Intracerebral Hemorrhage Secondary to Central Venous Occlusion and High-Flow Arteriovenous (AV) Fistula

Introduction: Intracerebral hemorrhage (ICH) is a life-threatening emergency with multiple etiologies (hypertensive arteriopathy, vascular malformations, coagulopathies). However, in select patients (dialysis-dependent ), more unusual mechanisms must be considered. Central venous occlusion (CVO) is a recognized complication in patients with long-standing vascular access for dialysis, particularly those with upper extremity arteriovenous fistulas. When combined with a high-flow AV fistula, CVO can lead to retrograde venous hypertension through collateral channels, including intracranial venous pathways. This rare but serious pathophysiological cascade may culminate in cerebral venous congestion and hemorrhage. Case Description: A 65-year-old male known to have ESRD complicating neurogenic bladder,on HD since 2010. He had a dilated left brachiocephalic AV fistula created in 2010 with Qa 2.3L/min. required multiple interventions. He presented with loss of consciousness and abnormal eye movement. CT brain revealed left temporal hematoma without obvious cause. Multidisciplinary team concluded that cerebral venous congestion secondary to CVO confirmed with central venogram revealed left brachiocephalic vein occlusion with retrograde flow through left internal jugular vein is the culprit. Angioplasty with stent deployment were done with clinical improvement regarding conscious level and proptosis. Discussion: In dialysis patients with neurologic symptoms and an upper limb AV fistula, CVO with retrograde flow is can cause ICH.A high-flow AV fistulas can lead to venous hypertension and rupture of cortical veins when central venous drainage is impaired.We present a rare case of ICH in a dialysis-dependent patient, secondary to cerebral venous hypertension caused by CVO and a high-flow BC AV fistula. This case underscores the importance of recognizing unusual etiologies of ICH in patients with altered venous hemodynamics due to dialysis access and highlights the need for early vascular evaluation in such settings.