Departments of Neurology (DDM, SMT), Ophthalmology (DDM), Neurosurgery (DDM), and Indiana University School of Medicine, Indianapolis, Indiana.
J Neuroophthalmol. 2020 Jun;40(2):218-225. doi: 10.1097/WNO.0000000000000964.
Central venous obstruction (stenosis or occlusion) is common in patients with renal failure on hemodialysis and may be associated with intracranial hypertension (IH). Causes include vein injury from an endoluminal device, lumen obstruction from a device or thrombus, external vein compression, and high venous flow leading to vein intimal hyperplasia. A combination of high venous flow and central venous obstruction can lead to intracranial venous hypertension, impaired cerebrospinal fluid (CSF) resorption, and subsequent IH.
We conducted a search of the English literature using the Ovid MEDLINE Database and PubMed, with a focus on reports involving IH and central venous obstruction in the setting of hemodialysis. We reviewed CSF flow dynamics, the risk factors and causes of central venous obstruction, and the evaluation, management, and outcomes of central venous obstruction-induced IH.
Twenty-four cases of IH related to central venous obstruction in hemodialysis patients were identified. Twenty patients had headaches (83.3%) and 9 had visual symptoms (37.5%). The brachiocephalic vein was the most common site of stenosis or occlusion (20/24, 83.3%). Twenty-one patients (87.5%) had resolution of IH with treatment. Two patients died from complications of IH (8.3%).
Central venous obstruction-induced IH is likely underrecognized by clinicians and mimics idiopathic IH. Hemodialysis patients with IH should be screened with computed tomography venography of the chest. Optimal treatment is with vascular intervention or a CSF diversion procedure and can help prevent vision loss from papilledema or nervous system damage. Medical management may be appropriate in mild cases or as a bridge to definitive interventional treatment. Increased awareness among clinicians has potential to facilitate the timely diagnosis of this treatable condition with potential for good neurologic and visual outcomes.
中心静脉阻塞（狭窄或闭塞）在血液透析的肾衰竭患者中很常见，可能与颅内高压（IH）有关。原因包括腔内装置导致的静脉损伤、装置或血栓导致的管腔阻塞、外部静脉压迫以及导致静脉内膜增生的高静脉血流。高静脉血流和中心静脉阻塞的结合可导致颅内静脉高压、脑脊液（CSF）吸收受损以及随后的 IH。
我们使用 Ovid MEDLINE 数据库和 PubMed 对英文文献进行了搜索，重点关注涉及血液透析中 IH 和中心静脉阻塞的报告。我们回顾了 CSF 流动动力学、中心静脉阻塞的危险因素和原因，以及中心静脉阻塞引起的 IH 的评估、管理和结果。
确定了 24 例与血液透析患者中心静脉阻塞相关的 IH 病例。20 例患者有头痛（83.3%），9 例有视觉症状（37.5%）。狭窄或闭塞最常见的部位是头臂静脉（24/24，83.3%）。21 例（87.5%）患者经治疗 IH 缓解。2 例患者因 IH 并发症死亡（8.3%）。
中心静脉阻塞引起的 IH 可能被临床医生低估，且类似于特发性 IH。有 IH 的血液透析患者应进行胸部 CT 静脉造影筛查。最佳治疗方法是血管介入或 CSF 分流术，可以帮助防止视乳头水肿或神经系统损伤导致的视力丧失。在轻度病例或作为对明确介入治疗的桥梁时，药物治疗可能是合适的。临床医生的认识提高有可能及时诊断出这种可治疗的疾病，从而获得良好的神经和视觉预后。
