Severe Bradycardia after Topical Use of Papaverine during a Pons Cavernoma Surgery

Abstract

Papaverine is a potent smooth muscle relaxant and has vasodilator properties. Topical use of papaverine is widely accepted in neurosurgery to prevent cerebral vasospasm. Growing evidence supports that papaverine may have a neural toxicity effect. We present a case of a 15 years-old patient that was operated on hemorrhagic cavernoma in the floor of the fourth ventricle. A transvermian approach was performed and neurophysiological monitoring was set up. During surgery, the motor evoked potentials diminished and papaverine solution was topically applied in soaked cotton pledgets. No other surgical manipulation or action by the anesthesiologist was made. The patsient suddenly developed a severe bradycardia that was successfully managed with IV atropine. Surgery ended uneventfully. Different side effects associated with intracisternal use of papaverine have been reported in intracranial surgery, including cranial nerves dysfunction and even fatal cardiac arrest. The case we present is a good example of an adverse effect of topical use of papaverine, even when carefully applied, and adds evidence to the probable papaverine neural toxicity.