• Marcey Osgood, Rebecca Compton, Raphael Carandang, Wiley Hall, Glenn Kershaw, and Susanne Muehlschlegel.
• Department of Neurology (Neurocritical Care), University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA, 01655, USA.
• Neurocrit Care. 2015 Apr 1; 22 (2): 176-83.

IntroductionWe aim to raise awareness for the potential for rapid brain edema and herniation in acutely brain-injured patients undergoing renal replacement therapy (RRT), including one case undergoing continuous veno-venous hemofiltration. Dialysis disequilibrium syndrome (DDS) may have been a possible cause for the brain edema.MethodsWe retrospectively reviewed four consecutive neurocritically ill patients in acute renal failure undergoing RRT between 2011 and 2013. Imaging, blood pressure, and laboratory data pre-, during, and post-RRT are presented in graphical form. We performed an extensive literature review.ResultsAll patients suffered rapidly progressive herniation and death from global brain edema closely related in time to RRT, without other identifiable causes even after detailed review by three neurointensivists. Common clinical symptoms included sudden onset fixed and dilated pupils with apnea, consistent with brain stem compression. Herniation was not reversed by high-dose osmotherapy, and all patients died. Our detailed literature review provides plausible mechanisms for DDS as the most likely cause for our patients' brain edema.ConclusionsEven today, sudden brain edema and herniation may occur in association with RRT in neurocritically ill patients. We call for the establishment of RRT guidelines in patients with acute neurological injuries.

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