We report 2 cases of accidental intrathecal vincristine administration. These injections were scheduled as intravenous injections of vincristine at the same time as other intrathecal drugs were scheduled. The mistakes were recognized immediately after administration, and a lumbar puncture was performed to lavage the cerebrospinal fluid (CSF) immediately after the incident. However, both cases developed progressive sensorimotor and radiculo-myelo-encephalopathy and the patients died 3 and 6 days after the incidents due to decerebration. A number of cases of accidental intrathecal vincristine administration have occurred in recent years in other settings, and we add our events to emphasize the need for a preventative and strictly followed protocol in oncology treatment units to prevent further unnecessary deaths. The best ‘cure' for mistakenly administered vincristine via lumbar puncture is prevention, which can be improved by strict adherence to a comprehensive guideline. Oncologic treatment centers should be aware of this guideline and evaluate their protocol for vincristine administration to prevent future incidents. Based on our past experiences, we strongly recommend ‘time-independent' procedures to prevent this type of incident.

1.
Gilbar PJ, Dooley MJ: Review of case reports of inadvertent intrathecal administration of vincristine: recommendations to reduce occurrence. Asia Pac J Clin Oncol 2007;3:59-65.
2.
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 1998;20:587-590.
3.
Schochet SS Jr, Lampert PW, Earle KM: Neuronal changes induced by intrathecal vincristine sulfate. J Neuropathol Exp Neurol 1968;27:645-658.
4.
Hennipman B, de Vries E, Bokkerink JP, Ball LM, Veerman AJ: Intrathecal vincristine: 3 fatal cases and a review of the literature. J Pediatr Hematol Oncol 2009;31:816-819.
5.
Reddy GK, Brown B, Nanda A: Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine? Clin Neurol Neurosurg 2011;113:68-71.
6.
Qweider M, Gilsbach JM, Rohde V: Inadvertent intrathecal vincristine administration: a neurosurgical emergency: case report. J Neurosurg Spine 2007;6:280-283.
7.
D'Addario A, Galuppo J, Navari C, Schultz M, Cuello N, Troncoso JC, Riudavets MA: Accidental intrathecal administration of vincristine. Am J Forensic Med Pathol 2010;31:83-84.
8.
Pongudom S, Chinthammitr Y: Inadvertent intrathecal vincristine administration: report of a fatal case despite cerebrospinal fluid lavage and a review of the literature. J Med Assoc Thai 2011;94:258-263.
9.
Dettmeyer R, Driever F, Becker A, Wiestler OD, Madea B: Fatal myeloencephalopathy due to accidental intrathecal vincristin administration: a report of two cases. Forensic Sci Int 2001;122:60-64.
10.
Dyke RW: Treatment of inadvertent intrathecal injection of vincristine. N Engl J Med 1989;321:1270-1271.
11.
Zaragoza MR, Ritchey ML, Walter A: Neurourologic consequences of accidental intrathecal vincristine: a case report. Med Pediatr Oncol 1995;24:61-62.
12.
Michelagnoli MP, Bailey CC, Wilson I, Livingston J, Kinsey SE: Potential salvage therapy for inadvertent intrathecal administration of vincristine. Br J Haematol 1997;99:364-367.
13.
Al Ferayan A, Russell NA, Al Wohaibi M, Awada A, Scherman B: Cerebrospinal fluid lavage in the treatment of inadvertent intrathecal vincristine injection. Childs Nerv Syst 1999;15:87-89.
14.
Iqbal Y, Abdullah MF, Tuner C, Al-Sudairy R: Intrathecal vincristine: long-term survivor of potentially fatal chemotherapeutic error. Ann Saudi Med 2002;22:108-109.
15.
Walter AW: Regarding ‘Intrathecal vincristine: 3 fatal cases and a review of the literature'. J Pediatr Hematol Oncol 2010;32:336-337.
16.
Gilbar PJ, Carrington CV: Preventing intrathecal administration of vincristine. Med J Aust 2004;181:464.
17.
Gilbar P: Inadvertent intrathecal administration of vincristine: has anything changed? J Oncol Pharm Pract 2011;18:155-157.
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