Ischemic monomelic neuropathy: A rare complication after brachiocephalic arteriovenous fistula

Abstract

Ischemic monomelic neuropathy (IMN) is a rare neuropathy of the distal nerves due to ischemia secondary to acute loss of proximal arterial supply as a result of shunting or non-compressive occlusion. The main features of IMN are multiple distal focal mononeuropathies with axonal injury. A 71 years old female patient with history of end stage renal disease on hemodialysis and type 2 diabetes. Presented with right hand persistent pain and reduced hand function that started 24 h after formation of right brachiocephalic arteriovenous (AV) fistula. Doppler scan was done suggesting of steal syndrome. Patient then underwent MILLER banding procedure for the fistula. Despite good vascular supply, the right hand pain did not improve and was partially responding to gabapentin and codeine+ paracetamol. On examination: The right hand was warm and the capillary refill was satisfactory, palpable radial pulse with no signs of tissue ischemia. She was unable to flex the wrist and fingers of the right hand and she had clawing of right hand. She had allodynia and hyperalgesia in the distribution of right median, ulnar nerves. Nerve conduction study showed absent sensory responses from the right median, ulnar and radial nerves. The right median and ulnar motor responses were significantly attenuated suggestive of a severe axonal neuropathy and peripheral neuropathy secondary to diabetes. She was referred to vascular surgery for fistula ligation. IMN is a potentially rare devastating complication of arteriovenous access for hemodialysis which can result in permanent disability.