Increased Intracranial Pressure during Hemodialysis in a Patient with Anoxic Brain Injury

Abstract

Dialysis disequilibrium syndrome (DDS) is a serious neurological complication of hemodialysis, and patients with acute brain injury are at increased risk. We report a case of DDS leading to intracranial hypertension in a patient with anoxic brain injury and discuss the subsequent dialysis strategy. A 13-year-old girl was admitted after prolonged resuscitation from cardiac arrest. Computed tomography (CT) revealed an inferior vena cava aneurysm and multiple pulmonary emboli as the likely cause. An intracranial pressure (ICP) monitor was inserted, and, on day 3, continuous renal replacement therapy (CRRT) was initiated due to acute kidney injury, during which the patient developed severe intracranial hypertension. CT of the brain showed diffuse cerebral edema. CRRT was discontinued, sedation was increased, and hypertonic saline was administered, upon which ICP normalized. Due to persistent hyperkalemia and overhydration, ultrafiltration and intermittent hemodialysis were performed separately on day 4 with a small dialyzer, low blood and dialysate flow, and high dialysate sodium content. During subsequent treatments, isolated ultrafiltration was well tolerated, whereas hemodialysis was associated with increased ICP necessitating frequent pauses or early cessation of dialysis. In patients at risk of DDS, hemodialysis should be performed with utmost care and continuous monitoring of ICP should be considered.

Use of non-invasive intracranial pressure pulse waveform to monitor patients with End-Stage Renal Disease (ESRD)

“…The symptoms like headache, nausea, and muscle cramps experienced by some patients of the current study during follow-up may represent a milder but not diagnosed spectrum of DDS [5]. Our understanding of the pathophysiology of DDS has improved since its initial description and it is now evident from animal and human studies that DDS is associated with the development of cerebral edema and increased ICP [21,22].…”

The CSF Diversion via Lumbar Drainage to Treat Dialysis Disequilibrium Syndrome in the Critically Ill Neurological Patient

“…Although previous case series have documented increases in ICP via invasive monitoring during hemodialysis, particularly in patients with traumatic brain injury [7,25], there is sparse evidence regarding ICP thresholds that may be necessary to undergo dialysis successfully without neurological sequelae in patients with DDS. Lund et al described successful management of elevated ICPs in a pediatric patient with anoxic brain injury and acute kidney failure from cardiac arrest, in which ICPs were reduced to 3 mm Hg with CSF diversion from an EVD prior to dialysis until she could be weaned off CSF drainage with eventual renal recovery [24]. In our patient, we utilized empiric CSF drainage of up to 30 cc immediately preceding dialysis to anticipate rises in ICP during hemodialysis sessions.…”

“…The patient in this study regained consciousness and experienced a normalization of intraocular pressures. A third study described successful management of elevated ICPs in a pediatric patient with anoxic brain injury and acute kidney failure from cardiac arrest, in which ICPs were reduced to 3 mm Hg with CSF diversion from an EVD prior to dialysis until she could be weaned off CSF drainage with eventual renal recovery [24].…”

Retrospective analysis of nontraumatic subdural hematoma incidence and outcomes in Egyptian patients with end-stage renal disease on hemodialysis

“…Hemodialysis has been associated with higher fluctuations in intracranial pressure, alteration in cerebral blood flow, and decreased pressure in subdural space during the intradialytic period [16]. Cortical atrophy may be linked to repeated hypotensive episodes in CMH patients [17,18].…”