Papilledema Due to a Permanent Catheter for Renal Dialysis and an Arteriovenous Fistula

Abstract

Elevated intracranial pressure in patients with chronic renal failure has several potential causes. Its rare occurrence secondary to the hemodynamic effects of hemodialysis is described and the findings support a multifactorial etiology ("two hits").

Reversible Encephalopathy Due to Venous Hypertension From Arteriovenous Hemodialysis Graft

“…A review of the literature yielded at least 15 publications reporting neurological signs and symptoms related to venous hypertension caused by altered cervical and cerebral blood flow from central vein access for hemodialysis. 1 -15 Most of these cases clinically manifested with visual changes and papilledema suggesting a more typical presentation of elevated intracranial pressure, while others presented in a manner similar to our patient with seizures, hemorrhages, ischemic events, and encephalopathy. The time from venous access placement to onset of symptoms was extremely variable, suggesting that this condition needs to be considered in patients with such venous access regardless of when the procedure was performed as long as it is still patent.…”

“…These findings seem to be in line with a recently proposed “2-hit” hypothesis that suggests that the presence of increased venous intracranial flow needs to coexist with venous outflow impairment to become symptomatic. 11 It is possible that the presence of fluctuating encephalopathy was due to presence of hemodynamic fluctuations, although this cannot be confirmed. A similar clinical syndrome has been described in patients with dural AV fistulas, in which combined high flow through the AV shunt and associated outflow obstruction cause increased venous pressure that leads to progressive cognitive decline, reversible with surgical intervention.…”

Hemodialysis graft-induced intracranial hypertension

“…One case progressed to superior sagittal sinus thrombosis, cerebral infarction, and death. 2 Intracranial hypertension is a rare complication of hemodialysis graft placement, and a recently proposed "2 hit" hypothesis suggests that both high venous flow and venous obstruction are required risk factors, which presumably overwhelm intracranial venous outflow channels leading to elevated intracranial venous pressure, increased resistance to CSF drainage, and 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.…”

“…1,2 Hemodialysis Reliable Outflow (HeRO) grafts (CryoLife, Inc., Kennesaw, GA) are designed to bypass preexisting central venous stenosis by connecting the brachial artery with the venous circulation through the ipsilateral internal jugular vein (IJV) (figure, C and D). 3 We report a case of intracranial hypertension immediately after placement of a HeRO graft, review similar cases in the medical literature, and discuss possible pathophysiology.…”