Dialysis dysequilibrium syndrome in a case of hemorrhagic stroke with chronic kidney disease: Bermuda triangle of neurocritical care

Background: Chronic renal failure in neurosurgical patients is not uncommon especially in the setting of hemorrhagic stroke. However, unfamiliarity with the syndrome of increased ICP during dialysis in these cases can lead a novice into the Bermuda Triangle. neurosurgeons prognosticating a patient with an ICH are often left in a state of ambiguity when the baseline blood reports reveal a deranged kidney function profile. To compound matters, Dialysis Disequilibrium syndrome presents with symptoms of raised intracranial pressure like nausea, headache, and vomiting and may even fatal in such cases. Case description: We describe a 64 yr old gentleman with right basal ganglia bleed who also had chronic kidney failure at presentation. An ICP monitor was placed in this case and dialysis was carried out along with anti-edema measures such as Mannitol with input-output and serum electrolyte monitoring. The ICP monitor showed a sudden rise in ICP during the dialysis sessions and this was reproducible over 3 such sessions. Eventually, further such sessions were stopped and the patient was managed with osmotic diuretics, antiepileptics. The eventual CT scan also did not show any sign of increased hematoma or mass effect thus pointing to a different mechanism of increase of the same. Conclusion: Too often neurosurgeons are faced with cases that may demand knowledge of a disease that may affect the neurological outcome. Avoiding high urea gradients during the procedure, minimizing the dialysis dose and isolated ultrafiltration may be the ideal approach.