title: Periprocedural Risk of Stroke Is Elevated in Patients with End-Stage Renal Disease on Hemodialysis.
abstract: OBJECTIVE
  To describe the most common clinical factors and stroke etiologies in a case series of patients with end-stage renal disease on hemodialysis (ESRD/HD) with transient ischemic attack (TIA) or ischemic stroke (IS).
  
  
  BACKGROUND
  Prior studies have shown that patients on HD are at an elevated risk of stroke, but these studies have focused on the overall stroke risk. This case series sought to determine the percentage of acute ischemic events that occur during or immediately after HD.
  
  
  METHODS
  ICD-9 codes were used to identify IS and TIA patients with ESRD/HD admitted to the stroke service from August 22, 2011, to June 21, 2014. Charts were reviewed to determine the age, sex, and race/ethnicity of the cohort. TIA/IS diagnosis was confirmed by a vascular neurologist. Clinical factors were assessed, including: onset during or shortly after HD, defined as occurring within 12 h of HD; the presence of a lesion on diffusion-weighted MRI; hypotension, hyponatremia, or hypoglycemia at symptom onset; the stroke etiology; the presence of focal neurologic deficits; whether the patient was in the window period for intravenous tissue plasminogen activator (IVtPA) upon presentation, and whether the patient received IVtPA.
  
  
  RESULTS
  We identified 34 ESRD/HD patients with a diagnosis of TIA/stroke in the specified time period. A majority of patients (70.6%) were African American. Patient age ranged from 32 to 84 years, with a median age of 67 years. Twenty-seven patients (79.4%) had confirmed ischemic infarcts on diffusion-weighted MRI. Seven patients (20.6%) were diagnosed with TIA. In 13 patients (38.2%), symptom onset occurred during or shortly after HD. Of these 13 patients, 8 (61.5%) had symptom onset during HD. Three patients (8.8%) had documented hypotension near the time of symptom onset, and 2 (5.9%) were hyponatremic on presentation to the emergency department. The distribution of stroke etiologies was as follows: 4 (11.8%) watershed distribution, 1 (2.9%) large artery atherosclerosis, 2 (20.6%) small vessel disease, 10 (29.4%) cardioembolic, and 9 (26.5%) cryptogenic. In 28 patients (82.4%), focal neurologic deficits were observed on presentation. Nine patients (26.5%) arrived within the window period for IVtPA, and 4 (11.8%) were eligible and received IVtPA.
  
  
  CONCLUSIONS
  Of all patients with ESRD on HD admitted to the stroke service over the study period, over one third (38.3%) had the onset of their ischemic event during or shortly after HD, and nearly one quarter (23.5%) had the onset during HD. While clinicians may be tempted to attribute neurologic changes after HD to metabolic etiologies, they should also be aware that HD represents a period of elevated risk for acute ischemia.
authors.affiliation: Section of Cerebrovascular Disease, Department of Neurology, Rush University Medical Center, Chicago, Ill., USA.
authors.forename: Laurel
authors.initials: L
authors.lastname: Cherian
authors.affiliation: Section of Cerebrovascular Disease, Department of Neurology, Rush University Medical Center, Chicago, Ill., USA.
authors.forename: James
authors.initials: J
authors.lastname: Conners
authors.affiliation: Section of Cerebrovascular Disease, Department of Neurology, Rush University Medical Center, Chicago, Ill., USA.
authors.forename: Shawna
authors.initials: S
authors.lastname: Cutting
authors.affiliation: Section of Cerebrovascular Disease, Department of Neurology, Rush University Medical Center, Chicago, Ill., USA.
authors.forename: Vivien H
authors.initials: VH
authors.lastname: Lee
authors.affiliation: Section of Cerebrovascular Disease, Department of Neurology, Rush University Medical Center, Chicago, Ill., USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Song
mesh_terms: D061605:Administration, Intravenous; D000328:Adult; D001741:Black or African American; D000368:Aged; D000369:Aged, 80 and over; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D006801:Humans; D002546:Ischemic Attack, Transient / Q000188:drug therapy / Q000208:ethnology / Q000209:etiology; D007676:Kidney Failure, Chronic / Q000208:ethnology / Q000503:physiopathology* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000009:adverse effects*; D012307:Risk Factors; D020521:Stroke / Q000188:drug therapy / Q000208:ethnology / Q000209:etiology*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Hemodialysis; Ischemic stroke; Renal disease