Headache, Blurred Vision and Seizure in Hemodialysis Patient

A 53-year-old man with severe headache, blurred vision, and single generalized tonic-clonic seizure during hemodialysis presented to the emergency department (ED). On admission to the ED, the patient was in postictal state and measured at the following levels: blood pressure 203/113 mmHg, pulse rate 80/ min, respiratory rate of 17/min, body temperature of 36,5 °C, peripheral O2 saturation of 96%, and GCS of 9. Neurologic examination revealed no focal deficit. Bedside finger-stick glucose test was detected at 59 mg/dl. ECG of the patient was in normal sinus rhythm and revealed no ischemic sign. Intravenous 25 g glucose was administered to the patient and control of finger stick glucose test was detected at 281 mg/ dl. However, the mental status of the patient did not improve. The patient had complaints of headache and blurred vision for at least one day according to family members. The patient had chronic renal failure and hemodialysis for 1.5 years and was on eye drops for glaucoma. On fundoscopic examination, acute pathology was not detected. Noncontrast enhanced cranial computerized tomography (CT) was performed and CT revealed no acute pathology. Laboratory tests of the patient showed creatinin 5.8 and urea 79 mg/dl and no electrolyte imbalance, leucositosis, or thrombocytopenia. GCS of the patient was detected at 14 without focal deficits at two hours after admission to the ED. Contrast enhanced magnetic resonance imaging (MRI) of cranial and diffusion MRI was also performed (Figure 1).