Inadvertent intrathecal vincristine administration: a neurosurgical emergency

Case report

Maher Qweider Department of Neurosurgery, University Hospital Aachen, Germany

Search for other papers by Maher Qweider in
jns
Google Scholar
PubMed
Close
 M.D.
,
Joachim M. Gilsbach Department of Neurosurgery, University Hospital Aachen, Germany

Search for other papers by Joachim M. Gilsbach in
jns
Google Scholar
PubMed
Close
 M.D.
, and
Veit Rohde Department of Neurosurgery, University Hospital Aachen, Germany

Search for other papers by Veit Rohde in
jns
Google Scholar
PubMed
Close
 M.D.
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $392.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $636.00
USD  $45.00
USD  $392.00
USD  $636.00
Print or Print + Online Sign in

✓ Vincristine has a high neurotoxicity level. If given intrathecally by accident, it can cause ascending radiculomyeloencephalopathy, which is almost always fatal. The authors report a rare case in which vincristine was accidentally injected intrathecally into a 32-year-old man. The patient, who had Burkitt lymphoma, was neurologically intact, and it is likely that his survival was made possible due to aggressive neurosurgical therapy. After immediate cerebrospinal fluid (CSF) aspiration, external ventricular and lumbar drains were placed for CSF irrigation, which was continued for 6 days. This CSF irrigation was combined with 1) the intrathecal administration of fresh-frozen plasma to bind the vincristine and 2) an intravenous antineurotoxic therapy involving pyridoxine, folic acid, and glutamic acid. The patient's first sensorimotor deficits occurred after 2 days, led to an incomplete sensorimotor dysfunction below T-9 within the next 17 days, but progressed no further. Supported by the scarce data culled from the reviewed literature, the authors hypothesize that prolonged CSF irrigation combined with antineurotoxic therapy contributed to the patient's satisfactory outcome. In conclusion, accidental intrathecal vincristine injection requires emergency and adequate neurosurgical therapy.

Abbreviations used in this paper:

CSF = cerebrospinal fluid; EVD = external ventricular drain; FFP = fresh-frozen plasma.
  • Collapse
  • Expand
  • 1

    Addiego JE, , Ridgway D, & Bleyer WA: The acute management of intrathecal methotrexate overdose: pharmacologic rationale and guidelines. J Pediatr 98:825828, 1981

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    al Fawaz IM: Fatal myeloencephalopathy due to intrathecal vincristine administration. Ann Trop Paediatr 12:339342, 1992

  • 3

    Al Ferayan A, , Russel NA, , Al Wohaibi M, , Awada A, & Scherman B: Cerebrospinal fluid lavage in the treatment of inadvertent intrathecal vincristine injection. Childs Nerv Syst 15:8789, 1999

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Bain PG, , Lantos PL, , Djurovic V, & West I: Intrathecal vincristine: a fatal chemotherapeutic error with devastating central nervous system effects. J Neurol 238:230234, 1991

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Bender RA, , Castle MC, , Margileth DA, & Oliverio VT: The pharmacokinetics of [3H]-vincristine in man. Clin Pharmacol Ther 22:430438, 1977

  • 6

    Bleck TP, & Jacobsen J: Prolonged survival following the inadvertent intrathecal administration of vincristine: clinical and electro-physiologic analyses. Clin Neuropharmacol 14:457462, 1991

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Boyle FM, , Wheeler HR, & Shenfield GM: Glutamate ameliorates experimental vincristine neuropathy. J Pharmacol Exp Ther 279:410415, 1996

  • 8

    Dettmeyer R, , Driever F, , Becker A, , Wiestler OD, & Madea B: Fatal myeloencephalopathy due to accidental intrathecal vincristine administration: a report of two cases. Forensic Sci Int 122:6064, 2001

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Dyke WR: Treatment of inadvertent intrathecal injection of vincristine. New Engl J Med 321:12701271, 1989

  • 10

    Fernandez CV, , Esau R, , Hamilton D, , Fitzsimmons B, & Pritchard S: Intrathecal vincristine: an analysis of reasons for recurrent fatal chemotherapeutic error with recommendations for prevention. J Pediatr Hematol Oncol 20:587590, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Gaidys W, , Dickerman JD, , Walters CL, & Young PC: Intrathecal vincristine: report of a fatal case despite CNS washout. Cancer 52:799801, 1983

  • 12

    Gilbar PJ, & Carrington CV: Preventing intrathecal administration of vincristine. Med J Aust 181:464, 2004

  • 13

    Jackson DV, , Wells HB, , Atkins JN, , Zekan PJ, , White DR, & Richards F, et al.: Amelioration of vincristine neurotoxicity by glutamic acid. Am J Med 84:10161022, 1988

  • 14

    Jackson DV Jr, , McMahan RA, , Pope EK, , Case LD, , Cooper MR, & Kaplon MK, et al.: Clinical trial of folinic acid to reduce vincristine neurotoxicity. Cancer Chemother Pharmacol 17:281284, 1986

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Jackson DV Jr, , Pope EK, , McMahan RA, , Cooper MR, , Atkins JN, & Callahan RD, et al.: Clinical trial of pyridoxine to reduce vincristine neurotoxicity. J Neurooncol 4:3741, 1986

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Jackson DV Jr, , Rosenbaum DL, , Carlisle LJ, , Long TR, , Wells HB, & Spurr CL: Glutamic acid modification of vincristine toxicity. Cancer Biochem Biophys 7:245252, 1984

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Kwack EK, , Kim DJ, , Park TI, , Cho KR, , Kwon IH, & Sohn YK: Neural toxicity induced by accidental intrathecal vincristine administration. J Korean Med Sci 14:688692, 1999

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Lau G: Accidental intraventricular vincristine administration: an avoidable iatrogenic death. Med Sci Law 36:263265, 1996

  • 19

    Manelis J, , Freundlich E, , Ezekiel E, & Doron J: Accidental intrathecal vincristine administration. J Neurol 228:209213, 1982

  • 20

    Meggs WJ, & Hoffman RS: Fatality resulting from intraventricular vincristine administration. J Toxicol Clin Toxicool 36:243246, 1998

  • 21

    Michelagnoli MP, , Bailey CC, , Wilson J, , Livingston J, & Kinsey SE: Potential salvage therapy for inadvertent intrathecal administration of vincristine. Br J Haematol 99:364367, 1997

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Schochet SS Jr, , Lampert PW, & Earle KM: Neuronal changes induced by intrathecal vincristine sulfate. J Neuropathol Exp Neurol 27:645658, 1968

  • 23

    Schochet SS Jr, , Lampert PW, & Earle KM: Oligodendroglial changes induced by intrathecal vincristine sulfate. Exp Neurol 23:113119, 1969

  • 24

    Shelanski ML, & Wisniewski H: Neurofibrillary degeneration induced by Vinca alkaloids: clinical and experimental. Trans Am Neurol Assoc 93:137140, 1968

  • 25

    Shepherd DA, , Steuber CA, , Starling KA, & Fernbach DJ: Accidental intrathecal administration of vincristine. Med Pediatr Oncol 5:8588, 1978

  • 26

    Slyter H, , Liwnicz B, , Herrick MK, & Mason R: Fatal myeloencephalopathy caused by intrathecal vincristine. Neurology 30:867871, 1980

  • 27

    Williams ME, , Walker AN, , Bracikowski JP, , Garner L, , Wilson KD, & Carpenter JT: Ascending myeloencephalopathy due to intrathecal vincristine sulfate. A fatal chemotherapeutic error. Cancer 51:20412047, 1983

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Zaragoza MR, , Ritchey ML, & Walter A: Neurologic consequences of accidental intrathecal vincristine: a case report. Med Pediatr Oncol 24:6162, 1995

Metrics

All Time Past Year Past 30 Days
Abstract Views 3360 485 46
Full Text Views 477 84 8
PDF Downloads 377 76 8
EPUB Downloads 0 0 0