Case report. Learning points. Conflicts of interest. Journal Article. Oxford Academic. Ismail Halfi, MD. Meryem Fikri, MD. Mohamed Jidane, MD. Firdaous Touarsa, MD. Revision received:. Select Format Select format. Permissions Icon Permissions. Figure 1. Open in new tab Download slide. Figure 2. Figure 3. Google Scholar PubMed. Google Scholar Crossref. Search ADS. Issue Section:. Download all slides. Views 1, More metrics information. Total Views 1, Email alerts Article activity alert. Advance article alerts. New issue alert. In progress issue alert. Subject alert. Receive exclusive offers and updates from Oxford Academic. Related articles in Google Scholar. Citing articles via Google Scholar. Pseudoarthrogram sign — a rare radiological appearance of implant failure in the knee. Intracranial vasculopathy with MR vessel wall imaging: a case series. Oesophageal injury mimicking a tubular congenital oesophageal duplication—a diagnostic dilemma: a case report. 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