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There are many reports on the disequilibrium syndrome due to dialysis in patients with chronic renal failure. However, they do not mention the findings of CT cisternography and MRI. We intend to investigate the mechanism of CSF dynamics in a patient with disequilibrium syndrome by means of these radiological examinations. A 31 year-old woman who had suffered from renal failure for 18 years was found to have prominent increase of serum creatinine (18.1 mg/dl) and BUN (127 mg/dl) 3 years ago. At that time, digital marking of the skull was already present by X-ray examination without other destruction in bone survey of the whole body. She was hemodialysed by the hollow fiber kidney three times weekly (dialysis time 4.5 hours, dialysate osmotic pressure 270 mOsm/kg H2O). Three months ago, she began to complain of severe headache, nausea and vomiting 2 hours after the beginning of dialysis, so that she was referred to Kosei Hospital. On admission, she showed exophthalmus, concentric narrowing of the visual field, optic atrophy and hyperreflexia in jaw and four extremities. After admission, she received hemodialysis therapy thrice weekly (dialysis time 5 hours, dialysate osmotic pressure 290 mOsm/kg H2O). At the same time, 200 ml of glycerol (contents of glycerin 10, fructose 5, NaCl 0.9%) was administered intravenously during dialysis, which ameliorated the symptoms of intracranial hypertension. Laboratory studies revealed marked decrease of serum creatinine, BUN and uric acid levels and osmotic pressure, and increase of blood pH at the time of postdialysis compared with predialysis. Manometric CSF pressure increased up to 310 mmH2O at the day without dialysis before the glycerol administration.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[A case of chronic renal hemodialysis and intracranial hypertension--a study on CSF dynamics]. 276 3

In proportion to a rapid increase of dialysis patient, death caused by neurological complications is increasing annually among long-term hemodialyzed patients. A case of chronic subdural hematoma during long-term hemodialysis is presented. A 35-year-old male had undergone hemodialysis three times weekly for four years. He had marked changes in body-weight and blood pressure between hemodialysis. In March 1983, he had a headache, vomiting, and left hemiparesis. The CT scan showed a right subdural hematoma. He was admitted to our hospital 10 days later because of progressive hemiparesis and speech disturbance. The neurological examination showed left hemiparesis with sensory deficit and dysarthria. The CT scan showed an increase in the size of the subdural hematoma. Bleeding time was over 10 minutes. A right-sided burr hole was made and altered blood was removed and irrigated. After operation, headache and weakness rapidly subsided, but the next morning, attacks of convulsion occurred. The CT scan showed the rebleeding in the subdural space. After correcting the level of serum potassium by hemodialysis, a right parietal craniotomy was performed. Hematoma of about 100 g was removed and the capsule of the hematoma showed organized tissue histologically. Postoperatively, although attacks of convulsion occurred temporarily, he gradually improved. The levels of serum potassium and BUN were controlled by several treatments of hemodialysis. He was discharged with only mild hemiparesis. Subdural hematoma caused by hemodialysis is a very important complication. Chronic subdural hematoma is sometimes very difficult to differentiate from dysequilibrium syndrome or dialysis dementia. The CT scan is a very valuable examination to rule out subdural hematoma.
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PMID:[A case of chronic subdural hematoma in a hemodialyzed patient]. 372 77

Among patients with renal failure, there have been impressive modifications of both the duration and quality of life as a result of dialysis, renal transplantation, and improved medical management. However, patients who have renal failure continue to manifest a variety of neurologic disorders. Patients with chronic renal failure who have not yet received dialytic therapy may develop a symptom complex progressing from mild sensorial clouding to delirium and coma, with tremor, asterixis, multifocal myoclonus, and seizures. Even after the institution of otherwise adequate maintenance dialysis therapy, patients may continue to be afflicted with more subtle nervous system dysfunction, including impaired mentation, generalized weakness, and peripheral neuropathy. The central nervous system disorders of both untreated renal failure and that persisting despite dialysis are referred to as uremic encephalopathy. The dialytic treatment of end stage renal disease has itself been associated with the emergence of two distinct, new disorders of the central nervous system: Dialysis dysequilibrium and dialysis dementia. The dialysis disequilibrium syndrome consists of headache, nausea, muscle cramps, obtundation and seizures, and is a consequence of the initiation of dialysis therapy in some patients. Dialysis dementia is a progressive, generally fatal encephalopathy which affects patients on chronic hemodialysis. This disease also appears to be a complication of the therapy for renal failure.
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PMID:Pathogenesis of dialysis encephalopathy. 636 3

Patients with renal failure may manifest a variety of neurologic disorders. Patients with chronic renal failure who have not yet received dialytic therapy may develop a symptom complex progressing from mild sensorial clouding to delirium and coma, with tremor, asterixis, multifocal myoclonus, and seizures. After the institution of adequate maintenance dialysis therapy, patients may continue to be afflicted with more subtle nervous dysfunction, including impaired mentation, generalized weakness, and peripheral neuropathy. These central nervous system disorders are referred to as uremic encephalopathy. The dialytic treatment of end-stage renal disease has itself been associated with the emergence of two distinct, new disorders of the central nervous system; dialysis dysequilibrium and dialysis dementia. The dialysis disequilibrium syndrome consists of headache, nausea, muscle cramps, obtundation, and seizures, and is a consequence of the initiation of dialysis therapy in some patients. Dialysis dementia is a progressive, generally fatal encephalopathy which affects patients on chronic hemodialysis. There are at least three different forms of dialysis encephalopathy: sporadic, epidemic; and that associated with renal disease in children. In addition to the foregoing neurologic diseases which are specifically related to uremia and/or dialysis, a number of other neurologic disorders occur with increased frequency in patients with end-stage renal disease on chronic hemodialysis. These include subdural hematoma, electrolyte disorders, vitamin deficiencies, drug intoxication, hypertensive encephalopathy, and acute trace element intoxication. Renal transplantation is associated with a variety of central nervous system infections, reticulum cell sarcoma, and central pontine myelinosis. The present manuscript will review the clinical, structural, and biochemical components of those neurologic disorders which are peculiar to the uremic state and its treatment with dialysis.
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PMID:Uremic encephalopathies: clinical, biochemical, and experimental features. 675 30

10 patients suffering from severe headache during Acetatedialysis were subsequently treated with Acetatedialysis (AD) and Bicarbonatedialysis (BD). During AD the headaches occurred more frequently and more intensely. After AD a deterioration of EEG-results was also seen more frequently than after BD. Urea, osmolarity and sodium in the blood as well as heart frequency and blood pressure showed no different variation. An essential difference was found in correction of the metabolic acidosis. After AD there could be seen a negative base excess and a fall in PaCO2, after BD the PaCO2 rose and the base excess was positive. Headaches and EEG-changes as signs of a cerebral dysfunction (disequilibrium syndrome) may perhaps be caused by a decrease of the cerebral blood flow. From our experience we recommend a change to BD for patients suffering from headaches during AD.
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PMID:[Headache and EEG changes caused by acetate and bicarbonate dialysis]. 686 43

In 29 patients suffering from chronic renal failure intraocular pressure was measured during different therapeutic regimens. Conventional hemodialysis (principle of transport diffusion, n = 15) led to an increase in IOP after one hours treatment. In individuals complaining of headaches during dialysis a marked increase in IOP was observed indicating a disequilibrium syndrome. Hemofiltration is characterized by mass transfer and exchange of plasma water. When this treatment was applied to 6 patients IOP was elevated during the second hour. Simultaneous hemofiltration/hemodialysis (n = 8) had no influence on IOP behaviour. Statistically there was no correlation between the behaviour of serum osmolarity, arterial blood pressure, loss of body weight and IOP.
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PMID:[Effect of serum osmolarity, arterial blood pressure and volume loss on IOP during hemodialysis, hemofiltration and simultaneous hemofiltration/hemodialysis (author's transl)]. 690 45

Two cases of ruptured cerebral aneurysm with chronic renal failure were successfully treated by selecting an appropriate dialysis during the pre- and postoperative period. Case 1; a 41-year-old male, who had been receiving hemodialysis for 4 years, complained of sudden onset of headache, and his consciousness deteriorated abruptly afterwards. A ruptured basilar-left superior cerebellar artery aneurysm was diagnosed, and an external ventricular drainage device was installed. The patient slowly recovered consciousness and was scheduled for delayed operation. During this period hemodialysis was suspended and continuous ambulatory peritoneal dialysis (CAPD) was performed instead. On the 24th day, the aneurysm was clipped, and CAPD switched to ordinary hemodialysis three days after the operation. However, consciousness deteriorated and CT scan showed diffuse cerebral swelling due to disequilibrium syndrome. The patient recovered consciousness 24 hours after hemodialysis. Frequent short-term dialysis eventually eliminated this syndrome. Case 2; a 60-year-old male, who had been receiving hemodialysis for 6 years, complained of a sudden severe headache, and a ruptured anterior communicating artery aneurysm was diagnosed. Emergency clipping of the aneurysm was performed and, except for mild vasospasm on the seventh day, the patient's recovery was uneventful postoperatively, with non-anticoagulative agent hemodialysis. These two cases demonstrate that chronic renal failure of a ruptured cerebral aneurysm patient can, with good prognosis, be treated by CAPD preoperatively, and non-anticoagulative agent hemodialysis postoperatively, followed by ordinary dialysis carefully avoiding the disequilibrium syndrome.
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PMID:[Ruptured cerebral aneurysm associated with chronic renal failure: case report and evaluation of dialysis]. 842 92

A 58-year-old woman developed slowly progressive hearing loss, anosmia, and unsteady gait. She had neither repeated episode of headache nor a past history of neurosurgical operation or head injury. Neurological examination revealed anosmia, moderate degree of sensorineural hearing loss. She showed loss of caloric response bilaterally. No nystagmus was found. Romberg sign was present. No cerebellar ataxia was noted in the finger-to-nose or the heel-to-knee test. No adiadochokinesis was noted. Deep tendon reflexes were increased in both upper and lower extremities. Sensation was intact. She showed disturbance of the righting reflex in the tilt-table examination. CSF were under normal pressure, xanthochromic with siderophages. CSF total protein and ferritin level were elevated. T2-weighted image (TE4000/TR100) of high field strength magnetic resonance imaging (MRI) showed marginal hypointensity of the brain stem, the Sylvian fissures, the tips of temporal lobes, anterior cerebellar surfaces and the entire spinal cord. Angiography of the cerebral vessels and spinal arteries failed to identify the source of bleeding. It seemed likely that she had lost bilateral vestibular and auditory functions caused by hemosidelin deposition to her eighth nerves which are often affected by this disorder. Her disturbance of gait and station was apparently similar to cerebellar ataxic gait, however, she did not have limb ataxia. The electronystagmogram revealed marked degree of vestibular dysfunction (VOR) and relative sparing of cerebellar function (OKN). Her disturbance of the righting reflex in the tilt-table examination and the characteristic feature of her Romberg sign with directional preponderance also indicate that the bilateral loss of vestibular functions, i.e., vestibular ataxia caused her dysequilibrium syndrome. It is our impression that vestibular ataxia might precede cerebellar ataxia commonly reported so far.
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PMID:[A case of superficial siderosis of the central nervous system with bilateral vestibular dysfunction]. 936 92

A 70-year-old woman, who had been receiving hemodialysis in a local hospital every other day for 2 years, complained of occasional headaches. Magnetic resonance imaging showed a large middle cerebral artery (MCA) aneurysm. Angiography in the midterm day of hemodialysis demonstrated a large aneurysm on the right MCA bifurcation. Her chronic renal failure made us hesitate to perform craniotomy. Intra-aneurysmal Guglielmi detachable coil (GDC) embolization was performed also in the midterm day of hemodialysis. She was admitted to our hospital after hemodialysis on the day before the embolization. The embolization was carried out under local anesthesia and systemic heparinization. The aneurysm was almost completely embolized with five GDCs. She was transferred to the local hospital to receive the next hemodialysis on the day after the embolization. Patients with chronic renal failure are not suitable for neurosurgical therapy because mortality of patients undergoing dialysis is 45-80%, which is mainly due to disequilibrium syndrome and a hemorrhagic tendency. We propose that some cases like this case should be treated with an intra-vascular neurosurgical technique. In conclusion, this report demonstrates that intra-aneurysmal embolization is less invasive and is a more suitable treatment for patients who are considered to be at high risk for surgery and general anesthesia.
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PMID:[A case of unruptured cerebral aneurysm treated by intra-aneurysmal embolization during outpatient hemodialysis for chronic renal failure]. 1019 Jan 61

Spontaneous intracranial hematoma is not rare, but with bad prognosis, complication in patients on maintenance hemodialysis (HD). Diagnostic difficulties result from a fact that symptoms of acute hematoma such as headaches,, nausea, vomitis, apathy, sleepiness, parestesia and seizures may also suggest dysequilibrium syndrome, dialytic dementia as well as hypertensive encephalopathy. We describe a case of female patient with 20-year interview data of hypertension on HD since 1981 because of end-stage renal failure in a course of chronic glomerulonephritis, who developed spontaneous epi- and subdural hematoma four year ago in 47 age of life. Performed CT examination confirmed diagnosis and on the same day the patient underwent right frontoparietotemporal craniotomy and the hematoma was removed. During postoperative period, HD sessions were performed without heparin. After surgery the patient developed transcient hypertonia, epileptic sizures and left-sided paresis. Currently, 48 months after craniotomy the patient is fully rehabilitated, with normal blood pressure, without epileptic sizures or palsy. Gradually we discontinued anticonvulsans and antihypertensives.
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PMID:[Long-term good results of surgical treatment for spontaneous epi- and subdural hematoma in a female patient on maintenance hemodialysis]. 1139 5


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