Dialysis-Induced Worsening of Cerebral Edema in Intracranial Hemorrhage: A Case Series and Clinical Perspective

Intracranial hemorrhage (ICH) is not an uncommon complication of end-stage renal disease (ESRD), and may be complicated by cerebral edema. Hemodialysis (HD) may induce rapid osmolar and fluid shifts, increasing brain water content with the potential to worsen cerebral edema. The dangers of HD in patients with acute ICH have only been highlighted in isolated reports. Case series and review of relevant literature. Two patients with ESRD presented with acute ICH (one with putaminal hematoma, the other with bilateral subdural hematomas) and developed fatal/near-fatal herniation during HD, associated with malignant worsening of cerebral edema. Both had interruptions in dialysis schedule prior to index event. Both were awake initially, but developed cerebral herniation syndrome toward the end of index HD, confirmed on imaging with worsening edema and effaced basal cisterns. In one case, herniation was reversed with hypertonic saline and hyperventilation, but in the other, the patient progressed to brain death despite these measures. We contrast these cases with a young patient with ESRD and large basal ganglia ICH who had elevated ICPs on admission, but safely underwent continuous veno-venous HD. Hemodialysis may worsen cerebral edema in the setting of ICH sufficient to precipitate cerebral herniation. Caution should be exercised when dialysing a patient with an acute mass lesion and reduced intracranial compliance, especially those in whom HD is new or not routine. Delaying HD till risk of edema is attenuated, or ensuring gradual urea removal (such as with continuous hemofiltration) may be advisable.