Neurological complications, caused by chronic nitrous oxide abuse in adolescents


  • Teodora Chamova UMHAT "Alexandrovska"; Medical university – Sofia
  • M. Ganeva University Pediatric Hospital "Prof. Ivan Mitev"; Medical university – Sofia
  • G. Tacheva University Pediatric Hospital "Prof. Ivan Mitev"; Medical university – Sofia
  • I. Litvinenko University Pediatric Hospital "Prof. Ivan Mitev"; Medical university – Sofia
  • M. Penkov UMHAT „St.Ivan Rilski”; Medical university – Sofia
  • I. Tournev UMHAT "Alexandrovska"; Medical university – Sofia; New Bulgarian University - Sofia, Bulgaria


Nitrous oxide, myeloneuropathy, vitamin B12, homocysteine, metylmalonic acid


Nitrous oxide misuse in adolescence and young adults is a recognized issue worldwide. Prolonged abuse inactivates vitamin B12, causing a myeloneuropathy.
We present five patients, aged between 15 and 18 years with a mean N2O consumption of 10-12 canisters twice a week during the last 3 months to 2 years. At presentation, paresthesias and gait unsteadiness were common, and one patient was with severely impaired gait. NCS were consistent with mixed sensorimotor neuropathy with more severe involvement of the lower limbs. Serum B12 levels were decreased in 4/5 and normal in one patients. In contrast, mean serum homocysteine and metylmalonic acid were more than 7 times increased. Spinal magnetic resonance imaging (MRI) showed characteristic dorsal column T2 hyperintensities in 1 patients. Patients were treated with intramuscular vitamin B12, with variable functional recovery.
Nitrous oxide misuse can cause a severe but potentially reversible subacute myeloneuropathy. Neurological deficits can improve with abstinence and B12 supplementation, even in the most severely affected patients.


van Amsterdam, J., Nabben, T., van den Brink, W. Recreational nitrous oxide use: Prevalence and risks. Regul Toxicol Pharmacol, 2015, 73, 3, 790-796.

Chen, S., Guo, L., Wang, Y. Acute pancreatitis after nitrous oxide abuse: A case report. JGH Open. 2022, 1, 7, 1, 75-77.

Home Office, 2014. Drug Misuse: Findings from the 2013/14 Crime Survey for England and Wales. Government. ONS, 2014 15/08/2014.

Keddie, S., Adams, A., Kelso, ARC., Turner, B., Schmierer, K., Gnanapavan, S., Malaspina, A., Giovannoni, G., Basnett, I., Noyce, AJ. No laughing matter: subacute degeneration of the spinal cord due to nitrous oxide inhalation, J Neurol, 2018, 265, 5, 1089-1095.

Lin, RJ., Chen, HF., Chang, YC., Su, JJ. Subacute combined degeneration caused by nitrous oxide intoxication: case reports. Acta Neurol, 2011Taiwan 20, 129e137.

Maze, M., Fujinaga, M. Pharmacology of nitrous oxide. Best. Pract. Res. Clin. Anaesthesiol. 2001, 15, 339e348.

McCormick, JP., Sharpe, S., Crowley, K., Dudley, A., O'Laoi, R., Barry, M., Owens, L., Doherty, CP., Redmond, J., Yeung, SJ. Nitrous oxide-induced myeloneuropathy: an emerging public health issue. Ir J Med Sci, 2023, 192, 1, 383-388.

Oulkadi, S., Peters, B., Vliegen, AS. Thromboembolic complications of recreational nitrous oxide (ab)use: a systematic review. J Thromb Thrombolysis, 2022, 54, 4, 686-695.

Oussalah, A., Julien, M., Levy, J., Hajjar, О., Franczak, C., Stephan, C., Laugel, E., Wandzel, M., Filhine-Tresarrieu, P., Green, R., Guéant, JL. Global burden related to nitrous oxide exposure in medical and recreational settings: a systematic review and individual patient data meta-analysis, J Clin Med, 2019, 8, 4, 551.

Richardson PG. Peripheral neuropathy following nitrous oxide abuse. Emerg. Med. Australas, 2010, 22, 88e90.

Schallner, N., Goebel, U. The perioperative use of nitrous oxide: renaissance of an old gas or funeral of an ancient relict? Curr= Opin. Anaesthesio, 2013, 26, 354e360.

Sluyts, Y., Pals, P., Amir, R., Vanherpe, P. Recreational use of nitrous oxide may cause collateral neurological damage, Acta Neurol Belg, 2021, 121, 4, 1097-1099.

Swart, G., Blair, C., Lu, Z., Yogendran, S., Offord, J., Sutherland, E., Barnes, S., Palavra, N., Cremer, P., Bolitho, S., Michael, Halmagyi, G. Nitrous oxide-induced myeloneuropathy, Eur J Neurol, 2021, 28, 12, 3938-3944.

van den Hoven, C., Lambrechts, S., Reynders, T. Neuro-image: nitrous oxide-induced myelopathy due to vitamin B(12)deficiency, Acta Neurol Belg. 2022, 122, 1, 203-205.

Winstock, A. Global Drug Survey 2019 8th Annual Survey Key Findings Report.



How to Cite

Chamova, T., Ganeva, M., Tacheva, G., Litvinenko, I., Penkov, M., & Tournev, I. (2023). Neurological complications, caused by chronic nitrous oxide abuse in adolescents. Bulgarian Neurology, 24(3), 118–121. Retrieved from