Papaverine Reactions 1680, p272 - 2 Dec 2017 Bilateral mydriasis and symptomatic, angiographic bilateral middle cerebral artery (MCA) vasospasm with end branch stroke in right MCA: case report A 55-year-old woman developed bilateral mydriasis and symptomatic, angiographic bilateral middle cerebral artery (MCA) vasospasm with end branch stroke in right MCA following papaverine toxicity. The woman with a history of rheumatoid arthritis was hospitalised for sudden onset of severe headache. A CT scan showed Hunt and Hess and modified Fisher along with aneurysms at the junction of left AI A2 and anterior communicating artery, left MCA, and right MCA. Subsequently, she underwent a left-sided craniotomy with lumbar drain placement for intraoperative cerebrospinal fluid diversion. Her left MCA was clipped and she was administered 3% intracisternal papaverine 60 mg/2mL over the manipulated vessels of the left anterior cerebral artery, MCA, and internal carotid artery in the oculomotor and suprachiasmatic cisterns as well as the Sylvian fissure. Following emergence from anaesthesia, her light reflex was absent bilaterally. Pilocarpine test showed no pupillary response. Following the neuro- ophthalmologic examination, an intracisternal mediated bilateral mydriasis was identified. Her mydriasis resolved after 23 days. However, her clinical course was complicated by occurrence of symptomatic and angiographic bilateral MCA vasospasm on day 7. Additional complication included minor end-branch stroke in the right MCA on day 20. These complications were considered to have occurred due to sustained papaverine toxicity. The woman received verapamil treatment for vasospasm. She underwent surgery and was discharged from the hospital to acute rehabilitation, after four weeks. Subsequently, she was discharged home. She was followed up in neurology and neurosurgery clinics where her National Institutes of Health Stroke Scale and modified Rankin Scale scores were zero. No residual deficit from the stroke was observed as she had a normal neurological (related with MCA vasospasm) and ophthalmologic examination results. Author comment: "However, in patients with aSAH and a previously spared pupillary examination who undergo aneurysmal clipping, the most likely culprits for a bilateral mydriasis include direct nerve manipulation, vasospasm, hemorrhage, and drug side effects". "In our case, we believe the sustained toxicity of papaverine for weeks occurred in the setting of a postoperative course complicated by clinically significant vasospasm and stroke. . . level." Zhou X, et al. Prolonged Intracisternal Papaverine Toxicity: Index Case Description and Proposed Mechanism of Action. World Neurosurgery 109: 251-257, Jan 2018. Available from: URL: j.wneu.2017.09.196 - USA 803284033 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680 Reactions Weekly Springer Journals


Reactions Weekly , Volume 1680 (1) – Dec 2, 2017
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Springer International Publishing
Copyright © 2017 by Springer International Publishing AG, part of Springer Nature
Medicine & Public Health; Drug Safety and Pharmacovigilance; Pharmacology/Toxicology
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