Should neurosurgeons ‘chase the dragon’? A case report

• Acute toxic leukoencephalopathy linked to polysubstance abuse is presented. • Case highlights neurological and systemic complications, including multi-organ failure. • Emergent cerebellar decompression performed but prognosis remained poor. • CT and postoperative findings detailed toxic and metabolic brain changes. • Distinction between ’chasing the dragon’ and CHANTER syndrome discussed. “Chasing the dragon” originally referred to the inhalation of vaporized heroin or opium, but it has since expanded to describe a condition affecting the brain. The term is associated with severe neurological complications, notably toxic leukoencephalopathy. Patients may present with acute neurological symptoms, including lowered consciousness and significant deficits. A 23-year-old male presented with a Glasgow Coma Scale score of E1M1V1 after prolonged unresponsiveness. Imaging showed cerebellar hypodensities, initially diagnosed as infarction with herniation. Immediate decompression of the posterior fossa was performed. Nevertheless, his clinical condition worsened and follow-up imaging revealed toxic leukoencephalopathy which was contributed to abuse of alcohol, quetiapine, 3-methylmethcathinone, cocaine and oxycodone, mimicking abnormalities seen in “chasing the dragon” syndrome. Additionally, severe systemic effects with multi-organ failure ensued, and treatment was withdrawn due to poor prognosis, resulting in the patient’s death. “Chasing the dragon” −like toxic leukoencephalopathy is associated with severe neurological complications, resulting from widespread white matter damage. Our case showed typical imaging findings of drug-induced leukoencephalopathy after polysubstance abuse. Despite undergoing neurosurgical decompression, the outcome was fatal. This highlights the limited effectiveness of surgical intervention in such severe cases, emphasizing that neurosurgeons should not “chase the dragon”. It is essential to consider the differential diagnosis of CHANTER, where neurosurgical intervention, can play a role in improving outcomes.