b rain injury associated with methanol toxicity can be ischemic , necrotic or hemorrhagic in nature . it most commonly affects the putamen area bilaterally ; however , it can be seen in other locations . possible hypotheses include a direct toxic effect of methanol or its metabolites , injury secondary to anoxia and acidosis and , more recently proposed , cerebral vasospasm induced by a large rise in intracellular calcium ( 1 , 2 ) . this report describes an intoxicated patient who developed an epidural hematoma and loss of consciousness following hemodialysis . a 22-year - old man presented to the emergency department ( ed ) with a history of tonic - clonic generalized seizures , loss of consciousness , and head trauma following consumption of 800 mg tramadol . on admission the patient 's vital signs were as follows : systolic blood pressure = 160 mm hg , diastolic blood pressure = 80 mm hg , o2 saturation = 85% , pulse rate = 106/min , respiratory rate = 24/min and axillary temperature = 37.4c . arterial blood gas ( abg ) analysis showed a high anion gap metabolic acidosis : ph = 6.80 , paco2 = 30.4 mm hg , hco3 = 4.6 meq / l , na = 139 meq / l , cl = 108 meq / l . the metabolic acidosis in this patient could not be explained solely by lactic acidosis following seizure activity so other potential causes were explored . a thorough history of the patient s family revealed that the patient drank homemade alcohol three days prior to presentation . methanol poisoning was diagnosed on the basis of the previously mentioned history and initial evaluation and the decision was made to begin hemodialysis . due to the history of head trauma , a computed tomography scan ( ct scan ) of the brain was performed prior to sending the patient to the dialysis unit ( figure 1 ) . protective measures including ethanol gavage , folic acid , and sodium bicarbonate were administered to the patient while waiting to begin hemodialysis . approximately one hour later , the patient s level of consciousness decreased and unilateral mydriasis with negative pupillary light response ( anisocoria ) developed in the right eye . the patient was immediately intubated and brain ct scan was repeated ( figure 2 ) . a large epidural hematoma was seen in the right fronto - parietal lobe with evidence of mass effect . tramadol and homemade alcohols are among the most commonly abused substances and each can result in several harmful consequences . extracorporeal removal plays a fundamental role in the management of methanol poisoning , though specific techniques and indications are not yet determined . conventional hemodialysis is typically the best method to rapidly remove both alcohol and its toxic metabolites because of its widespread availability and known efficacy ( 3 , 4 ) . peritoneal dialysis and other forms of continuous renal replacement therapy are inefficient and are not recommended except in specific rare situations such as cerebral hemorrhagic complications following regular hemodialysis ( 3 , 5 ) . systemic heparinization during hemodialysis may contribute to the hemorrhage observed in the necrotic areas of the brain in these poisoned patients . awareness of the potential complications of hemodialysis may assist in their prevention ( 6 ) . there are numerous reports about both the different types of cerebral hemorrhagic insults in methanol poisoning and following hemodialysis , but reports of epidural hematoma ( edh ) are rare ( 7 ) . most edhs are caused by direct impact injuries to the skull ( 8) . while it is unlikely that a false negative primary interpretation of a brain ct scan in a crowded emergency department may contribute to the occurrence of edh secondary to hemodialysis , it is possible ( 9 ) . a review of the published literature reveals that heparinization during hemodialysis may contribute to cerebral hemorrhagic complications in methanol poisoning ( 10 , 11 ) . considering a positive history of head trauma even with a normal brain ct scan may also raise the incidence of this complication , though further research is needed . heparin - free dialysis or peritoneal dialysis may be a good option in these cases . all authors passed four criteria for authorship contribution based on the recommendations of the international committee of medical journal editors .
brain injury associated with methanol toxicity can be ischemic , necrotic or hemorrhagic in nature . 
 it most commonly affects the putamen area bilaterally ; however , it can be seen in other locations . 
 this report describes a 22-year - old intoxicated patient who developed an epidural hematoma following hemodialysis . 
 heparinization during hemodialysis may contribute to cerebral hemorrhagic complications in methanol poisoning . 
 in addition , a history of head trauma may raise the incidence of post - hemodialysis hemorrhagic brain insults . 
 heparin - free dialysis or peritoneal dialysis can be a good option in these cases .