(1326) Massive Cerebral Edema From Dialysis Disequilibrium Syndrome Complicated by Acute Stroke

Introduction: Dialysis disequilibrium syndrome (DDS) refers to various neurological manifestations seen during or following dialysis. The symptoms can range from mild symptoms such as headache, and blurry vision to severe manifestations such as seizure or coma. This case report represents massive vasogenic edema in a patient with acute stroke following hemodialysis.

Description: A 66-year-old female with a history of ESRD on hemodialysis presented with acute aphasia for an uncertain duration. On physical examination, the patient could not follow commands and right-sided weakness and facial droop were also noted. CT head was unremarkable, but CTA head and neck showed left M1 MCA occlusion. Neurosurgery was contacted and recommended against thrombectomy. Brain MRI later confirmed diffuse MCA distribution infarction. The patient was admitted for medical management. Hemodialysis was resumed for her ESRD. Over the hospitalization, the patient had made a minimal improvement and stayed aphasic. Upon returning from the second dialysis session over the hospitalization, patient suddenly became unresponsive with GCS 6. The patient was transferred to the intensive care unit and was intubated for airway protection. Repeat CT head scan revealed extensive vasogenic edema involving the majority of the left frontal, parietal, and temporal lobes, with 13 mm rightward midline shift. The neurosurgery team was consulted again; however, they ultimately decided against performing decompressive hemicraniectomy as the patient was deemed a poor surgical candidate. The family ultimately decided to provide the patient with comfort measures only, and the patient unfortunately passed.

Discussion: The pathophysiology of DDS is not clearly defined, but current theories include the reverse urea effect and intracerebral acidosis. Rapid fluid and electrolyte shifts during dialysis sessions lead to disruption of the brain osmotic balance, which can ultimately lead to cerebral edema and neurological manifestation. It may be more prominent in patients with an acute cerebral insult, as in this case. This case report signifies the importance of more careful consideration in management such as careful hemodynamic monitoring during the hemodialysis sessions or more gradual fluid removal in the high-risk patient population along with ESRD.