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.