We report here a 19-year-old woman with Down syndrome and end-stage renal disease who presented with left-sided weakness and fever. She had a massive pericardial effusion of unclear origin that required daily hemodialysis (HD) and cardiac intervention. She developed an acute right middle cerebral artery infarction with severe edema; her cerebral edema significantly improved with daily HD. Later in her hospitalization, she developed seizures and new onset of multiple acute embolic infarctions in left middle cerebral artery, left anterior cerebral artery (ACA), and right posterior cerebral artery (PCA) distributions with midline shift. However, we again noticed a dramatic decrease in cerebral edema with frequent HD. Although there is controversy about the use of dialysis in patients with stroke, our case suggests that daily HD may provide an alternate strategy for treating massive cerebral infarction. More studies are needed in these patients. © 2009 National Stroke Association.