Neurological sequelae from brachiocephalic vein stenosis

Abstract

Stenosis of central veins (brachiocephalic vein [BCV] and superior vena cava) occurs in 30% of hemodialysis patients, rarely producing intracranial pathology. The authors present the first cases of BCV stenosis causing perimesencephalic subarachnoid hemorrhage and myoclonic epilepsy. In the first case, a 73-year-old man on hemodialysis presented with headache and blurry vision, and was admitted with presumed idiopathic intracranial hypertension after negative CT studies and confirmatory lumbar puncture. The patient mildly improved until hospital Day 3, when he experienced a seizure; emergency CT scans showed perimesencephalic subarachnoid hemorrhage. Cerebral angiography failed to find any vascular abnormality, but demonstrated venous congestion. A fistulogram found left BCV occlusion with jugular reflux. The occlusion could not be reopened percutaneously and required open fistula ligation. Postoperatively, symptoms resolved and the patient remained intact at 7-month follow-up. In the second case, a 67-year-old woman on hemodialysis presented with right arm weakness and myoclonic jerks. Admission MRI revealed subcortical edema and a possible dural arteriovenous fistula. Cerebral angiography showed venous engorgement, but no vascular malformation. A fistulogram found left BCV stenosis with jugular reflux, which was immediately reversed with angioplasty and stent placement. Postprocedure the patient was seizure free, and her strength improved. Seven months later the patient presented in myoclonic status epilepticus, and a fistulogram revealed stent occlusion. Angioplasty successfully reopened the stent and she returned to baseline; she was seizure free at 4-month follow-up. Central venous stenosis is common with hemodialysis, but rarely presents with neurological findings. Prompt recognition and endovascular intervention can restore normal venous drainage and resolve symptoms.

Neurological Symptoms Due to Intracranial Venous Congestion in a Hemodialysis Patient With Arteriovenous Shunted Flow

“…Previous studies have reported that approximately 16% to 50% of central venous catheter placements can cause central venous stenosis. 5,7,9 Other causes, including radiation to the neck and chest area, tumor compression or invasion of the central veins, and deep vein thrombosis, have been also reported. 7 Patients who have developed severe kidney dysfunction often require the insertion of hemodialysis catheters into the central veins for emergency hemodialysis.…”

“…However, stenosis or obstruction of the outflow and/or central vein often causes venous congestion, resulting in edema of the affected upper limb. [5][6][7] In addition, albeit rare, the occurrence of venous congestive encephalopathy and subarachnoid hemorrhage has also been reported. 7,8 Here, we report a case of cerebral hemorrhage due to intracranial venous congestion in a hemodialysis patient with an AVG in her left forearm.…”

“…[5][6][7] In addition, albeit rare, the occurrence of venous congestive encephalopathy and subarachnoid hemorrhage has also been reported. 7,8 Here, we report a case of cerebral hemorrhage due to intracranial venous congestion in a hemodialysis patient with an AVG in her left forearm. The intracranial venous congestion had developed via blood flow from the AVG, severe stenosis of the left brachiocephalic vein, and backward flow of the left internal jugular vein.…”

Society of Interventional Radiology Reporting Standards for Thoracic Central Vein Obstruction

“…Neurologic manifestations.-Neurologic symptoms may be caused by TCVO, particularly when associated with SVC obstruction, even though a recent report (58) noted neurologic compromise with isolated BCV obstruction. Neurologic symptoms include visual or auditory disturbances, cognitive disabilities, headaches, or seizures.…”

Hemodialysis graft-induced intracranial hypertension

“…2,[5][6][7][8] Furthermore, intracranial hypertension has not been reported in association with HeRO grafts, despite increasing venous flow specifically in patients with central venous stenosis, suggesting the contribution of additional factors to the pathogenesis of hemodialysis graft-induced intracranial hypertension. Although usually treated by graft ligation or venoplasty with or without a stent, CSF shunting without graft ligation is also a treatment option in patients with isolated intracranial hypertension whose venous anatomy is seriously compromised.…”