Autori: F. Maritati (1), I. Paladini (2), V. Blanco (1), F. Abu Shalhoub (1), M. Minari (1), I. Minnella (1), F. Santarsia (1), S. David (1), L. Manenti (1)
Affiliazioni: (1) Nephrology Unit, University Hospital, Parma, Italy (2) Radiology Unit. University Hospital, Parma, Italy
INTRODUCTION
Complications related to the vascular access account for 20 – 30% of hospitalizations of dialysis patients and are primarily due to sepsis and thrombosis. Access thrombosis is usually a result of outflow obstruction because of stenosis at various points in the anatomical course of the access. Central venous occlusion has been identified in almost 25% of dialysis patients with dysfunctional arteriovenous (AV) fistula, most of them with a history of previous catheter placement. Occurrence of central vein stenosis commonly presents with ipsilateral upper extremity, chest and neck oedema, inadequate dialysis and AV access failure. Few case reports describe neurological sequelae due to abnormal cerebral venous drainage and intracranial venous congestion in patients with peripheral hemodialysis shunt and central vein stenosis. Herein, we report the case of a patient with a venous cerebral thrombosis resulting from a high blood flow AV fistula and the occlusion of the left innominate vein.
CASE REPORT
In February 2016, a 37-year old African man presented to the emergency department of our Hospital because of headache followed by generalized seizures and stupor. His medical history was remarkable for end-stage renal disease due to malignant hypertension since 2010 for which he was on regular hemodialysis through an aneurysmatic mid-arm radiocephalic fistula in his left arm. After hospitalization, he was intubated under sedation because of repeated seizures. He developed swelling in the left arm, neck and face. Diffusion-weighted magnetic resonance imaging (MRI) of the brain showed a partial thrombosis of the left transverse sinus and an abnormal intensity in the signal of the left cavernous sinus indicating venous congestion (Fig. 1 A). Cerebral angiography confirmed a thrombosis of the left transverse and sigmoid sinus. Duplex sonography of the left arm showed the mid-arm radiocephalic fistula functioning but with a decelerated blood flow. The neck venous vessels revealed retrograde flow toward the brain in the left jugular vein and venous collaterals developed along the neck and lower mandibular region. A chest CT scan showed a severe stenosis of the left innominate vein. The stenosis was confirmed also by a venography (Fig. 1 C and D). Anticoagulation with unfractionated heparin was immediately started, followed by the ligation of the arteriovenous fistula. After that, the patient’s mental status, left swelling in the arm and face improved dramatically. Follow up brain MRI, performed one year after the event, showed thrombosis resolution with no signs of venous congestion (Fig. 1 B).
CONCLUSION
Central venous stenosis is a common finding in patients receiving hemodialysis. To the best of our knowledge, this is the first report of venous cerebral thrombosis resulting from intracranial venous congestion due to hyperperfusion from an AV fistula and innominate vein occlusion. Given the large number of patients with AV fistula as well as the considerable frequency of associated central venous stenosis, it is surprising that this kind of complication is not reported more often. However, clinical awareness of the potential for neurological complications related to intracranial venous hypertension in patients undergoing hemodialysis may increase the detection rate of such symptoms.
C and D: Chest CT and venography showing innominate vein stenosis (arrows).
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