Retrograde cerebral venous reflux from a hemodialysis fistula without central venous occlusive disease: a case report

Background: Intracranial venous hypertension resulting from hemodialysis arteriovenous fistulas (AVFs) is rare and typically linked to central venous occlusive disease (CVOD). Here, we report a case of dural AVF-like cerebral venous reflux without CVOD, caused by a moderate-flow dialysis AVF. Case Report: A 71-year-old woman undergoing hemodialysis via a right-arm AVF presented with a seizure-like episode, transient loss of consciousness, and new left-sided weakness with neglect. Computed tomography angiography and magnetic resonance venography revealed diffuse pial venous engorgement and dural sinus hyperenhancement, mimicking a dural AVF. Prior catheter angiography had demonstrated retrograde flow from the AVF through the right internal jugular vein into the superior sagittal sinus without evidence of central venous stenosis or intracranial arterial feeders. Surgical ligation of the AVF resulted in improvement of cerebral edema, papilledema, and neurological deficits. Conclusion: Moderate-flow dialysis AVFs can cause symptomatic cerebral venous hypertension in the absence of CVOD. Venous-phase angiography is critical for detecting extracranial reflux and guiding definitive source control.