Discussion:
We herein report a 75-year-old female patient on dialysis with serious sequelae caused by intracranial hemorrhage following anaphylactic shock treated with intramuscular administration of adrenaline.
Leukopenia, non-occlusive mesenteric ischemia, ischemic stroke, and intracerebral hemorrhage are adverse events after anaphylactic shock that have previously been reported in the medical literature [5][10][11][12][13].
Although other etiologies cannot be excluded, we assume that acute hypertensive attack induced by adrenaline and dialysis with a high risk of hemorrhage may be associated with the pathogenesis of intracerebral hemorrhage, in our case at least partially. Indeed, during anaphylactic shock, our patient’s cerebral blood flow decreased more than what could be anticipated based on the blood pressure observed in animal experiments[14]. Therefore, the pathogenesis of intracerebral hemorrhage may have etiologies other than anaphylaxis. Similar to our case, previous reports have hypothesized that intracerebral hemorrhage after anaphylactic shock can result from elevated blood pressure induced by adrenaline administration when there is no evidence of vascular abnormality or intracerebral tumor[5][6].
Adrenaline is one of the most commonly used medications to manage conditions such as cardiac arrest, asthma, septic shock, and anaphylactic shock, but serious adverse events can occur, including arrhythmias, lactic acidosis, pulmonary edema, and cerebrovascular disease[6][15][16][17]. Intracerebral hemorrhage after administration of adrenaline via different routes, including intravenous and intramuscular administration and inhalation, has previously been described[5][8][18]. Adrenaline can lead to stimulation of all α and β adrenergic receptors, eliciting short-term systolic hypertension, and suppress inflammatory mediators released from mast cells and basophils[19]. Adrenaline influences a significant dysfunction of cerebral autoregulation and the blood brain barrier in animal experiments[20]. These pharmacological mechanisms may have contributed to intracerebral hemorrhage.
A second hypothesis for the cause of the intracerebral hemorrhage is dialysis. Intracerebral hemorrhage is a common and potential risk for dialysis patients due to altered platelet-vessel wall interactions and platelet dysfunction, as well as factors that impair normal platelet aggregation and adhesion [21]. Moreover, hemodialysis patients have received anticoagulants during dialysis. The number of elderly people with multiple comorbidities who require dialysis tends to increase every year[9]. Therefore, clinicians must consider the risk of intracerebral hemorrhage in dialysis patients.