Hemodialysis in patients with intracerebral hemorrhage may cause dialysis disequilibrium syndrome, in which severe brain edema occurs due to the osmotic gradient resulting in a sudden rise in brain pressure. Based on our recent findings, we report the utility of Goreisan administration for the management of these conditions, i.e., prevention of increased brain pressure and exacerbation of brain edema during hemodialysis.

Goreisan was administered 30 minutes prior to dialysis. The dose was adjusted according to the hematoma size and the degree of brain edema. All 17 patients completed acute phase dialysis and were either transferred to other hospitals or discharged. Three representative cases are reported herein.

The first patient was a 77-year-old woman admitted to the hospital for right thalamic hemorrhage and intraventricular rupture. After stereotactic hematoma aspiration had been performed, increased blood pressure, tachypnea, and anisocoria appeared at the first postoperative dialysis session. We attributed this to a sudden increase in brain pressure, but a crisis was prevented by the administration of an osmotic diuretic. Considering that her condition was disequilibrium syndrome, saireito, a combination of Goreisan and Sho-saiko-to, was administered 30 minutes prior to dialysis. This combination prevented the increase in brain pressure. The second patient was a 45-year-old man hospitalized for right brainstem hemorrhage with intraventricular hematoma. He was treated conservatively. Difficulties at the time of dialysis were prevented by administration of Goreisan prior to dialysis. The third patient was a 74-year-old man who was admitted to the hospital for right thalamus hemorrhage with intraventricular hematoma. His condition was complicated by acute hydrocephalus; therefore, ventricular drainage was performed. Pretreatment with Goreisan prevented a rise in brain pressure during dialysis. Hydrocephalus did not relapse even after drain removal.

Goreisan is a representative treatment for sui disturbance and is considered to be an effective means of managing disequilibrium syndrome, which is an iatrogenic sui disturbance. Its mechanism of action is considered to involve aquaporin 4 in the cell membrane. Goreisan exerts an inhibitory effect on aquaporin 4 and thus may have inhibited the progression of brain edema by inhibiting the sudden transfer of water from the blood vessels to the brain due to the osmotic gradient induced by dialysis. Regarding the acute phase management of patients with intracerebral hemorrhage receiving hemodialysis, administration of Goreisan 30 minutes prior to dialysis is useful for preventing the exacerbation of brain edema.

症例は48歳男性. 糖尿病性腎症にて透析開始直前のX月Y日に倒れ, 当院に搬送された. 来院時, 軽度の硬膜外出血, 腎機能増悪, 代謝性アシドーシス, JCS 2程度の意識障害を認めた. 頭部外傷を考慮し初日は降圧のみで経過観察し頭蓋内血腫は縮小したが, 意識レベルはJCS 3程度にやや増悪した. 尿毒症性脳症の関連を疑いY+1日に緩徐に血液透析を開始したが, Y+2日に意識レベルがJCS 100まで増悪したため, 持続血液透析濾過に移行した. Y+4日に頭部MRIを施行し, 脳梁に強い腫脹性変化を認めた. 外傷, 脳梗塞, 感染症を含めさまざまな疾患を鑑別し, 今回の意識障害は頭部外傷と全身状態悪化を背景とした