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June 2016

Delayed Cerebral Infarction Following Intra-arterial Chemotherapy for Retinoblastoma

Author Affiliations
  • 1Department of Ophthalmology, University of California, San Francisco
  • 2Department of Radiology, University of California, San Francisco
JAMA Ophthalmol. 2016;134(6):712-714. doi:10.1001/jamaophthalmol.2016.0025

Intra-arterial chemotherapy with melphalan has been used as primary treatment for retinoblastoma since the 1990s, leading to globe conservation in most patients with few adverse events and no neurological complications in previous reports.1 We describe a case of delayed cerebral infarction following ophthalmic artery melphalan administration.

An infant with no family history of retinoblastoma presented with nystagmus and right exotropia. Fundus examination revealed bilateral retinoblastoma, group C in the right eye (Figure 1A) and group A in the left eye based on the International Classification System for Intraocular Retinoblastoma.2 An isolated anterior tumor in the left eye was treated with cryotherapy. The right eye was treated with superselective intra-arterial chemotherapy, placing the tip of a microcatheter at the orifice of the ophthalmic artery to infuse melphalan.3 The patient was premedicated with intravenous heparin, 1050 U, to avoid thrombosis. Vasospasm of the right ophthalmic artery developed during the procedure and 1 mg of verapamil hydrochloride was administered intra-arterially, with resolution documented on road map angiography. Melphalan (4 mg in 30 mL of normal saline, prepared and filtered 1 hour prior to administration) was then delivered over 30 minutes in the right ophthalmic artery. The endovascular procedure time was 2 hours without any instances of excessively high or low blood pressure. After the procedure, the patient was neurologically unchanged from baseline, and he was discharged in stable condition.