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Neurological complications of excessive recreational nitrous oxide use: a case series based on a text mining algorithm

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Abstract

Background

The recreational use of nitrous oxide (N2O) has gained popularity over recent years. We present a case series of excessive N2O users with neurological complications.

Methods

In this retrospective three-centre study, we used a text mining algorithm to search for patients who used N2O recreationally and visited a neurologist.

Results

We identified 251 patients. The median duration of N2O use was 11 months (interquartile range [IQR], 3–24) and the median amount of N2O used per occasion 1.6 kg (IQR 0.5–4.0). Clinically, polyneuropathy (78%), myelopathy (41%), and encephalopathy (14%) were the most common diagnoses. An absolute vitamin B12 deficiency of < 150 pmol/L was found in 40% of cases. In 90%, at least one indicator of functional vitamin B12 status (vitamin B12, homocysteine, or methylmalonic acid) was abnormal. MRI showed signs of myelopathy in 30/55 (55%) of cases. In 28/44 (64%) of those who underwent electromyography, evidence of axonal polyneuropathy was found. Most (83%) patients were treated with vitamin B12 supplementation, and 23% were admitted to the hospital. Only 41% had follow-up for ≥ 30 days, and 79% of those showed partial or complete recovery.

Conclusions

In this case series of excessive N2O users, we describe a high prevalence of polyneuropathy, myelopathy, and encephalopathy. Stepwise testing for serum levels of vitamin B12, homocysteine, and methylmalonic acid may support the clinical diagnosis. Due to low sensitivity, MRI of the spinal cord and electromyography have limited value. Effective treatment should incorporate supplementation of vitamin B12 and strategies to prevent relapses in N2O use.

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Data availability

Data are available on reasonable request. Anonymised data will be shared on reasonable request with any qualified investigator.

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Acknowledgements

We thank Max Heijting, Baruch Kiestra, and Tiny Simons-Sporken for their assistance in data acquisition.

Funding

There was no funding source for the conduction of this research.

Author information

Authors and Affiliations

  1. Department of Neurology, OLVG, Amsterdam, the Netherlands

    B. J. Ruijter, M. J. de Mooij & V. I. H. Kwa

  2. Department of Neurology, Zuyderland Medical Centre, Heerlen, the Netherlands

    J. E. Bruijnes

  3. Department of Neurology, Maastricht UMC+, Maastricht, the Netherlands

    J. E. Bruijnes

  4. Department of Neurology, Zaans Medical Centre, Zaandam, the Netherlands

    W. P. J. van Oosterhout

Authors
  1. B. J. Ruijter
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  2. M. J. de Mooij
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  3. J. E. Bruijnes
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  4. W. P. J. van Oosterhout
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  5. V. I. H. Kwa
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Contributions

BRJ: designed and conceptualized study; major role in acquisition of data; analysed and interpreted the data; drafted and revised the manuscript for intellectual content; had full access to all the data in the study and takes responsibility as guarantor for the integrity of the data and the accuracy of the data analysis. MJdM: major role in acquisition of data; interpreted the data; revised the manuscript for intellectual content. JEB: major role in acquisition of data; interpreted the data; revised the manuscript for intellectual content. WPJvO: major role in acquisition of data; interpreted the data; revised the manuscript for intellectual content. VIHK: designed and conceptualised study; interpreted the data; revised the manuscript for intellectual content.

Corresponding author

Correspondence to B. J. Ruijter.

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Conflicts of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

The institutional ethical review board of each centre approved the conduction of this study. Since this was a retrospective study, and participants were not subjected to additional procedures apart from standard care, the ethical review boards of OLVG and ZMC waived the need for informed consent. In Zuyderland MC, written informed consent was requested. When there was no response after a reminder, the need for informed consent was waived.

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Ruijter, B.J., de Mooij, M.J., Bruijnes, J.E. et al. Neurological complications of excessive recreational nitrous oxide use: a case series based on a text mining algorithm. J Neurol 271, 1267–1276 (2024). https://doi.org/10.1007/s00415-023-12061-x

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  • DOI: https://doi.org/10.1007/s00415-023-12061-x

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