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Accidental intraventricular vincristine administration: an avoidable iatrogenic death
1Department of Forensic Medicine, Institute of Science and Forensic Medicine, Singapore, Republic of Singapore.
Medicine, Science, and the Law
|July 1, 1996
Abstract:
A patient with acute lymphoblastic leukaemia was mistakenly given vincristine intraventricularly, as part of an intensified course of chemotherapy. Despite a CNS washout and supportive treatment, the patient developed progressive ascending paralysis, gradually lapsed into coma and died some 10 days later. Autopsy and post-mortem histological examination showed evidence of brain death caused by florid encephalomyelitis, apparently induced by the intraventricular administration of vincristine.