Progressive intracranial venous reflux with cognitive decline in a hemodialysis patient: illustrative case

Intracranial venous reflux associated with long-standing hemodialysis (HD) arteriovenous fistulas (AVFs) is rare and may cause neurological symptoms. Its longitudinal progression to cortical venous reflux (CVR) remains poorly characterized.

An 81-year-old female undergoing HD via a left upper extremity AVF for 15 years was incidentally found to have sinus-only intracranial venous reflux 7 years before presentation. She remained asymptomatic until she developed rapidly progressive cognitive decline, with Mini-Mental State Examination (MMSE) scores decreasing from 26 to 16 within 6 months. MR angiography demonstrated progression to CVR. Digital subtraction angiography confirmed retrograde drainage into cortical veins without evidence of intracranial arteriovenous shunting. Severe left brachiocephalic vein stenosis with extrinsic compression was identified. Percutaneous transluminal angioplasty achieved minimal improvement. Following staged ligation of the left AVF, intracranial venous reflux resolved completely and cognitive function improved to an MMSE score of 22.

HD AVF-related intracranial venous reflux may progress from a sinus-only pattern to CVR, even in older patients. The emergence of CVR may signal advanced venous hypertension and present insidiously with cognitive decline. When endovascular treatment is insufficient, definitive flow reduction should be considered. https://thejns.org/doi/10.3171/CASE26230.