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• W2032727929 abstract "To the Editor: Intracisternal application of papaverine, a vasodilator, is common after aneurysmal clipping at our Institute. Ipsilateral dilated and nonreactive pupil attributed to papaverine instillation has been reported (1,2). The present case report describes bilateral dilated and nonreactive pupils subsequent to an uncomplicated craniotomy for anterior communicating artery aneurysm clipping in which intracisternal papaverine hydrochloride was used. A 50-yr-old female presented with severe headache, nausea, and vomiting and tonic clonic type of seizures. She was a poorly controlled hypertensive patient. On admission her Glasgow Coma Scale score was E4V4M5 and both pupils were equal in size and reactive to light. The computed tomography scan of head revealed a subarachnoid hemorrhage. Subsequent angiography revealed an anterior communicating artery aneurysm with vasospasm of right anterior and middle cerebral arteries. A standard general anesthesia technique was followed for aneurysmal clipping. The patient was placed supine with head turned 30° to left and held in place with Mayfield head holder. The aneurysm was uneventfully clipped via a right pterional approach. The oculomotor nerve was not manipulated. Papaverine 60 mg diluted in 10 mL of normal saline was instilled intracisternally by the neurosurgeon before dural closure. The patient was hemodynamically stable throughout the surgery. At the end of the procedure both pupils were dilated and nonreactive to light. An emergent computed tomography scan of head showed normal postoperative changes. The patient was electively ventilated for 24 h in the neurosurgical intensive care unit. Her right and left pupils became normal size and reactive to light after approximately 3 h and 4 h, respectively. Her subsequent postoperative course was uneventful, and she recovered without any neurological deficit. Papaverine relaxes smooth muscles, especially when they are spasmodically contracted (3). The drug is highly lipid soluble and is also a weak central analgesic and local anesthetic (4). Pritz (1) reported ipsilateral dilated and nonreactive pupil, lasting 2–4 h, in three patients after clipping of supratentorial aneurysm in which the oculomotor nerve was not manipulated. The author attributed these pupillary changes to intracisternal application of papaverine before dural closure. Lang et al. (2) reported a case of transient ipsilateral mydriasis (90 min) and prolonged facial nerve palsy (2 mo) after intracisternal papaverine application. We did not find any explanation in the literature regarding mechanisms of pupillary dilation after topical intracisternal application of papaverine. We hypothesize that papaverine acts locally on the oculomotor nerve. On leaving the brainstem, the nerve enters the subarachnoid space and courses forward and laterally between the posterior cerebral artery above and superior cerebellar artery below to run briefly along side the posterior communicating artery. At this level the pupillomotor fibers are located dorsally and peripherally (5). Papaverine, being a weak local anesthetic (4), probably blocks these superficial pupillomotor fibers leading to dilated and nonreactive pupil. Our patient had bilateral dilated and nonreactive pupils, which has not been reported before. Free communication between various cisterns (6) and patient head tilt 30° to the left might have facilitated the flow of papaverine to the opposite oculomotor nerve. The pupillary changes persisted for 3–4 h, and the patient recovered without any neurological deficit. Therefore, intracisternal instillation of papaverine appears to be the most probable cause of dilated and nonreactive pupils in our patient. Why these pupillary changes do not occur in all patients is difficult to explain. Indu Bala, MD Babita Ghai, MD, DNB Arun Kumar, MD Monica Pratap, MD, DNB Department of Anaesthesia and Intensive Care Postgraduate Institute of Medical Education and Research Chandigarh, India [email protected]" @default.
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• W2032727929 date "2006-03-01" @default.
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• W2032727929 title "Bilateral Pupillary Dilatation After Intracisternal Papaverine Application" @default.
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• W2032727929 doi "https://doi.org/10.1213/01.ane.0000190791.56084.23" @default.
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