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We present a case of a 29-year-old male who was brought into the hospital due to unresponsiveness and found to have heroin inhalational leukoencephalopathy (HLE). HLE is one component of a broad spectrum of opioid encephalopathies that is associated with heroin inhalation and other opioids. There is considerable overlap of HLE with other toxic and hypoxic-ischemic encephalopathies; however, the specific territories of brain involvement help distinguish it from other cerebral insults. The goal of this study is to help elucidate the findings of HLE and compare these findings to other toxic and hypoxic-ischemic encephalopathies.

We present a case of a 70-year-old male who was brought to the hospital with altered mental status and was found to have 2 serious complications of cocaine use which are Cerebellar Hippocampal and Basal Nuclei Transient Edema with Restricted diffusion (CHANTER) syndrome and mesenteric ischemia. CHANTER syndrome is a recently described constellation of radiologic and clinical findings and has a strong association with opiates, and/or other drugs of abuse, including cocaine. Even though CHANTER has many similarities with other ischemic, anoxic, and/or toxic injuries related to substance abuse such as clinical presentation and restricted diffusion on magnetic resonance imaging (MRI); the typical distribution of affected regions in the brain is helpful in differentiating from other injuries. With this study, we aim to emphasize the clues that separate CHANTER syndrome from other acute neurologic problems in the setting of substance use. Our case also suggests that the obstructive hydrocephalus, a known possible complication of CHANTER, is likely seen in the cases with severe and central cerebellar involvement. Additionally, it is not common to see complications in 2 different systems concurrently and a multisystemic approach is crucial to a patient with cocaine use to prevent missed life-threatening consequences throughout the various body systems.

Spontaneous intracranial hypotension is a rare disease that results from low cerebrospinal fluid (CSF) volume caused by leakage of CSF from the spine in the absence of lumbar puncture, spine surgery, or intervention. The most common presentation is the headache that is usually but not invariably orthostatic. The underlying pathology is a CSF leak resulting from dural weakness involving the nerve root sleeves, ventral dural tears associated with calcified disc herniations, or CSF venous fistula. In severe cases, neuropsychiatric symptoms and changes in mental status may develop. Some case reports also mention gait disturbances, slurred speech, and urinary incontinence. The constellation of neuropsychiatric symptoms similar to behavior variant frontotemporal dementia in the presence of “brain sag” on MRI is known as frontotemporal brain sagging syndrome, first described by Wicklund et al. (4). The disease presents a diagnostic challenge to the primary care physicians, who are the first to see these patients. Brain and spine imaging is key to diagnoses but requires a high index of suspicion, as very rarely are all classic findings of intracranial hypotension present in the same patient. Here we discuss a case of spontaneous intracranial hypotension in a 45-year-old male patient who presented with headache, drowsiness, incoherent speech, behavior symptoms, and altered mental status.

Remote Cerebellar Hemorrhage is a rare entity that manifests spontaneously after supratentorial craniotomy and spinal surgeries. We present a 53-year-old male who was admitted due to subdural hematoma along the left frontoparietotemporal convexity. After treatment of the subdural hematoma with craniotomy and evacuation, he developed remote cerebellar hemorrhage 1 week later. Brain computed tomography demonstrated the zebra sign. Follow-up imaging showed complete recovery without any neurologic symptoms or signs. Keywords: Cerebellum, Hemorrhage, Remote, RCH, Zebra sign