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Tawakul A, Alluqmani MM, Badawi AS, Alawfi AK, Alharbi EK, Aljohani SA, Mogharbel GH, Alahmadi HA, Khawaji ZY. Risk Factors for Cerebral Vasospasm After Subarachnoid Hemorrhage: A Systematic Review of Observational Studies. Neurocrit Care 2024:10.1007/s12028-024-02059-2. [PMID: 39048760 DOI: 10.1007/s12028-024-02059-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/25/2024] [Indexed: 07/27/2024]
Abstract
Cerebral vasospasm (CV) following subarachnoid hemorrhage (SAH) remains one of the leading causes of high mortality and poor outcomes. Understanding the risk factors associated with CV is pivotal to improving patients' outcomes. We conducted an extensive search for analytical observational studies that analyzed the correlation between various variables and the likelihood of CV development among adult patients with SAH (age ≥ 18 years). Five scholar databases were used, namely, PubMed, EBSCO, Web of Science, Science Direct, and Google Scholar. Relevant studies published between January 1st, 2016, and August 9th, 2023, were included. The Newcastle-Ottawa Scale was adopted to assess the risk of bias among included observational studies. A total of 33 studies met the inclusion criteria. Of the 24,958 patients with SAH who were identified, 6,761 patients had a subsequent CV (27.1%). Several statistically significant risk factors were reported across the literature. Younger age, female sex, smoking, alcohol intake, modified Fisher grade 3-4, higher Hunt and Hess grading, and the presence of multiple comorbidities (diabetes, hypertension, congestive heart failure, and history of stroke) were among the well-established risk factors for CV. Additionally, leukocytosis was consistently reported to be a significant predictor in multiple studies, providing compelling evidence for its association with CV. Even though single studies reported an association between CV and certain variables, further research is necessary to investigate the implications of these findings. These include arterial tortuosity, hypokalemia, potassium to glucose gradient, hypoalbuminemia, anemia, von Willebrand factor and vascular endothelial growth factor, use of desflurane, and hemodynamic stability. Overall, this systemic review provides a comprehensive summary of the current data that evaluates the potential risk factors for the development of CV after SAH. However, because of data heterogeneity, certain factors require further validation in their correlation with CV development. Larger-scale observational and clinical trials are mandatory to extensively investigate the significant predictors of CV to lay the scientific foundation for improving outcomes in susceptible patients with SAH.
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Affiliation(s)
- Abdullah Tawakul
- Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Majed Mohammedali Alluqmani
- Department of Neurology and Neuroimmunology and Neuroinflammatory, Demyelinating Disease, College of Medicine, Taibah University, Madinah, Saudi Arabia
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Breuler C, Lynn JV, Buchman L, Matusko N, Makar K, Ranganathan K, Mouch C, Muraszko K, Buchman SR. Low Prevalence of Clinically Significant Hyponatremia following Cranial Vault Reconstruction for Single-Suture Craniosynostosis. Plast Reconstr Surg 2024; 153:1379-1386. [PMID: 38810163 DOI: 10.1097/prs.0000000000010852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Patients are commonly monitored for hyponatremia after intracranial procedures, yet the prevalence of hyponatremia after cranial vault reconstruction (CVR) remains unclear. The purpose of this study is to define the prevalence, risk factors, and complications of hyponatremia after CVR to optimize postoperative sodium surveillance protocols. METHODS Patients with nonsyndromic, single-suture craniosynostosis who underwent primary CVR between 2009 and 2020 at Michigan Medicine were included (n = 231). Demographic, intraoperative, and postoperative characteristics were compared by postoperative hyponatremia status at P < 0.05 significance. Hyponatremia was defined as mild (<135 mEq/L), moderate (<130 mEq/L), or severe (<125 mEq/L) based on the lowest postoperative laboratory draw. RESULTS Twenty-three patients (10.0%) developed mild postoperative hyponatremia. No patient developed moderate or severe postoperative hyponatremia. On multivariable regression, decreased preoperative sodium level (P = 0.03) and decreased preoperative weight (P = 0.02) were significantly associated with mild postoperative hyponatremia. No patient developed complications or required hospital readmission because of hyponatremia. CONCLUSIONS This large retrospective cohort study of patients with nonsyndromic single-suture craniosynostosis demonstrated a 10% prevalence of mild, clinically inconsequential hyponatremia and 0% prevalence of moderate or severe, clinically significant hyponatremia after primary CVR. Patients with low preoperative sodium level or weight were at increased risk for developing mild postoperative hyponatremia. The results suggest that patients with preoperative sodium greater than 140 mEq/L or preoperative weight greater than 10 kg may be candidates for limited postoperative sodium surveillance; however, future prospective studies are warranted before implementation. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Hamming AL, van Dijck JTJM, Visser T, Baarse M, Verbaan D, Schenck H, Haeren RHL, Fakhry R, Dammers R, Aquarius R, Boogaarts JHD, Peul WC, Moojen WA. Study on prognosis of acutely ruptured intracranial aneurysms (SPARTA): a protocol for a multicentre prospective cohort study. BMC Neurol 2024; 24:68. [PMID: 38368355 PMCID: PMC10873988 DOI: 10.1186/s12883-024-03567-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 02/12/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Ruptured intracranial aneurysms resulting in subarachnoid haemorrhage can be treated by open surgical or endovascular treatment. Despite multiple previous studies, uncertainties on the optimal treatment practice still exists. The resulting treatment variation may result in a variable, potentially worse, patient outcome. To better inform future treatment strategies, this study aims to identify the effectiveness of different treatment strategies in patients with ruptured intracranial aneurysms by investigating long-term functional outcome, complications and cost-effectiveness. An explorative analysis of the diagnostic and prognostic value of radiological imaging will also be performed. METHODS This multi-centre observational prospective cohort study will have a follow-up of 10 years. A total of 880 adult patients with a subarachnoid haemorrhage caused by a ruptured intracranial aneurysm will be included. Calculation of sample size (N = 880) was performed to show non-inferiority of clip-reconstruction compared to endovascular treatment on 1 year outcome, assessed by using the ordinal modified Rankin Scale. The primary endpoint is the modified Rankin Scale score and mortality at 1 year after the initial subarachnoid haemorrhage. Patients will receive 'non-experimental' regular care during their hospital stay. For this study, health questionnaires and functional outcome will be assessed at baseline, before discharge and at follow-up visits. DISCUSSION Despite the major healthcare and societal burden, the optimal treatment strategy for patients with subarachnoid haemorrhage caused by ruptured intracranial aneurysms is yet to be determined. Findings of this comparative effectiveness study, in which in-between centre variation in practice and patient outcome are investigated, will provide evidence on the effectiveness of treatment strategies, hopefully contributing to future high value treatment standardisation. TRIAL REGISTRATION NUMBER NCT05851989 DATE OF REGISTRATION: May 10th, 2023.
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Affiliation(s)
- Alexander L Hamming
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands.
| | - Jeroen T J M van Dijck
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands
| | - Tjitske Visser
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands
| | - Martine Baarse
- Department of Neurosurgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Hanna Schenck
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Roel H L Haeren
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Rahman Fakhry
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - René Aquarius
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jeroen H D Boogaarts
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands
| | - Wouter A Moojen
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands.
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Qian A, Zheng L, He Z, Zhou J, Tang S, Xing W. Predictive value of hyponatremia for short-term mortality in supratentorial spontaneous intracerebral hemorrhage: a single center study. Front Neurol 2024; 15:1301197. [PMID: 38333609 PMCID: PMC10851875 DOI: 10.3389/fneur.2024.1301197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 01/10/2024] [Indexed: 02/10/2024] Open
Abstract
Background Hyponatremia is a common electrolyte disturbance in patients with neurological disease; however, its predictive role for outcome in patients with supratentorial spontaneous intracerebral hemorrhage (sICH) is controversial. This study aims to explore the association between hyponatremia within 7 days after bleeding and 90-day mortality in patients with supratentorial sICH. Methods A retrospective analysis was conducted at our institution. Patients with sICH meeting the inclusion criteria were enrolled in this study. Multivariate regression analyses were performed to determine the predictive value of hyponatremia (serum sodium <135 mmol/L) for 90-day mortality and functional outcome. Subgroup analysis was performed based on the degree and duration of hyponatremia and therapeutic strategies. The Spearman correlation test was performed to explore the relationship between hyponatremia severity and duration with variables in a multivariate regression model. Kaplan-Meier curve was depicted to reveal the relationship between hyponatremia and mortality. The receiver operating characteristic (ROC) curve was plotted to show the diagnostic effect of the minimum concentration of serum sodium (sodiummin) on 90-day mortality. Results A total of 960 patients were enrolled, 19.6% (188) of whom were patients with hyponatremia and 26.0% (250) had 90-day mortality. The incidence of hyponatremia was roughly 2.5 times in non-survivors compared with survivors (34.8% vs. 14.2%). Multivariate regression analysis revealed that hyponatremia was the independent predictor of 90-day mortality (OR 2.763, 95%CI 1.836-4.157) and adverse outcome (OR 3.579, 95%CI 2.332-6.780). Subgroup analysis indicated an increased trend in mortality risk with both duration (more or less than 48 h) and severity of hyponatremia (mild, moderate, and severe) and confirmed the predictive value of hyponatremia for mortality in patients undergoing surgical intervention (external ventricular drainage, craniotomy, and decompressive craniectomy; all p < 0.05). The Spearman correlation test indicated no moderate or strong relationship between hyponatremia severity and duration with other variables in the multivariate model (all |rs| < 0.4). The ROC curve suggested the moderate diagnostic performance of sodiummin for mortality in both general patients and subgroups of therapeutic method patients (AUC from 0.6475 to 0.7384). Conclusion Hyponatremia occurring in the first 7 days after bleeding is an independent predictor of 90-day morality and adverse outcome. Rigorous electrolyte scrutiny in patients treated surgically is required.
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Affiliation(s)
- Ao Qian
- Department of Cerebrovascular Disease, Suining Central Hospital, Suining, Sichuan, China
| | - Longyi Zheng
- Department of Radiology, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Zeyuan He
- Department of Cerebrovascular Disease, Suining Central Hospital, Suining, Sichuan, China
| | - Jing Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuang Tang
- Department of Cerebrovascular Disease, Suining Central Hospital, Suining, Sichuan, China
| | - Wenli Xing
- Department of Cerebrovascular Disease, Suining Central Hospital, Suining, Sichuan, China
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Solou M, Ydreos I, Papadopoulos EK, Demetriades AK, Boviatsis EJ. Management of neurological complications related to aneurysmal subarachnoid hemorrhage: A comparison of the bedside therapeutic algorithms. Surgeon 2023; 21:e328-e345. [PMID: 37451887 DOI: 10.1016/j.surge.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/09/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is of the most serious emergencies in neurosurgical practice and continues to be associated with high morbidity and mortality. Beyond securing the ruptured aneurysm to prevent a rebleed, physicians continue to be concerned about potential complications such as cerebral vasospasm-delayed cerebral ischemia (DCI), an area where management remains highly variable. This study aimed at reviewing the most recent literature and assessing any up-to-date schemes for treating the most common aSAH neurological complications in adults that can be applied in daily clinical practice towards optimising outcomes. METHODS A systematic review was performed according to PRISMA guidelines on the management of aSAH neurological complications in adults. The literature surveyed was between 2016 and 2022 inclusive, using the Pubmed search engine. Comparisons between the methods suggested by existing therapeutic algorithms were discussed. RESULTS Six stepwise algorithms assisting the decision-making for treating cerebral vasospasm-DCI were recognised and compared. No algorithm was found for the management of any other neurological complications of aSAH. Despite differences in the algorithms, induced hypertension and endovascular therapy were common treatments in all approaches. Controversy in the therapeutic process of these complications surrounds not only the variability of methods but also their optimal application towards clinical outcome optimisation. CONCLUSIONS A universal approach to managing aSAH complications is lacking. Despite advances in the techniques to secure a ruptured aneurysm, there persist a high rate of neurological deficit and mortality, and several unanswered questions. More research is required towards stratification of current treatment algorithms as per the quality of their evidence.
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Affiliation(s)
- Mary Solou
- Department of Neurosurgery, "Attikon" University General Hospital, National and Kapodistrian University, Athens Medical School, Greece.
| | - Ioannis Ydreos
- Department of Neurosurgery, "Attikon" University General Hospital, National and Kapodistrian University, Athens Medical School, Greece
| | - Evangelos K Papadopoulos
- Department of Neurosurgery, "Attikon" University General Hospital, National and Kapodistrian University, Athens Medical School, Greece
| | - Andreas K Demetriades
- Department of Neurosurgery, Royal Infirmary Edinburgh, UK; Department of Neurosurgery, Leiden University Medical Centre, the Netherlands
| | - Efstathios J Boviatsis
- Department of Neurosurgery, "Attikon" University General Hospital, National and Kapodistrian University, Athens Medical School, Greece
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Ergezen S, Wiegers EJ, Klijn E, van der Jagt M. Fluid therapy in the acute brain injured patient. Minerva Anestesiol 2023; 89:936-944. [PMID: 37822149 DOI: 10.23736/s0375-9393.23.17328-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Adequate fluid therapy in the acute brain injured (ABI) patient is essential for maintaining an adequate brain and systemic physiology and preventing intra- and extracranial complications. The target of euvolemia, implying avoidance of both hypovolemia and fluid overloading (or "hypervolemia," by definition associated with fluid extravasation leading to tissue edema) is of key importance. Primary brain injury can be aggravated by secondary brain injury and systemic deterioration through diverse pathways which can challenge appropriate fluid management, e.g. neuroendocrine and electrolyte disorders, stress cardiomyopathy (also known as cardiac stunning) and neurogenic pulmonary edema. This is an updated expert opinion aiming to provide a practical overview on fluid therapy in the ABI patient, partly based on more recent work and stressing the fact that intravenous fluids should be regarded as drugs, with their inherent potential for both benefit and (unintended) harm.
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Affiliation(s)
- Saliha Ergezen
- Department of Adults Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands -
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands -
| | - Eveline J Wiegers
- Department of Adults Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eva Klijn
- Department of Adults Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Adults Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
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Busl KM, Rabinstein AA. Prevention and Correction of Dysnatremia After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:70-80. [PMID: 37138158 DOI: 10.1007/s12028-023-01735-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/12/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Dysnatremia occurs commonly in patients with aneurysmal subarachnoid hemorrhage (aSAH). The mechanisms for development of sodium dyshomeostasis are complex, including the cerebral salt-wasting syndrome, the syndrome of inappropriate secretion of antidiuretic hormone, diabetes insipidus. Iatrogenic occurrence of altered sodium levels plays a role, as sodium homeostasis is tightly linked to fluid and volume management. METHODS Narrative review of the literature. RESULTS Many studies have aimed to identify factors predictive of the development of dysnatremia, but data on associations between dysnatremia and demographic and clinical variables are variable. Furthermore, although a clear relationship between serum sodium serum concentrations and outcomes has not been established-poor outcomes have been associated with both hyponatremia and hypernatremia in the immediate period following aSAH and set the basis for seeking interventions to correct dysnatremia. While sodium supplementation and mineralocorticoids are frequently administered to prevent or counter natriuresis and hyponatremia, evidence to date is insufficient to gauge the effect of such treatment on outcomes. CONCLUSIONS In this article, we reviewed available data and provide a practical interpretation of these data as a complement to the newly issued guidelines for management of aSAH. Gaps in knowledge and future directions are discussed.
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Affiliation(s)
- Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA.
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Hoh BL, Ko NU, Amin-Hanjani S, Chou SHY, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2023; 54:e314-e370. [PMID: 37212182 DOI: 10.1161/str.0000000000000436] [Citation(s) in RCA: 135] [Impact Index Per Article: 135.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
AIM The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage. METHODS A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Loan JJM, Tominey S, Baweja K, Woodfield J, Chambers TJG, Haley M, Kundu SS, Tang HYJ, Wiggins AN, Poon MTC, Brennan PM. Prospective, multicentre study of screening, investigation and management of hyponatraemia after subarachnoid haemorrhage in the UK and Ireland. Stroke Vasc Neurol 2023; 8:207-216. [PMID: 36150732 PMCID: PMC10359796 DOI: 10.1136/svn-2022-001583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 09/13/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Hyponatraemia often occurs after subarachnoid haemorrhage (SAH). However, its clinical significance and optimal management are uncertain. We audited the screening, investigation and management of hyponatraemia after SAH. METHODS We prospectively identified consecutive patients with spontaneous SAH admitted to neurosurgical units in the United Kingdom or Ireland. We reviewed medical records daily from admission to discharge, 21 days or death and extracted all measurements of serum sodium to identify hyponatraemia (<135 mmol/L). Main outcomes were death/dependency at discharge or 21 days and admission duration >10 days. Associations of hyponatraemia with outcome were assessed using logistic regression with adjustment for predictors of outcome after SAH and admission duration. We assessed hyponatraemia-free survival using multivariable Cox regression. RESULTS 175/407 (43%) patients admitted to 24 neurosurgical units developed hyponatraemia. 5976 serum sodium measurements were made. Serum osmolality, urine osmolality and urine sodium were measured in 30/166 (18%) hyponatraemic patients with complete data. The most frequently target daily fluid intake was >3 L and this did not differ during hyponatraemic or non-hyponatraemic episodes. 26% (n/N=42/164) patients with hyponatraemia received sodium supplementation. 133 (35%) patients were dead or dependent within the study period and 240 (68%) patients had hospital admission for over 10 days. In the multivariable analyses, hyponatraemia was associated with less dependency (adjusted OR (aOR)=0.35 (95% CI 0.17 to 0.69)) but longer admissions (aOR=3.2 (1.8 to 5.7)). World Federation of Neurosurgical Societies grade I-III, modified Fisher 2-4 and posterior circulation aneurysms were associated with greater hazards of hyponatraemia. CONCLUSIONS In this comprehensive multicentre prospective-adjusted analysis of patients with SAH, hyponatraemia was investigated inconsistently and, for most patients, was not associated with changes in management or clinical outcome. This work establishes a basis for the development of evidence-based SAH-specific guidance for targeted screening, investigation and management of high-risk patients to minimise the impact of hyponatraemia on admission duration and to improve consistency of patient care.
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Affiliation(s)
- James J M Loan
- Translational Neurosurgery, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
- Neurosurgery, NHS Lothian, Edinburgh, UK
| | - Steven Tominey
- Neurosurgery, Institute of Neurological Sciences, Glasgow, UK
- Department of Medicine, School of Medicine, Dentisty and Nuring, University of Glasgow, Glasgow, UK
| | - Kirun Baweja
- Internal Medicine, Queen's University, Kingston, Ontario, Canada
| | - Julie Woodfield
- Translational Neurosurgery, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
- Neurosurgery, NHS Lothian, Edinburgh, UK
| | - Thomas J G Chambers
- Centre for Discovery Brain Sciences, University of Edinburgh, Edinburgh, UK
- Edinburgh Centre for Diabetes and Endocrinology, NHS Lothian, Edinburgh, UK
| | - Mark Haley
- Radiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Simran S Kundu
- Department of Medicine, Cork University Hospital, University College Cork, Cork, Ireland
| | - H Y Josephine Tang
- Department of Medicine, School of Medicine, Dentisty and Nuring, University of Glasgow, Glasgow, UK
| | | | - Michael T C Poon
- Translational Neurosurgery, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
- Neurosurgery, NHS Lothian, Edinburgh, UK
| | - Paul M Brennan
- Translational Neurosurgery, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
- Neurosurgery, NHS Lothian, Edinburgh, UK
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Helliwell A, Snow R, Wendell LC, Thompson BB, Reznik ME, Furie KL, Mahta A. Highs and Lows: Dysnatremia and Patient Outcomes in Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 173:e298-e305. [PMID: 36787854 DOI: 10.1016/j.wneu.2023.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Disturbances in serum sodium concentration (dysnatremia) are common following aneurysmal subarachnoid hemorrhage (aSAH), but its direct impact on outcomes is not well understood. This study aimed to examine the association between dysnatremia following aSAH and patient outcomes. METHODS A retrospective cohort study of consecutive patients with aSAH who were admitted to an academic referral center between 2015 and 2021 was performed. Multivariate logistic regression was used to test the association of dysnatremia and outcomes including modified Rankin Scale score at 3 months after discharge and vasospasm. Multiple linear regression was used to test the association of hospital length of stay and dysnatremia. RESULTS We included 320 patients with confirmed aneurysmal etiology (mean [SD] age = 57.8 [14.3] years; 61% female; 70% White). No independent associations were found between hyponatremia or hypernatremia and functional outcome or vasospasm. However, hospital length of stay was longer in patients with hypernatremia (7 more days; 95% confidence interval = 4.4-9.6, P < 0.001) independent of age, Hunt and Hess grade, modified Fisher score, delayed cerebral ischemia, and other hospital complications. CONCLUSIONS Although dysnatremia may not directly impact functional outcome or vasospasm risk, hypernatremia may prolong hospital length of stay. Judicious use of hypertonic saline solutions and avoidance of unnecessary dysnatremia in patients with aSAH should be considered.
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Affiliation(s)
- Alexandra Helliwell
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ryan Snow
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Linda C Wendell
- Division of Neurology, Mount Auburn Hospital, Cambridge, Massachusetts, USA
| | - Bradford B Thompson
- Department of Neurology, St. Elizabeth's Medical Center, Brighton, Massachusetts, USA
| | - Michael E Reznik
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Karen L Furie
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ali Mahta
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
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Electrolyte Imbalance Among Patients With and With No ST-Elevation Myocardial Infarction: A Cohort Study. Crit Care Nurs Q 2023; 46:136-144. [PMID: 36823740 DOI: 10.1097/cnq.0000000000000446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Electrolytes imbalances are highly prevalent and have shown a high impact on mortality in patients with acute myocardial infarction. These electrolytes imbalance have prognostic value in predicting mortality in patients with acute myocardial infarction. The purpose of this study was to assess the prognostic value of electrolyte imbalances in predicting 1-month mortality among patients with myocardial infarction with and with no ST-elevation. This cohort study was conducted in a referral hospital in the West Bank, Palestine. All patients with confirmed medical diagnosis of acute myocardial infarction and admitted to the medical coronary care unit in the hospital were eligible participants. A convenience sample of 186 participants was obtained. These participants were followed up for 1 month to assess their survival (alive or dead). Demographic and clinical data were recorded by reviewing their health records. The derived data were analyzed using SPSS version 19. About 36% of all patients were found to be hyponatremic, 15% of them have hypokalemia, and 9% of patients had hypocalcemia. There was a significant difference between STEMI and non-STEMI in sodium (t = 4.7, P < .001). A multivariate logistic regression analysis was performed to predict 1-month mortality for patients with myocardial infarction with and with no ST-elevation. The predictors that were found to be significant are sodium (odds ratio [OR] = 0.789, P = .010), calcium (OR = 0.221, P = .014), diastolic blood pressure (OR = 0.933, P = .047), and blood urea nitrogen (OR = 0.821, P = .005). Electrolyte imbalance was highly prevalent among patients with acute myocardial infarction. Hyponatremia and hypocalcemia were present and associated significantly with predicting 1-month mortality. Health care providers should take into consideration the electrolytes of patients with acute myocardial infarction from the first moment of admission and correct them early to maximize the clinical outcomes and survival for patients.
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12
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Lee Y, Yoo KD, Baek SH, Kim YG, Kim HJ, Ryu JY, Paek JH, Suh SH, Oh SW, Lee J, Jhee JH, Suh JS, Yang EM, Park YH, Kim YL, Choi M, Oh KH, Kim S. Korean Society of Nephrology 2022 recommendations on controversial issues in diagnosis and management of hyponatremia. Korean J Intern Med 2022; 37:1120-1137. [PMID: 36245341 PMCID: PMC9666265 DOI: 10.3904/kjim.2022.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/06/2022] [Indexed: 11/27/2022] Open
Abstract
The Korean Society for Electrolyte and Blood Pressure Research, in collaboration with the Korean Society of Nephrology, has published a clinical practice guideline (CPG) document for hyponatremia treatment. The document is based on an extensive evidence-based review of the diagnosis, evaluation, and treatment of hyponatremia with the multidisciplinary participation of representative experts in hyponatremia with methodologist support for guideline development. This CPG consists of 12 recommendations (two for diagnosis, eight for treatment, and two for special situations) based on eight detailed topics and nine key questions. Each recommendation begins with statements graded by the strength of the recommendations and the quality of the evidence. Each statement is followed by rationale supporting the recommendations. The committee issued conditional recommendations in favor of rapid intermittent bolus administration of hypertonic saline in severe hyponatremia, the use of vasopressin receptor antagonists in heart failure with hypervolemic hyponatremia, and syndrome of inappropriate antidiuresis with moderate to severe hyponatremia, the individualization of desmopressin use, and strong recommendation on the administration of isotonic fluids as maintenance fluid therapy in hospitalized pediatric patients. We hope that this CPG will provide useful recommendations in practice, with the aim of providing clinical support for shared decision-making to improve patient outcomes.
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Affiliation(s)
- Yeonhee Lee
- Division of Nephrology, Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu,
Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan,
Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong,
Korea
| | - Yang Gyun Kim
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul,
Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan,
Korea
| | - Ji Young Ryu
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong,
Korea
| | - Jin Hyuk Paek
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu,
Korea
| | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju,
Korea
| | - Se Won Oh
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, Seoul,
Korea
| | - Jeonghwan Lee
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul,
Korea
| | - Jong Hyun Jhee
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul,
Korea
| | - Jin-Soon Suh
- Division of Pediatric Nephrology, Department of Pediatrics, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon,
Korea
| | - Eun Mi Yang
- Division of Pediatric Nephrology, Department of Pediatrics, Chonnam National University Hospital, Gwangju,
Korea
| | - Young Ho Park
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul,
Korea
| | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency (NECA), Seoul,
Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Sejoong Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
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13
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Jin D, Jin S, Liu B, Ding Y, Zhou F, Jin Y. Association between serum sodium and in-hospital mortality among critically ill patients with spontaneous subarachnoid hemorrhage. Front Neurol 2022; 13:1025808. [PMID: 36388235 PMCID: PMC9662614 DOI: 10.3389/fneur.2022.1025808] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/11/2022] [Indexed: 11/29/2022] Open
Abstract
Objective The aim of this study was to retrospectively explore the relationship between serum sodium and in-hospital mortality and related factors in critically ill patients with spontaneous subarachnoid hemorrhage (SAH). Methods Data were collected from the Medical Information Mart for Intensive Care IV database. Restricted cubic splines were used to explore the relationship between serum sodium and in-hospital mortality. Receiver operating characteristic analysis was used to calculate the optimal cutoff value of sodium fluctuation, and decision curve analysis was plotted to show the net benefit of different models containing serum sodium. Results A total of 295 patients with spontaneous SAH were included in the retrospective analysis. The level of sodium on ICU admission and minimum sodium in the ICU had a statistically significant non-linear relationship with in-hospital mortality (non-linear P-value < 0.05, total P-value < 0.001). Serum sodium on ICU admission, minimum serum sodium during ICU, and sodium fluctuation were independently associated with in-hospital mortality with odds ratios being 1.23 (95% confidence interval (CI): 1.04-1.45, P = 0.013), 1.35 (95% CI: 1.18-1.55, P < 0.001), and 1.07 (95% CI: 1.00-1.14, P = 0.047), respectively. The optimal cutoff point was 8.5 mmol/L to identify in-hospital death of patients with spontaneous SAH with sodium fluctuation, with an AUC of 0.659 (95% CI 0.573-0.744). Conclusion Among patients with spontaneous SAH, we found a J-shaped association between serum sodium on ICU admission and minimum sodium values during ICU with in-hospital mortality. Sodium fluctuation above 8.5 mmol/L was independently associated with in-hospital mortality. These results require being tested in prospective trials.
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Affiliation(s)
| | | | | | | | | | - Yuhong Jin
- Department of Critical Care Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, China
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14
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Lee Y, Yoo KD, Baek SH, Kim YG, Kim HJ, Ryu JY, Paek JH, Suh SH, Oh SW, Lee J, Jhee JH, Suh JS, Yang EM, Park YH, Kim YL, Choi M, Oh KH, Kim S. Korean Society of Nephrology 2022 Recommendations on controversial issues in diagnosis and management of hyponatremia. Kidney Res Clin Pract 2022; 41:393-411. [PMID: 35919925 PMCID: PMC9346392 DOI: 10.23876/j.krcp.33.555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/23/2022] [Indexed: 11/28/2022] Open
Abstract
The Korean Society for Electrolyte and Blood Pressure Research, in collaboration with the Korean Society of Nephrology, has published a clinical practice guideline (CPG) document for hyponatremia treatment. The document is based on an extensive evidence-based review of the diagnosis, evaluation, and treatment of hyponatremia with the multidisciplinary participation of representative experts in hyponatremia with methodologist support for guideline development. This CPG consists of 12 recommendations (two for diagnosis, eight for treatment, and two for special situations) based on eight detailed topics and nine key questions. Each recommendation begins with statements graded by the strength of the recommendations and the quality of the evidence. Each statement is followed by rationale supporting the recommendations. The committee issued conditional recommendations in favor of rapid intermittent bolus administration of hypertonic saline in severe hyponatremia, the use of vasopressin receptor antagonists in heart failure with hypervolemic hyponatremia, and syndrome of inappropriate antidiuresis with moderate to severe hyponatremia, the individualization of desmopressin use, and strong recommendation on the administration of isotonic fluids as maintenance fluid therapy in hospitalized pediatric patients. We hope that this CPG will provide useful recommendations in practice, with the aim of providing clinical support for shared decision-making to improve patient outcomes.
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Affiliation(s)
- Yeonhee Lee
- Division of Nephrology, Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Republic of Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Yang Gyun Kim
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Ji Young Ryu
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Jin Hyuk Paek
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Se Won Oh
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jeonghwan Lee
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jong Hyun Jhee
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin-Soon Suh
- Division of Pediatric Nephrology, Department of Pediatrics, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Mi Yang
- Division of Pediatric Nephrology, Department of Pediatrics, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Young Ho Park
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sejoong Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Correspondence: Sejoong Kim Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173beon-gil, Bundang-gu, Seongnam 13620, Republic of Korea. E-mail:
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15
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Lee Y, Yoo KD, Baek SH, Kim YG, Kim HJ, Ryu JY, Paek JH, Suh SH, Oh SW, Lee J, Jhee JH, Suh JS, Yang EM, Park YH, Kim YL, Choi M, Oh KH, Kim S. Korean Society of Nephrology 2022 Recommendations on controversial issues in diagnosis and management of hyponatremia. Kidney Res Clin Pract 2022. [PMCID: PMC9351400 DOI: 10.23876/j.krcp.33.666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Yeonhee Lee
- Division of Nephrology, Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Republic of Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Yang Gyun Kim
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Ji Young Ryu
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Jin Hyuk Paek
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Se Won Oh
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jeonghwan Lee
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jong Hyun Jhee
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin-Soon Suh
- Division of Pediatric Nephrology, Department of Pediatrics, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Mi Yang
- Division of Pediatric Nephrology, Department of Pediatrics, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Young Ho Park
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sejoong Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Correspondence: Sejoong Kim Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173beon-gil, Bundang-gu, Seongnam 13620, Republic of Korea. E-mail:
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16
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Mistry AM, Magarik JA, Feldman MJ, Wang L, Lindsell CJ, Fusco MR, Chitale RV, Bernard GR, Self WH, Rice TW, Hughes CG, Mistry EA, Semler MW. Saline versus Balanced Crystalloids for Adults with Aneurysmal Subarachnoid Hemorrhage: A Subgroup Analysis of the SMART Trial. STROKE (HOBOKEN, N.J.) 2022; 2:e000128. [PMID: 36186896 PMCID: PMC9518828 DOI: 10.1161/svin.121.000128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Whether the composition of intravenous crystalloid solutions affects outcomes in adults with aneurysmal subarachnoid hemorrhage (aSAH) remains unknown. Therefore, we determined whether the use of saline is associated with lower risk of disability and death in aSAH patients compared to balanced crystalloids. METHODS We conducted a post hoc subgroup analysis of the Isotonic Solutions and Major Adverse Renal Events Trial (SMART), a pragmatic, unblinded, cluster-randomized, multiple-crossover clinical trial that enrolled 15,802 adults between June 2015 and April 2017. We compared intravenous administration of saline to balanced crystalloids in consecutively enrolled aSAH patients aged 18 years or older whose ruptured aneurysm was procedurally secured at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (mRS, range, 0 [no symptoms] to 6 [death]) at 90 days obtained from a prospective institutional stroke registry. Secondary outcome included death by 90 days. Logistic or proportional odds regression models were used to test for between-group differences adjusted for age, hypertension, aSAH grade, and procedure type. RESULTS Of the 79 aSAH patients procedurally treated during the SMART study period, 78 were enrolled (median age, 58 years; IQR, 49 to 64.5; 64% female), with 41 (53%) assigned to saline and 37 (47%) to balanced crystalloids. Plasma-Lyte was the primary balanced crystalloid used. Among 72 patients with 90-day mRS assessment, the adjusted common odds ratio, aOR, for mRS was 0.68 (95% CI, 0.28-1.63; P=0.39), with values less than 1.0 favoring saline. By 90 days, 2/39 patients (5%) in the saline group and 9/35 (26%) in the balanced-crystalloids group had died (aOR, 0.06; 95% CI, 0.00-0.50; P=0.02). CONCLUSIONS Among procedurally treated aSAH patients, the risk of disability or death at 90 days did not significantly differ between saline and balanced crystalloids. Death occurred less frequently with saline than balanced crystalloids.
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Affiliation(s)
| | - Jordan A. Magarik
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael J. Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Matthew R. Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rohan V. Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gordon R. Bernard
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher G. Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eva A. Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W. Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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17
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Aleksandrowicz M, Kozniewska E. Hyponatremia as a risk factor for microvascular spasm following subarachnoid hemorrhage. Exp Neurol 2022; 355:114126. [DOI: 10.1016/j.expneurol.2022.114126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 11/04/2022]
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18
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Tominey S, Baweja K, Woodfield J, Chambers TJG, Poon MTC, Wiggins AN, Brennan PM, Loan JJM. Investigation and management of serum sodium after subarachnoid haemorrhage (SaSH): a survey of practice in the United Kingdom and Republic of Ireland. Br J Neurosurg 2022; 36:192-195. [PMID: 33470851 DOI: 10.1080/02688697.2020.1859460] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/21/2020] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hyponatraemia is a common complication of aneurysmal subarachnoid haemorrhage (SAH). We aimed to determine current neurosurgical practice for the identification, investigation and management of hyponatraemia after SAH. METHODS An online questionnaire was completed by UK and Irish neurosurgical trainees and consultant collaborators in the Sodium after Subarachnoid Haemorrhage (SaSH) audit. RESULTS Between August 2019 and June 2020, 43 responses were received from 31 of 32 UK and Ireland adult neurosurgical units (NSUs). All units reported routine measurement of serum sodium either daily or every other day. Most NSUs reported routine investigation of hyponatraemia after SAH with paired serum and urinary osmolalities (94%), urinary sodium (84%), daily fluid balance (84%), but few measured glucose (19%), morning cortisol (13%), or performed a short Synacthen test (3%). Management of hyponatraemia was variable, with units reporting use of oral sodium supplementation (77%), fluid restriction (58%), hypertonic saline (55%), and fludrocortisone (19%). CONCLUSIONS Reported assessment of serum sodium after SAH was consistent between units, whereas management of hyponatraemia varied. This may reflect the lack of a specific evidence-base to inform practice.
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Affiliation(s)
- Steven Tominey
- Department of General Medicine, Queen Elizabeth University Hospital, Glasgow, UK
| | - Kirun Baweja
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Julie Woodfield
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Thomas J G Chambers
- Centre for Discovery Brain Sciences, University of Edinburgh, Edinburgh, UK
- Edinburgh Centre for Diabetes and Endocrinology, NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael T C Poon
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, Edinburgh, UK
| | | | - Paul M Brennan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - James J M Loan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Centre for Discovery Brain Sciences, University of Edinburgh, Edinburgh, UK
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19
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Ridwan S, Kandyba JA, Schug A, Malsagov E, Karageorgos N, Hans FJ. Delayed Leukoencephalopathy and Foreign Body Reaction After Endovascular Treatment in Patients With Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage-A Systematic Review of the Literature. Front Surg 2022; 8:732603. [PMID: 35004833 PMCID: PMC8733731 DOI: 10.3389/fsurg.2021.732603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Delayed leukoencephalopathy and foreign body reaction are rare complications after endovascular treatment of intracranial aneurysms. However, cases are increasingly being described, given the rising case numbers and complexity. Methods: Clinical presentation, differentials, diagnostics, treatment, and formerly published data were reviewed in light of available cases. A systematic search of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Results: This article provides an extensive literature review of previously described cases, and discusses the causes and management of this rare and delayed complication by referring to 17 articles on this topic, with a total of 50 cases with sufficient data in the literature. Furthermore, we present the case of a 53-year-old female patient with subarachnoid hemorrhage from a large anterior communicating artery aneurysm with tortuous cervical vessels who was treated with endovascular coiling and has suffered delayed leukoencephalopathy 6 weeks after discharge. Diagnostics, treatment, and clinical course of this rare complication are presented on this case and based on formerly published literature. The patient timely recovered under high dose corticosteroid treatment and follow up MRI showed almost complete remission of the described lesions within 10 days in accordance with previously published data. Conclusion: Foreign body reaction might result in delayed leukoencephalopathy, especially following complex endovascular aneurysm treatment. Early high dose followed by low dose ongoing corticosteroid treatment might result in timely remission.
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Affiliation(s)
- Sami Ridwan
- Department of Neurosurgery, Paracelsus-Klinik Osnabrueck, Osnabrueck, Germany
| | - Jörg Andreas Kandyba
- Department of Interventional Neuroradiology, Marien-Hospital Osnabrueck, Osnabrueck, Germany
| | - Anita Schug
- Department of Neurosurgery, Paracelsus-Klinik Osnabrueck, Osnabrueck, Germany
| | - Elina Malsagov
- Department of Neurosurgery, Paracelsus-Klinik Osnabrueck, Osnabrueck, Germany
| | | | - Franz-Josef Hans
- Department of Neurosurgery, Paracelsus-Klinik Osnabrueck, Osnabrueck, Germany
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20
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Lee Y, Yoo KD, Baek SH, Kim YG, Kim HJ, Ryu JY, Paek JH, Suh SH, Oh SW, Lee J, Jhee JH, Suh JS, Yang EM, Park YH, Kim YL, Choi M, Oh KH, Kim S. Korean Society of Nephrology 2022 Recommendations on Controversial Issues in Diagnosis and Management of Hyponatremia. Electrolyte Blood Press 2022; 20:21-38. [DOI: 10.5049/ebp.2022.20.1.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/01/2022] [Accepted: 07/02/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Yeonhee Lee
- Division of Nephrology, Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji University, Gyeonggi-do, Republic of Korea
| | - Kyung Don Yoo
- Division of Nephrology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Yang Gyun Kim
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University, College of Medicine, Seoul, Republic of Korea
| | - Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Ji Young Ryu
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Jin Hyuk Paek
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Sang Heon Suh
- Division of Nephrology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Se Won Oh
- Division of Nephrology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jeonghwan Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Jong Hyun Jhee
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin-Soon Suh
- Division of Pediatric Nephrology, Department of Pediatrics, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Mi Yang
- Division of Pediatric Nephrology, Department of Pediatrics, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Young Ho Park
- Department of Neurology, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Miyoung Choi
- Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sejoong Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
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Lee J, Kong MH, Kim JH, Jang SY, Kim S, Hong S, Song KY. Analysis of Factors Related to Growth and Growth Patterns of Unruptured Intracranial Aneurysms. Korean J Neurotrauma 2022; 18:45-55. [PMID: 35557637 PMCID: PMC9064743 DOI: 10.13004/kjnt.2022.18.e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/02/2021] [Accepted: 12/20/2021] [Indexed: 11/15/2022] Open
Abstract
Objective Methods Results Conclusion
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Affiliation(s)
- Jonggu Lee
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Min Ho Kong
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Jung Hee Kim
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Se Youn Jang
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Sunghoon Kim
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Soono Hong
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Kwan Young Song
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
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22
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Chua MMJ, Enríquez-Marulanda A, Gomez-Paz S, Akamatsu Y, Salem MM, Maragkos GA, Ascanio LC, Hanafy KA, Fehnel CR, Ogilvy CS, Moore J, Thomas AJ. Sodium Variability and Probability of Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 31:106186. [PMID: 34749298 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106186] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Vasospasm is a well-known complication of aneurysmal subarachnoid hemorrhage (aSAH) that generally occurs 4-14 days post-hemorrhage. Based on American Heart Association guidelines, the current understanding is that hyponatremic episodes may lead to vasospasm. Therefore, we sought to determine the association between repeated serum sodium levels of aSAH patients and its relationship to radiographic vasospasm. MATERIALS AND METHODS A single-center retrospective analysis from 2007-2016 was conducted of aSAH patients. Daily serum sodium levels were recorded up to day 14 post-admission. Hyponatremia was defined as a serum sodium value of < 135 mEq/L. We evaluated the relationship to radiologic vasospasm, neurologic deterioration, functional status at discharge, and mortality. A repeated measures analysis using a mixed-effect regression model was performed to assess the interindividual relationship between serum sodium trends and outcomes. RESULTS A total of 296 aSAH patients were included. There were no significant differences in interindividual serum sodium values over time and occurrence of radiographic vasospasm, neurologic deterioration, functional, or mortality outcomes (p = .59, p = .42, p = .94, p = .99, respectively) using the mixed-effect regression model. However, overall mean serum sodium levels were significantly higher in patients who had neurologic deterioration, poor functional outcome (mRS 3-6), and mortality. CONCLUSIONS Serum sodium level variations are not associated with subsequent development of cerebral vasospasm in aSAH patients. These findings indicate that serum sodium may not have an impact on vasospasm, and avoiding hypernatremia may provide a neurologic, functional and survival benefit.
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Affiliation(s)
- Melissa M J Chua
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, BTM 4th floor, Boston, MA 02215, United States.
| | - Alejandro Enríquez-Marulanda
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Santiago Gomez-Paz
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Yosuke Akamatsu
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Mohamed M Salem
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Georgios A Maragkos
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States.
| | - Luis C Ascanio
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States.
| | - Khalid A Hanafy
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Corey R Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Justin Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
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Subba H, Riker RR, Dunn S, Gagnon DJ. Vasopressin-Induced Hyponatremia in Patients With Aneurysmal Subarachnoid Hemorrhage: A Case Series and Literature Review. J Pharm Pract 2021; 36:689-694. [PMID: 34674580 PMCID: PMC9021328 DOI: 10.1177/08971900211053497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Vasopressin may be administered to treat vasospasm following aneurysmal subarachnoid hemorrhage (aSAH). The objectives of this study were to describe five cases of suspected vasopressin-induced hyponatremia after aSAH and to review the literature. DESIGN Single-center, observational case series of intensive care unit (ICU) patients. SETTINGS Ten-bed neurological ICU at Maine Medical Center in Portland, Maine. PATIENTS Convenience sample of patients with aSAH treated with a vasopressin for symptomatic, radiologically confirmed vasospasm. RESULTS A total of five patients were included in the case series with a median age of 57 (51, 65) years and all were women. The median Glasgow coma scale score was 15 (11, 15) on admission, and the Hunt and Hess scale score was 3, (3, 4). All patients were treated with endovascular coiling of their aneurysm. Vasopressin was administered to treat symptomatic, radiographically confirmed vasospasm on median post-bleed day (PBD) 10 (10, 15) at a fixed-dose of .03 units/min. Serum sodium at baseline was 140 (140, 144) mEq/L and decreased to 129 (126, 129) mEq/L within 26 (17, 83) hours of vasopressin initiation for a median change of -16 (-10, -16) mEq/L. Serum sodium returned to baseline within 18 (14, 22) hours of stopping the infusion. CONCLUSIONS Vasopressin use in vasospasm after aSAH may be associated with clinically significant hyponatremia within 24 hours of starting the infusion. Hyponatremia appears to resolve within 24 hours of stopping the infusion. Additional study in a larger sample size is needed to determine if a causal relationship exist.
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Affiliation(s)
- Hilamber Subba
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Richard R Riker
- Neuroscience Institute and Department Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Susan Dunn
- Division of Nephrology and Transplantation, Maine Medical Center, Portland, ME, USA
| | - David J Gagnon
- Department of Pharmacy, Faculty Scientist I, Maine Medical Center Research Institute, Maine Medical Center, Portland, ME, USA
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Constantinou S, Cheng PH, Holmes D, Mcgarrity P, Abouharb A, Simms HN. Prevention of hyponatraemia with prophylactic oral sodium chloride in good grade aneurysmal subarachnoid haemorrhage. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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25
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Huang H, Mai Z, Chen L, Li Q, Chen S, Bao K, Tang R, Wei W, Yu Y, Huang Z, Lai W, Wang B, Tan N, Chen J, Liu J, Liu Y. Prevalence and Mortality of Hypochloremia Among Patients with Coronary Artery Disease: A Cohort Study. Risk Manag Healthc Policy 2021; 14:3137-3145. [PMID: 34349574 PMCID: PMC8326930 DOI: 10.2147/rmhp.s306125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/15/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Hypochloremia is a predictor for short-term mortality in patients with cardiovascular disease, but its association with coronary artery disease (CAD) is still unclear. We aimed to assess the impact of hypochloremia on all-cause mortality (short-and long-term) among patients with CAD. PATIENTS AND METHODS Based on the registry at Guangdong Provincial People's Hospital in China, we analyzed data of 49,025 hospitalized patients who underwent coronary angiography (CAG) and were diagnosed with CAD from January 2007 to December 2018. To assess the association between hypochloremia and the study endpoints, a logistic-regression model (for 30-day all-cause mortality) and a Cox regression model (for long-term all-cause mortality) were fitted. RESULTS Overall, 4.4% of the study population showed hypochloremia (<98 mmol/L). During a median follow-up of 5.2 (3.1-7.8) years, a total of 6486 (13.2%) patients died. Patients with hypochloremia were generally older and at risk for diabetes, cardiorenal dysfunction, and morbidity than those without hypochloremia. After adjustment for confounders, hypochloremia remained a significant predictor of mortality risk (30-day all-cause death: adjusted odds ratio [aOR], 1.99; 95% confidence interval, 1.08-3.18; P=0.017 and long-term all-cause death: adjusted hazard ratio [aHR], 1.32; 95% confidence interval, 1.19-1.47; P<0.001). CONCLUSION Hypochloremia is mildly common in patients with CAD and is associated with increased short-and long-term mortality. Meanwhile, it is necessary to further investigate effective and preventive measures and the potential mechanisms of hypochloremia in patients with CAD.
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Affiliation(s)
- Haozhang Huang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, People’s Republic of China
| | - Ziling Mai
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
- Guangdong General Hospital, Affiliated with South China University of Technology, Guangzhou, 510515, People’s Republic of China
| | - Liling Chen
- Department of Cardiology, Longyan First Hospital Affiliated with Fujian Medical University, Longyan, 364000, People’s Republic of China
| | - Qiang Li
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Shiqun Chen
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Kunming Bao
- Department of Cardiology, Longyan First Hospital Affiliated with Fujian Medical University, Longyan, 364000, People’s Republic of China
| | - Ronghui Tang
- Yunnan Fuwai Cardiovascular Hospital, Department of Ultrasound Imaging, Yunnan, 650000, People’s Republic of China
| | - Wen Wei
- Department of Cardiology, Longyan First Hospital Affiliated with Fujian Medical University, Longyan, 364000, People’s Republic of China
| | - Yaren Yu
- The First People’s Hospital of Foshan, Foshan, Guangdong Province, 528000, People’s Republic of China
| | - Zhidong Huang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Wenguang Lai
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
- Guangdong General Hospital, Affiliated with South China University of Technology, Guangzhou, 510515, People’s Republic of China
| | - Bo Wang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Ning Tan
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, People’s Republic of China
- Guangdong General Hospital, Affiliated with South China University of Technology, Guangzhou, 510515, People’s Republic of China
| | - Jiyan Chen
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, People’s Republic of China
- Guangdong General Hospital, Affiliated with South China University of Technology, Guangzhou, 510515, People’s Republic of China
| | - Jin Liu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Yong Liu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, People’s Republic of China
- Guangdong General Hospital, Affiliated with South China University of Technology, Guangzhou, 510515, People’s Republic of China
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Dysnatremia and 6-Month Functional Outcomes in Critically Ill Patients With Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study. Crit Care Explor 2021; 3:e0445. [PMID: 34124687 PMCID: PMC8189636 DOI: 10.1097/cce.0000000000000445] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
OBJECTIVES To investigate the association between plasma sodium concentrations and 6-month neurologic outcome in critically ill patients with aneurysmal subarachnoid hemorrhage. DESIGN Prospective cohort study. SETTING Eleven ICUs in Australia and New Zealand. PARTICIPANTS Three-hundred fifty-six aneurysmal subarachnoid hemorrhage patients admitted to ICU between March 2016 and June 2018. The exposure variable was daily measured plasma sodium. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Six-month neurologic outcome as measured by the modified Rankin Scale. A poor outcome was defined as a modified Rankin Scale greater than or equal to 4. The mean age was 57 years (± 12.6 yr), 68% were female, and 32% (n = 113) had a poor outcome. In multivariable analysis, including age, illness severity, and process of care measures as covariates, higher mean sodium concentrations (odds ratio, 1.17; 95% CI, 1.05-1.29), and greater overall variability-as measured by the sd (odds ratio, 1.53; 95% CI, 1.17-1.99)-were associated with a greater likelihood of a poor outcome. Multivariable generalized additive modeling demonstrated, specifically, that a high initial sodium concentration, followed by a gradual decline from day 3 onwards, was also associated with a poor outcome. Finally, greater variability in sodium concentrations was associated with a longer ICU and hospital length of stay: mean ICU length of stay ratio (1.13; 95% CI, 1.07-1.20) and mean hospital length of stay ratio (1.08; 95% CI, 1.01-1.15). CONCLUSIONS In critically ill aneurysmal subarachnoid hemorrhage patients, higher mean sodium concentrations and greater variability were associated with worse neurologic outcomes at 6 months, despite adjustment for known confounders. Interventional studies would be required to demonstrate a causal relationship.
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Acute hyponatremia after aneurysmal subarachnoid hemorrhage: Frequency, treatment, and outcome. J Clin Neurosci 2021; 88:237-242. [PMID: 33992191 DOI: 10.1016/j.jocn.2021.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/27/2021] [Accepted: 04/03/2021] [Indexed: 11/21/2022]
Abstract
We retrospectively examined the course of serum sodium levels in 180 patients with acute aneurysmal subarachnoid hemorrhage (SAH) who had been admitted to the anesthesiologic-neurosurgical intensive care unit of the University Medical Center Regensburg, Germany, between January 2014 and December 2018. Each patient file was analyzed regarding the frequency and intensity of hyponatremic episodes and the administered medication. At admission to the intensive care unit (ICU), 18patients had shown initial hyponatremia (<135 mmol/L) and 4 patients hypernatremia (greater than145 mmol/L). 88(48.9%) of the 158 patients with normal serum sodium levels developed at least one hyponatremic episode during ICU treatment. The number of hyponatremic episodes was similar between patients with higher-grade and lower-grade aneurysmal SAH (P = 0.848). At the end of ICU treatment, outcome did not differ between patients with and without hyponatremia (40/88, 45.5% vs. 38/70, 54.3%, P = 0.270). At 6 months after SAH, however, good outcome (Glasgow outcome scale, GOS 4-5) was more frequently observed in patients with hyponatremia (26/88, 29.5% vs. 32/70, 45.7%, P = 0.036). Medication with sodium chloride, fludrocortisone, or tolvaptan was initiated in 75.4% patients with mild hyponatremia (130-134 mmol/L) and in 92.9% with moderate hyponatremia (125-129 mmol/L). At 6 months after SAH, patients treated with tolvaptan had a lower rate of poor outcome than patients who had not received tolvaptan (1/14, 7.1% vs. 25/74, 33.8%, P = 0.045). In patients with acute aneurysmal SAH and hyponatremic episodes, consequent treatment of hyponatremia prevented impaired outcome. Because administration of tolvaptan rapidly normalized serum sodium levels, this therapy seems to be a promising treatment approach.
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Castle-Kirszbaum M, Kyi M, Wright C, Goldschlager T, Danks RA, Parkin WG. Hyponatraemia and hypernatraemia: Disorders of Water Balance in Neurosurgery. Neurosurg Rev 2021; 44:2433-2458. [PMID: 33389341 DOI: 10.1007/s10143-020-01450-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/26/2020] [Accepted: 11/25/2020] [Indexed: 12/23/2022]
Abstract
Disorders of tonicity, hyponatraemia and hypernatraemia, are common in neurosurgical patients. Tonicity is sensed by the circumventricular organs while the volume state is sensed by the kidney and peripheral baroreceptors; these two signals are integrated in the hypothalamus. Volume is maintained through the renin-angiotensin-aldosterone axis, while tonicity is defended by arginine vasopressin (antidiuretic hormone) and the thirst response. Edelman found that plasma sodium is dependent on the exchangeable sodium, potassium and free-water in the body. Thus, changes in tonicity must be due to disproportionate flux of these species in and out of the body. Sodium concentration may be measured by flame photometry and indirect, or direct, ion-sensitive electrodes. Only the latter method is not affected by changes in plasma composition. Classification of hyponatraemia by the volume state is imprecise. We compare the tonicity of the urine, given by the sodium potassium sum, to that of the plasma to determine the renal response to the dysnatraemia. We may then assess the activity of the renin-angiotensin-aldosterone axis using urinary sodium and fractional excretion of sodium, urate or urea. Together, with clinical context, these help us determine the aetiology of the dysnatraemia. Symptomatic individuals and those with intracranial catastrophes require prompt treatment and vigilant monitoring. Otherwise, in the absence of hypovolaemia, free-water restriction and correction of any reversible causes should be the mainstay of treatment for hyponatraemia. Hypernatraemia should be corrected with free-water, and concurrent disorders of volume should be addressed. Monitoring for overcorrection of hyponatraemia is necessary to avoid osmotic demyelination.
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Affiliation(s)
| | - Mervyn Kyi
- Department of Endocrinology, Melbourne Health, Melbourne, Australia
| | - Christopher Wright
- Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - R Andrew Danks
- Department of Neurosurgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - W Geoffrey Parkin
- Department of Surgery, Monash University, Melbourne, Australia.,Department of Intensive Care, Monash Health, Melbourne, Australia
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29
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Shima S, Niimi Y, Moteki Y, Takahashi O, Sato S, Inoue T, Okada Y. Prognostic Significance of Hyponatremia in Acute Stroke: A Systematic Review and Meta-Analysis. Cerebrovasc Dis 2020; 49:531-539. [DOI: 10.1159/000510751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/04/2020] [Indexed: 11/19/2022] Open
Abstract
<b><i>Objective:</i></b> Hyponatremia is a common electrolyte disorder in patients with stroke, which leads to various fatal complications. We performed a systematic review and meta-analysis to investigate the outcomes of acute stroke patients with hyponatremia. <b><i>Methods:</i></b> We searched MEDLINE, EMBASE, and the Cochrane Library databases for relevant literature in English published up to March 2020. Two review authors independently screened and selected the studies by assessing the eligibility and validity based on the inclusion criteria. Mortality at 90 days was set as the primary end point, and in-hospital mortality and length of hospital stay were set as the secondary end points. We conducted the data synthesis and analyzed the outcomes by calculating the odds ratio (OR) and mean difference. <b><i>Results:</i></b> Of 835 studies, 15 studies met the inclusion criteria (<i>n</i> = 10,745). The prevalence rate of stroke patients with hyponatremia was 7.0–59.2%. They had significantly higher 90-day mortality (OR, 1.73; 95% confidence interval (CI), 1.24–2.42) and longer length of hospital stay (mean difference, 10.68 days; 95% CI, 7.14–14.22) than patients without hyponatremia. Patients with hyponatremia had a higher tendency of in-hospital mortality than those without hyponatremia (OR, 1.61; 95% CI, 0.97–2.69). <b><i>Conclusions:</i></b> The development of hyponatremia in the clinical course of stroke is associated with higher short-term mortality and a longer hospital stay. Although the causal relationship is unclear, hyponatremia could be a significant predictor of poor outcomes after stroke.
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30
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Liu H, Xu Q, Li A. Nomogram for predicting delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage in the Chinese population. J Stroke Cerebrovasc Dis 2020; 29:105005. [PMID: 32807421 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Delayed cerebral ischemia is a serious complication of aneurysmal subarachnoid hemorrhage with debilitating and fatal consequences. Lack of well-established risk factors impedes early identification of high-risk patients with delayed cerebral ischemia. A nomogram provides personalized, evidence-based, and accurate risk estimation. To offset the lack of a predictive tool, we developed a nomogram to predict delayed cerebral ischemia before performing surgical interventions for aneurysmal subarachnoid hemorrhage to aid surgical decision-making. METHODS We retrospectively collected data from 887 consecutive eligible Chinese patients who underwent surgical clipping or endovascular coiling for aneurysmal subarachnoid hemorrhage. Patients who previously underwent surgery formed the training cohort (n = 621) for nomogram development; those who underwent surgery later formed the validation cohort (n = 266) to confirm the performance of the model. A multivariate logistic regression analysis identified the independent risk factors associated with delayed cerebral ischemia, which were then incorporated into the nomogram. RESULTS Delayed cerebral ischemia was identified in 158/621 patients (25.4%) in the training cohort and in 66/266 patients (24.8%) in the validation cohort. Preoperative factors associated with delayed cerebral ischemia were age > 65 years, modified Fisher grade of 3-4, ruptured aneurysm in the anterior circulation, Hunt-Hess grade of 4-5, high blood pressure on admission, and plasma homocysteine level ≥ 10 μmol/L. Incorporating these six factors in the nomogram achieved efficient concordance indices of 0.73 (95% confidence interval, 0.68-0.77) and 0.65 (95% confidence interval, 0.57-0.72) in predicting delayed cerebral ischemia in the training and validation cohorts, respectively. CONCLUSIONS Our model can help determine an individual's risk of developing delayed cerebral ischemia in the Chinese population, and thereby, facilitate reasonable treatment-related decision-making.
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Affiliation(s)
- Haonan Liu
- Department of Neurosurgery, Lianyungang Clinical College of Nanjing Medical University (The First People's Hospital of Lianyungang), 182 Tongguan North Road, Lianyungang 222002, China
| | - Qian Xu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Aimin Li
- Department of Neurosurgery, Lianyungang Clinical College of Nanjing Medical University (The First People's Hospital of Lianyungang), 182 Tongguan North Road, Lianyungang 222002, China.
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31
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Quinn L, Tian DH, Fitzgerald E, Flower O, Andersen C, Hammond N, Davidson K, Delaney A. The association between hyponatraemia and long-term functional outcome in patients with aneurysmal subarachnoid haemorrhage: A single centre prospective cohort study. J Clin Neurosci 2020; 78:353-359. [PMID: 32622650 DOI: 10.1016/j.jocn.2020.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/23/2020] [Accepted: 06/06/2020] [Indexed: 11/17/2022]
Abstract
To assess the association between hyponatraemia and long-term functional outcome and other relevant outcomes in patients with aneurysmal subarachnoid haemorrhage (aSAH) we conducted a prospective cohort study in a Neurosciences Intensive Care Unit (ICU) in Sydney, Australia. The primary exposure variable was hyponatraemia (Na+ <135 mmol/L). The primary outcome was favourable outcome, a score of 5-8 on the extended Glasgow Outcome Score (GOSe) at 12 months. We also measured mortality, the incidence of delayed cerebral ischaemia (DCI) and cerebral arterial vasospasm and duration of ICU and hospital admission. There were 200 participants, 111 (56%) developed hyponatraemia. Hyponatraemia was not associated with favourable outcome at 12 months (unadjusted odds ratio [OR] OR 1.31, 95% confidence interval [CI] 0.65-2.65, p = 0.56). The result was similar after adjustment for baseline covariates (adjusted OR 0.60, 95% CI 0.16-1.99, p = 0.43). There was no association between hyponatraemia and the incidence of DCI (OR 0.95, 95% CI 0.46 to 2.0, p > 0.99) nor cerebral arterial vasospasm (OR 1.4, 95% CI 0.8 to 2.5, p = 0.27). Those who developed hyponatraemia had a longer median duration of ICU admission (17 days, interquartile range [IQR] 12 to 20, compared to 13 days, IQR 8-21, p = 0.02) and longer median duration of hospital admission (24 days, IQR 21-30, compared to 22 days IQR 14-31, p = 0.05). While hyponatraemia is common following aSAH, it is not associated with worse long-term functional outcome, increased rate of DCI, nor cerebral arterial vasospasm. Hyponatraemia in patients with aSAH was associated with longer duration of ICU and hospital admission.
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Affiliation(s)
- Liam Quinn
- Department of Anaesthesia, St. George Hospital, University of New South Wales, Sydney, Australia
| | - David H Tian
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Emily Fitzgerald
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Oliver Flower
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Chris Andersen
- Kadoorie Centre for Critical Care Research and Education, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Keryn Davidson
- Department of Neurosurgery, Royal North Shore Hospital, Sydney, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, Australia.
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Impact of Complications and Comorbidities on the Intensive Care Length of Stay after Aneurysmal Subarachnoid Haemorrhage. Sci Rep 2020; 10:6228. [PMID: 32277142 PMCID: PMC7148333 DOI: 10.1038/s41598-020-63298-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 03/28/2020] [Indexed: 12/15/2022] Open
Abstract
In this observational study, we analysed a cohort of 164 subarachnoid haemorrhage survivors (until discharge from intensive care) with the aim to detect factors that influence the length of stay (LOS) in intensive care with multiple linear regression methods. Moreover, binary logistic regression methods were used to examine whether the time in intensive care is a predictor of outcome after 1 year. The clinical 1-year outcome was measured prospectively in a 12-month follow-up by telephone interview and categorised by the modified Rankin Scale (mRS). Patients who died during their stay in intensive care were excluded. Complications like pneumonia (β = 5.11; 95% CI = 1.75–8.46; p = 0.0031), sepsis (β = 9.54; 95% CI = 3.27–15.82; p = 0.0031), hydrocephalus (β = 4.63; 95% CI = 1.82–7.45; p = 0.0014), and delayed cerebral ischemia (DCI) (β = 3.38; 95% CI = 0.19–6.56; p = 0.038) were critical factors depending the LOS in intensive care as well as decompressive craniectomy (β = 5.02; 95% CI = 1.35–8.70; p = 0.0077). All analysed comorbidities such as hypertension, diabetes, hypothyroidism, cholesterinemia, and smoking history had no significant impact on the LOS in intensive care. LOS in intensive care (OR = 1.09; 95% CI = 1.03–1.15; p = 0.0023) as well as WFNS grade (OR = 3.72; 95% CI = 2.23–6.21; p < 0.0001) and age (OR = 1.06; 95% CI = 1.02–1.10; p = 0.0061) were significant factors that had an impact on the outcome after 1 year. Complications in intensive care but not comorbidities are associated with higher LOS in intensive care. LOS in intensive care is a modest but significant predictor of outcomes after subarachnoid haemorrhage.
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Temporal Relationship between Hyponatremia and Development of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage Patients: A Retrospective Observational Study. J Stroke Cerebrovasc Dis 2020; 29:104789. [PMID: 32205028 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104789] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/19/2020] [Accepted: 02/24/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Hyponatremia is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). Previous studies have reported an association between hyponatremia and vasospasm, however whether hyponatremia directly contributes to the pathogenesis of cerebral vasospasm (CVS), or is a by-product is still unclear. The aim of this study was to explore an association between hyponatremia and CVS after aSAH, and evaluating the temporality of these 2 events. METHODS A retrospective study of consecutive patients with aSAH admitted to the Baylor St. Luke's Medical center between January 2008 and December 2012 was conducted. Demographics, baseline characteristics, serum sodium levels, and evidence of vasospasm detected by transcranial Doppler, CT Angiogram, MR angiogram, and digital subtracted angiography were collected. Patients were dichotomized into a hyponatremic and a normonatremic group. CVS incidence and clinical outcome was compared between groups. Timing of CVS after initial hyponatremia episodes was recorded Results: One hundred and sixty 4 patients with aSAH were included. Hyponatremia was identified in 66 patients (40.2%) and CVS occurred in 71 subjects (43.2%). The incidence of CVS was higher in the hyponatremic group compared to the normonatremic group, 65.1 % versus 28.5%, respectively (P < .001). Hyponatremia preceded CVS by median 1.5 days suggesting a temporal trend. CONCLUSIONS Our study shows a significant association between hyponatremia and CVS, with hyponatremia preceding CVS events. This retrospective finding denotes the need for larger prospective studies, aiming to clarify the temporal relationship of serum sodium levels and CVS.
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Aleksandrowicz M, Klapczynska K, Kozniewska E. Dysfunction of the endothelium and constriction of the isolated rat's middle cerebral artery in low sodium environment in the presence of vasopressin. Clin Exp Pharmacol Physiol 2019; 47:759-764. [PMID: 31876005 DOI: 10.1111/1440-1681.13242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 01/20/2023]
Abstract
Hyponatraemia, a water-electrolyte disorder diagnosed in patients with subarachnoid haemorrhage (SAH), increases a risk of persistent vasospasm. In majority of cases, hyponatraemia results from inappropriate secretion of vasopressin (AVP). The effect of AVP-associated hyponatraemia on cerebral vasculature is unknown. The present study aimed to elucidate the role of AVP in the response of the middle cerebral artery (MCA) of the rat to hyponatraemia. Isolated, cannulated, and pressurized rat MCAs were perfused/superfused with physiological (Na+ = 144 mmol/L) buffer or low-sodium (Na+ = 121 mmol/L) buffer containing either AVP or angiotensin II (ANG II). ANG II was used to check if the effect of low plasma sodium concentration combined with AVP on the MCA tone is unique to vasopressin. At physiological Na+ concentration, vasopressin (1.4 × 10-11 mol/L) or angiotensin II (10-9 mol/L) resulted in relaxation of the MCA. Substitution of low-sodium for the normal sodium buffer with the same concentration of AVP, resulted in the constriction of the MCA. This effect was absent after removal of the endothelium, administration of vasopressin V1 receptor antagonist or concomitant inhibition of endothelin-1 receptors and synthesis of thromboxane A2. In contrast, no constriction of the MCA in low-sodium buffer was observed when AVP was replaced with ANG II. Our data suggest that presence of vasopressin and low sodium ion concentration results in the change of endothelium phenotype from pro-vasodilatory to pro-vasoconstrictory. This phenomenon may be an overlooked factor contributing to vasospasm in SAH patients with hyponatraemia caused by inappropriate antidiuretic hormone secretion (SIADH).
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Affiliation(s)
- Marta Aleksandrowicz
- Laboratory of Experimental and Clinical Neurosurgery, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | - Katarzyna Klapczynska
- Faculty of Physical Education and Health Promotion, University of Szczecin, Szczecin, Poland
| | - Ewa Kozniewska
- Laboratory of Experimental and Clinical Neurosurgery, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
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Eagles ME, Tso MK, Macdonald RL. Significance of fluctuations in serum sodium levels following aneurysmal subarachnoid hemorrhage: an exploratory analysis. J Neurosurg 2019; 131:420-425. [PMID: 30117765 DOI: 10.3171/2018.3.jns173068] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 03/12/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Fluctuations in patient serum sodium levels are common after aneurysmal subarachnoid hemorrhage (aSAH), but their effect on patient outcome is not well described in the literature. The goal of this work was to better characterize the relationship between fluctuations in serum sodium levels, outcome, and the development of delayed cerebral ischemia (DCI) after aSAH. METHODS The authors performed a post hoc analysis of data from the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) trial. Patients had their serum sodium values recorded daily for 14 days post-aSAH. Average and average absolute daily differences in sodium levels were calculated for each patient based on 3 reference points: admission sodium levels, a normal sodium level (defined as 140 mmol/L), and the previous day's sodium level. These variables were also calculated for the classic "vasospasm window" (days 3-12) post-aSAH. A stepwise logistic regression model, locally weighted scatterplot smoothing curves, and receiver operator characteristic curve analysis were used to evaluate the relationship between alterations in serum sodium levels and clinical outcome or the development of DCI after aSAH. Poor outcome was defined as a modified Rankin Scale (mRS) score of > 2 at 3 months. RESULTS The average daily difference in sodium values from baseline (p < 0.001), average daily difference from a normal sodium level (p < 0.001), average absolute daily difference from a normal sodium level (p = 0.015), and average absolute daily difference from the previous day's sodium level (p = 0.017) were significant predictors of poor outcome in a stepwise multivariate regression model. There was a trend toward significance for average absolute daily difference from admission sodium levels during the vasospasm window as an independent predictor of DCI (p = 0.052). There was no difference in the predictive capacity for DCI when sodium fluctuations from post-aSAH days 1-14 were compared with those from the classic vasospasm window (days 3-12). CONCLUSIONS Fluctuations in serum sodium levels may play a role in clinical outcome and the development of DCI after aSAH. The timing of these fluctuations appears to have no significant effect on the development of DCI.
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Affiliation(s)
- Matthew E Eagles
- 1Section of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Alberta
| | - Michael K Tso
- 1Section of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Alberta
| | - R Loch Macdonald
- 2Division of Neurosurgery and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto; and
- 3Institute of Medical Science, University of Toronto, Ontario, Canada
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Abstract
INTRODUCTION The prevalence of pituitary dysfunction is high following aneurysmal subarachnoid hemorrhage (aSAH) and when occurs it may contribute to residual symptoms of aSAH such as decreased cognition and quality of life. Hypopituitarism following aSAH may have non-specific, subtle symptoms and potentially serious consequences if remained undiagnosed. METHODS We reviewed the literature on epidemiology, pathophysiology, diagnostic methods and management of neuroendocrine changes after aSAH as well as on the impact of pituitary dysfunction on outcome of the patient. RESULTS The prevalence rates of pituitary dysfunction after aSAH varies greatly across studies due to different diagnostic methods, though growth hormone deficiency is generally the most frequently reported followed by adrenocorticotropic hormone, gonadotropin and thyroid stimulating hormone deficiencies. Pituitary deficiency tends to improve over time after aSAH but new onset deficiencies in chronic phase may also occur. There are no clinical parameters to predict the presence of hypopituitarism after aSAH. Age of the patient and surgical procedures are risk factors associated with development of hypopituitarism but the effect of pituitary dysfunction on outcome of the patient is not clear. Replacement of hypocortisolemia and hypothyroidism is essential but treatment of other hormonal insufficiencies should be individualized. CONCLUSIONS Hypopituitarism following aSAH necessitates screening despite lack of gold standard evaluation tests and cut-off values in the follow up, because missed diagnosis may lead to untoward consequences.
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Affiliation(s)
- Zuleyha Karaca
- Department of Endocrinology and Metabolism, Erciyes University Medical School, Kayseri, Turkey.
| | - Aysa Hacioglu
- Department of Endocrinology and Metabolism, Erciyes University Medical School, Kayseri, Turkey
| | - Fahrettin Kelestimur
- Department of Endocrinology and Metabolism, Yeditepe University Medical School, Istanbul, Turkey
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Hyponatremia After Spontaneous Aneurysmal Subarachnoid Hemorrhage-A Prospective Observational Study. World Neurosurg 2019; 129:e538-e544. [PMID: 31154098 DOI: 10.1016/j.wneu.2019.05.210] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Hyponatremia has been frequently observed after aneurysmal subarachnoid hemorrhage (SAH), and some data have suggested a correlation with symptomatic cerebral vasospasm and poor outcomes. The present prospective study investigated sodium and water disturbances after aneurysmal SAH with regard to symptomatic vasospasm and patient outcomes. METHODS Data from all patients with aneurysmal SAH treated in our department during a 2-year period were collected. Daily natriuresis, sodium levels, water balance, and serum and urine osmolality were measured at 4 different points: day 1 of admission or bleeding, day 3, day 7, and day 14-21 or discharge. The clinical parameters (i.e., Hunt and Hess grade, aneurysm location and treatment, onset of vasospasm) were reviewed. The patients' outcome was assessed using the Glasgow outcome score and modified Rankin scale. RESULTS A total of 101 patients (70 women; median age, 52 years) were enrolled in the present study. Of these 101 patients, 59.4% had a good grade SAH (Hunt and Hess grade 1-3). The most common aneurysm location was the anterior communicating artery (37%). The results from an electrolyte analysis were available for ≤91 patients at days 1 and 78 at discharge. In 33 patients (32.7%), hyponatremia had been diagnosed at any time point. Hyponatremia was most frequently observed at day 1 and later at days 7-10. A location in the anterior communicating artery resulted in hyponatremia more frequently only at day 1 (P = 0.007). The main causes of hyponatremia were cerebral salt-wasting syndrome (early onset) and syndrome of inappropriate antidiuretic hormone secretion (early and late onset). CONCLUSION Distinguishing early- and late-onset hyponatremia is of major relevance, because different therapeutic approaches are required. Only hyponatremia at discharge resulted in less favorable outcomes.
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Shikata E, Tamura T, Shinno K, Okayama Y, Shinohara N, Shimada K, Kanematsu Y, Kitazato KT, Nagahiro S, Takagi Y. Importance of Managing the Water-Electrolyte Balance by Delivering the Optimal Minimum Amount of Water and Sodium After Subarachnoid Hemorrhage. World Neurosurg 2019; 129:e352-e360. [PMID: 31132492 DOI: 10.1016/j.wneu.2019.05.152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND After aneurysmal subarachnoid hemorrhage (aSAH), crystalloid fluids with a relatively high sodium concentration have been used to maintain the cerebral blood flow. However, the prophylactic delivery of water and sodium by intravenous (IV) infusion will not necessarily improve the prognosis of patients after aSAH, and the excessive supply of water and sodium can negatively affect the outcome. We hypothesized that the delivery of an optimal amount of water and sodium separately might improve the outcome after aSAH. METHODS We recruited 55 consecutive patients who had undergone clipping or endovascular coil embolization after aSAH. Group 1 (n = 33) received conventional therapy (i.e., prophylactic IV sodium and water [protocol 1]). Group 2 (n = 22) received the optimal amount of water and sodium separately (protocol 2). RESULTS The median total of water and sodium chloride supplied in group 1 was significantly greater than that supplied in group 2 (P < 0.01). The modified Rankin scale score at discharge was 0-2 in 15 patients (95%) in group 2 and 23 patients (55%) in group 1 (P < 0.001). On multivariate logistic regression analysis, the odds ratio for a discharge modified Rankin scale score of 0-2 or 3-6 was significantly associated with the treatment protocol (P < 0.05) and the net fluid balance on days 4-8 (P < 0.05). CONCLUSION The separate delivery of optimal amounts of water and sodium could be a promising therapeutic strategy to improve the prognosis after aSAH.
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Affiliation(s)
- Eiji Shikata
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan.
| | - Tetsuya Tamura
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Kiyohito Shinno
- Department of Neurosurgery, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Yoshihiro Okayama
- Clinical Trial Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
| | - Naoki Shinohara
- Department of Neurosurgery, HITO Medical Center, Ehime, Japan
| | - Kenji Shimada
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Yasuhisa Kanematsu
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Keiko T Kitazato
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Shinji Nagahiro
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
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Modi S, Shah K, Schultz L, Tahir R, Affan M, Varelas P. Cost of hospitalization for aneurysmal subarachnoid hemorrhage in the United States. Clin Neurol Neurosurg 2019; 182:167-170. [PMID: 31151045 DOI: 10.1016/j.clineuro.2019.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/13/2019] [Accepted: 05/19/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Recent large-scale studies describing hospitalization cost trends secondary to aneurysmal subarachnoid hemorrhage (aSAH) in the United States are lacking. We sought to discover the impact of aSAH-related factors upon its hospitalization cost. PATIENTS AND METHODS Patients with a primary diagnosis of aSAH were selected utilizing the National Inpatient Sample. Regression analyses were used to evaluate the impact of aSAH-related factors on hospitalization costs. RESULTS From 2002-2014, 22,831 cases of aSAH were identified. The inflation-adjusted mean cost of hospitalization was $82,514 (standard deviation ± $54,983). The proportion of males was lower (31%), but a higher cost of $3385 (± $685; p < .001) remained compared to females. Median length of hospitalization was 16 days (interquartile range 11-23) and each day increase in hospitalization was associated with a cost increase of $3228 (± $19; p < .001). There was no difference in cost between patients undergoing aneurysmal coiling or clipping. When compared to patients < 40 years old, the increase in cost for patients 40-59 years old was $3829 (± $914; p < .001), and $4573 (± $1033; p < .001) for patients 60-79 years old; however, for patients ≥ 80 years old, there was a decrease in cost of $8124 (± $1722; p < .001). Several central nervous system complications were also associated with increased cost. CONCLUSION aSAH is a significant financial burden on the United States healthcare system. We were able to identify many important factors associated with higher costs, and these results may help us understand resource utilization and develop future cost-reduction strategies.
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Affiliation(s)
- Sumul Modi
- Department of Neurology, Henry Ford Macomb Hospital, 15855 19 Mile Road, Clinton Township, MI, 48038, United States
| | - Kavit Shah
- Department of Neurology, University of Pittsburgh Medical Center, 811 Kaufmann Medical Building, 3471 Fifth Avenue, Pittsburgh, PA, 15213, United States
| | - Lonni Schultz
- Departments of Public Health Sciences, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, United States
| | - Rizwan Tahir
- Departments of Neurosurgery, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, United States.
| | - Muhammad Affan
- Departments of Neurology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, United States
| | - Panayiotis Varelas
- Departments of Neurology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, United States
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Nakajima Y, Schmidt SM, Malmgren Fänge A, Ono M, Ikaga T. Relationship between Perceived Indoor Temperature and Self-Reported Risk for Frailty among Community-Dwelling Older People. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16040613. [PMID: 30791516 PMCID: PMC6406492 DOI: 10.3390/ijerph16040613] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 12/12/2022]
Abstract
This study investigated the relationship between perceived indoor temperature in winter and frailty among community-dwelling older people. This cross-sectional study included 342 people 65 years and older in Japan. Participants answered questions about demographics, frailty, housing, and perceived indoor temperature in winter. Participants were grouped based on perceived indoor temperature (Cold or Warm) and economic satisfaction (Unsatisfied or Satisfied). Differences in the frailty index between perceived indoor temperature groups and economic satisfaction groups were tested by using ANCOVA and MANCOVA. An interaction effect showed that people in the Cold Group and unsatisfied with their economic status had significantly higher frailty index scores (F(1, 336) = 5.95, p = 0.015). Furthermore, the frailty index subscale of fall risk was the specific indicator of frailty that accounted for this significant relationship. While previous research has shown the risks related to cold indoor temperature in homes, interestingly among those who reported cold homes, only those who were not satisfied with their economic situation reported being at increased risk for frailty. This highlights the potential importance of preventing fuel poverty to prevent frailty.
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Affiliation(s)
- Yukie Nakajima
- School of Science for Open and Environmental Systems, Graduate School of Science and Technology, Keio University, Hiyoshi 3 14 1, Kohoku, Yokohama, Kanagawa 2238522, Japan.
- Japan Society for the Promotion of Science, Koujimachi 5 3 1, Chiyoda, Tokyo 1020083, Japan.
| | - Steven M Schmidt
- School of Science for Open and Environmental Systems, Graduate School of Science and Technology, Keio University, Hiyoshi 3 14 1, Kohoku, Yokohama, Kanagawa 2238522, Japan.
- Department of Health Sciences, Faculty of Medicine, Lund University, Box 157, 22100 Lund, Sweden.
| | - Agneta Malmgren Fänge
- Department of Health Sciences, Faculty of Medicine, Lund University, Box 157, 22100 Lund, Sweden.
| | - Mari Ono
- School of Science for Open and Environmental Systems, Graduate School of Science and Technology, Keio University, Hiyoshi 3 14 1, Kohoku, Yokohama, Kanagawa 2238522, Japan.
| | - Toshiharu Ikaga
- Department of System Design Engineering, Faculty of Science and Technology, Keio University, Hiyoshi 3 14 1, Kohoku, Yokohama, Kanagawa 2238522, Japan.
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Abstract
PURPOSE OF REVIEW The acute care of a patient with severe neurological injury is organized around one relatively straightforward goal: avoid brain ischemia. A coherent strategy for fluid management in these patients has been particularly elusive, and a well considered fluid management strategy is essential for patients with critical neurological illness. RECENT FINDINGS In this review, several gaps in our collective knowledge are summarized, including a rigorous definition of volume status that can be practically measured; an understanding of how electrolyte derangements interact with therapy; a measurable endpoint against which we can titrate our patients' fluid balance; and agreement on the composition of fluid we should give in various clinical contexts. SUMMARY As the possibility grows closer that we can monitor the physiological parameters with direct relevance for neurological outcomes and the various complications associated with neurocritical illness, we may finally move away from static therapy recommendations, and toward individualized, precise therapy. Although we believe therapy should ultimately be individualized rather than standardized, it is clear that the monitoring tools and analytical methods used ought to be standardized to facilitate appropriately powered, prospective clinical outcome trials.
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Liao H, Zhu Z, Rong X, Wang H, Peng Y. Hyponatremia is a potential predictor of progression in radiation-induced brain necrosis: a retrospective study. BMC Neurol 2018; 18:130. [PMID: 30157800 PMCID: PMC6114772 DOI: 10.1186/s12883-018-1135-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 08/22/2018] [Indexed: 12/02/2022] Open
Abstract
Background To investigate the prognostic value of hyponatremia, defined as serum sodium level < 135 mEq/L, in radiation-induced brain necrosis (RN) patients. Methods We performed a retrospective analysis of the RN patients (The patients included in our study had a history of primary cancers including nasopharyngeal carcinoma/glioma/oral cancer and received radiotherapy previously and then were diagnosed with RN) treated in Sun yat-sen Memorial Hospital from January 2013 to August 2015. Patients without cranial magnetic resonance imaging (MRI) scan and serum sodium data were excluded. Progression was identified when the increase of edema area ≥ 25% on the MRI taken in six months comparing with those taken at the baseline. Factors that might associate with prognosis of RN were collected. Multivariable logistic regression analyses were used to identify potential predictors. Results We total included 135 patients, 32 (23.7%) of them with hyponatremia and 36 (26.7%) with RN progression. Percentage of progression was roughly three fold in hyponatremia patients compared with nonhyponatremia patients (53.1% versus 18.4%), translating into a 5-fold increased odds ratio (P < 0.001). Multivariable analyses identified hyponatremia as a potential predictor of progression (OR, 4.82; 95% CI [1.94–11.94]; P = 0.001). Conclusions Hyponatremia was identified as a potential predictor for the progression of patients with RN. Hyponatremia management in patients with RN should be paid much more concern in clinical practice.
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Affiliation(s)
- Huan Liao
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, No. 107 West Yanjiang Road, Guangzhou, 510120, China
| | - Zhuoting Zhu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xiaoming Rong
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, No. 107 West Yanjiang Road, Guangzhou, 510120, China
| | - Hongxuan Wang
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, No. 107 West Yanjiang Road, Guangzhou, 510120, China
| | - Ying Peng
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, No. 107 West Yanjiang Road, Guangzhou, 510120, China. .,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
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Sharma R, Sharma P, Katiyar V, Vora Z, Gurjar H. Hyponatremia Following Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2018; 115:481. [DOI: 10.1016/j.wneu.2018.02.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 02/28/2018] [Indexed: 11/16/2022]
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Target Serum Sodium Levels During Intensive Care Unit Management of Aneurysmal Subarachnoid Hemorrhage. Shock 2018; 48:558-563. [PMID: 28498294 DOI: 10.1097/shk.0000000000000897] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Dysnatremia commonly occur in the intensive care unit (ICU) management of patients with aneurysmal subarachnoid hemorrhage (SAH). However, detailed management strategies have not been provided even by current guidelines. The purposes of this study were to examine the association of abnormal serum sodium levels with unfavorable neurologic outcomes and to identify the target range of serum sodium in patients with SAH. METHODS We retrospectively reviewed all patients who were consecutively hospitalized with a confirmed diagnosis of SAH between January 2009 and December 2015. Univariate/multivariate analyses were performed to identify the independent predictors of an unfavorable neurologic outcome (modified Rankin scale of 3-6 upon hospital discharge). RESULTS There were 131 patients included in this study. Unfavorable neurologic outcomes occurred in 45% of patients. On multiple regression analysis, age, Hunt and Kosnik grade, and serum sodium levels in the ICU at the maximum [odds ratio (OR), 1.18; 95% CI, 1.05-1.35; P < 0.01] and minimum (OR, 0.88; 95% CI, 0.77-0.99; P = 0.048) values were significantly associated with unfavorable neurologic outcomes. The receiver operating characteristic curve analysis showed that the cut-off serum sodium levels were 145 mmol/L for maximum value and 132 mmol/L for minimum value. Patients with hyponatremia and hypernatremia during the first 2 weeks in the ICU accounted for 88.2% of patients with an unfavorable neurologic outcome; whereas, those with normal sodium levels accounted for only 15.6%. CONCLUSIONS In patients with SAH, both hyponatremia and hypernatremia during ICU management were significantly associated with unfavorable neurologic outcomes.
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Okazaki T, Kuroda Y. Aneurysmal subarachnoid hemorrhage: intensive care for improving neurological outcome. J Intensive Care 2018; 6:28. [PMID: 29760928 PMCID: PMC5941608 DOI: 10.1186/s40560-018-0297-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/29/2018] [Indexed: 12/18/2022] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage is a life-threatening disease requiring neurocritical care. Delayed cerebral ischemia is a well-known complication that contributes to unfavorable neurological outcomes. Cerebral vasospasm has been thought to be the main cause of delayed cerebral ischemia, and although several studies were able to decrease cerebral vasospasm, none showed improved neurological outcomes. Our target is not cerebral vasospasm but improving neurological outcomes. The purpose of this review is to discuss what intensivists should know and can do to improve clinical outcomes in subarachnoid hemorrhage patients. Main body of the abstract Delayed cerebral ischemia is thought to be due to not only vasospasm but also multifactorial mechanisms. Additionally, the concept of early brain injury, which occurs within the first 72 h after the hemorrhage, has become an important concern. Increasing sympathetic activity after the hemorrhage is associated with cardiopulmonary complications and poor outcomes. Serum lactate measurement may be a valuable marker reflecting the severity of sympathetic activity. The transpulmonary thermodilution method will bring about an advanced understanding of hemodynamic management. Fever is a well-recognized symptom and targeted temperature management is an anticipated intervention. To avoid hyperglycemia and hypoglycemia, performing moderate glucose control and minimizing glucose variability are important concepts in glycemic management, but the optimal target range remains unknown. Dysnatremia seems to be associated with negative outcomes. It is not clear yet that maintaining normonatremia actively improves neurological outcomes. Optimal duration of intensive care management has not been determined. Short conclusion Although we have an advanced understanding of the pathophysiology and clinical characteristics of subarachnoid hemorrhage, there are many controversies in the intensive care unit management of subarachnoid hemorrhage. With an awareness of not only delayed cerebral ischemia but also early brain injury, more attention should be given to various aspects to improve neurological outcomes.
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Affiliation(s)
- Tomoya Okazaki
- 1Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793 Japan
| | - Yasuhiro Kuroda
- 2Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki, Kita, Kagawa 761-0793 Japan
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Mogollon JP, Smoll NR, Panwar R. Association Between Neurological Outcomes Related to Aneurysmal Subarachnoid Hemorrhage and Onsite Access to Neurointerventional Radiology. World Neurosurg 2018; 113:e29-e37. [PMID: 29410100 DOI: 10.1016/j.wneu.2018.01.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE An onsite access to neurointerventional radiology (NIR) may be useful for managing patients with aneurysmal subarachnoid hemorrhage (aSAH) after the aneurysm-securing procedure. We aimed to assess the association between neurological outcomes related to aSAH and onsite access to NIR service. METHODS This was a sequential period study of 47 patients with aSAH admitted consecutively during the pre-NIR period (January 2010 to June 2012) compared with 81 patients with aSAH admitted consecutively during the post-NIR period (January 2013 to June 2015) at an academic tertiary referral intensive care unit (ICU). The primary end point was the incidence of poor neurological outcome, defined as modified Rankin scale of ≥3 at 6 months from ictus. Secondary outcomes included incidence of symptomatic vasospasm (SV) and length of stay in ICU/hospital. RESULTS The primary end point was observed in 18 of 47 (38%) patients during the pre-NIR period versus 25 of 81 (31%) patients during the post-NIR period (P = 0.39). The post-NIR period did not have an independent impact on neurological outcomes (adjusted odds ratio = 0.8, 95% confidence interval 0.3-2.1; P = 0.66). Of the patients who developed SV, 10 of 47 (21%) were during the pre-NIR period versus 33 of 81 (41%) during the post-NIR period (P = 0.02). The post-NIR period and higher Fisher grade were independent predictors of SV. Patients with SV had similar outcomes, but with longer stay in ICU during the post-NIR period compared with the pre-NIR period. CONCLUSIONS Among patients with aSAH, the post-NIR period was associated with more frequent detection of SV, more endovascular procedures, longer hospital stay, but with no appreciable improvement in neurological outcomes either overall or in the subset of patients with SV. STUDY REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12616000201471.
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MESH Headings
- Adult
- Aged
- Aneurysm, Ruptured/complications
- Aneurysm, Ruptured/surgery
- Aneurysm, Ruptured/therapy
- Brain Damage, Chronic/epidemiology
- Brain Damage, Chronic/etiology
- Brain Damage, Chronic/prevention & control
- Computed Tomography Angiography
- Embolization, Therapeutic
- Endovascular Procedures/statistics & numerical data
- Female
- Humans
- Incidence
- Intensive Care Units/statistics & numerical data
- Intracranial Aneurysm/complications
- Intracranial Aneurysm/surgery
- Intracranial Aneurysm/therapy
- Length of Stay/statistics & numerical data
- Ligation
- Male
- Middle Aged
- Radiography, Interventional/statistics & numerical data
- Recurrence
- Severity of Illness Index
- Subarachnoid Hemorrhage/diagnostic imaging
- Subarachnoid Hemorrhage/epidemiology
- Subarachnoid Hemorrhage/etiology
- Subarachnoid Hemorrhage/surgery
- Tertiary Care Centers/statistics & numerical data
- Treatment Outcome
- Vasospasm, Intracranial/epidemiology
- Vasospasm, Intracranial/etiology
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Affiliation(s)
| | - Nicolas Roydon Smoll
- Melbourne School of Population Health, University of Melbourne, Melbourne, Australia
| | - Rakshit Panwar
- Intensive Care Unit, John Hunter Hospital, Newcastle, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.
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Hoffman H, Ziechmann R, Gould G, Chin LS. The Impact of Aneurysm Location on Incidence and Etiology of Hyponatremia Following Subarachnoid Hemorrhage. World Neurosurg 2018; 110:e621-e626. [DOI: 10.1016/j.wneu.2017.11.058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 11/10/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
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Sbardella E, Isidori AM, Arnaldi G, Arosio M, Barone C, Benso A, Berardi R, Capasso G, Caprio M, Ceccato F, Corona G, Della Casa S, De Nicola L, Faustini-Fustini M, Fiaccadori E, Gesualdo L, Gori S, Lania A, Mantovani G, Menè P, Parenti G, Pinto C, Pivonello R, Razzore P, Regolisti G, Scaroni C, Trepiccione F, Lenzi A, Peri A. Approach to hyponatremia according to the clinical setting: Consensus statement from the Italian Society of Endocrinology (SIE), Italian Society of Nephrology (SIN), and Italian Association of Medical Oncology (AIOM). J Endocrinol Invest 2018; 41:3-19. [PMID: 29152673 DOI: 10.1007/s40618-017-0776-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 10/13/2017] [Indexed: 12/17/2022]
Affiliation(s)
- E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - G Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Università Politecnica delle Marche Azienda Ospedaliero-Universitaria, Ospedali Riuniti Umberto I-GM Lancisi-G Salesi, Ancona, Italy
| | - M Arosio
- Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Barone
- UOC di Oncologia Medica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - A Benso
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - R Berardi
- Clinica Oncologica, Università Politecnica delle Marche Azienda Ospedaliero-Universitaria; Ospedali Riuniti Umberto I-GM Lancisi-G Salesi, Ancona, Italy
| | - G Capasso
- Dipartimento di Scienze Cardio-Toraciche e Respiratorie, Università della Campania "Luigi Vanvitelli", Caserta, Italy
| | - M Caprio
- Laboratory of Cardiovascular Endocrinology, IRCCS San Raffaele Pisana, Rome, Italy
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy
| | - F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padua, Italy
| | - G Corona
- Endocrinology Unit, Medical Department, Azienda Usl Bologna Maggiore-Bellaria Hospital, Bologna, Italy
| | - S Della Casa
- Endocrinology and Metabolic Diseases Unit, Catholic University of the Sacred Heart, Rome, Italy
| | - L De Nicola
- Nephrology, Medical School, University of Campania Luigi Vanvitelli, Naples, Italy
| | - M Faustini-Fustini
- Pituitary Unit, IRCCS Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | - E Fiaccadori
- Renal Unit, Parma University Medical School, Parma, Italy
| | - L Gesualdo
- Nephrology Dialysis and Transplantation, Bari University Medical School, Bari, Italy
| | - S Gori
- UOC Oncologia Medica, Ospedale Sacro Cuore Don Calabria, Negrar, Verona, Italy
| | - A Lania
- Endocrine Unit, Department of Biomedical Sciences, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | - G Mantovani
- Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - P Menè
- Nephrology, Sapienza University of Rome, Rome, Italy
| | - G Parenti
- Endocrine Unit, Careggi Hospital, Florence, Italy
| | - C Pinto
- Oncologia Medica IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Naples, Italy
| | - P Razzore
- Endocrine Unit, AO Ordine Mauriziano, Turin, Italy
| | - G Regolisti
- Renal Unit, Parma University Medical School, Parma, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padua, Italy
| | - F Trepiccione
- Dipartimento di Scienze Cardio-Toraciche e Respiratorie, Università della Campania "Luigi Vanvitelli", Caserta, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A Peri
- Endocrine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", AOU Careggi, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy.
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Bei HZ, You SJ, Zheng D, Zhong CK, Du HP, Zhang Y, Lu TS, Cao LD, Dong XF, Cao YJ, Liu CF. Prognostic role of hypochloremia in acute ischemic stroke patients. Acta Neurol Scand 2017; 136:672-679. [PMID: 28613005 DOI: 10.1111/ane.12785] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVES The impact of electrolyte imbalance on clinical outcomes after acute ischemic stroke (AIS) is still not understood. We investigated the association between hypochloremia and hyponatremia upon hospital admission and in-hospital mortality in AIS patients. MATERIALS AND METHODS A total of 3314 AIS patients enrolled from December 2013 to May 2014 across 22 hospitals in Suzhou city were included in this study. Hypochloremia was defined as having a serum chloride concentration <98 mmol/L and hyponatremia as having a serum sodium concentration <135 mmol/L. The Cox proportional hazard model was used to examine the effect of hypochloremia and hyponatremia on all-cause in-hospital mortality in AIS patients. RESULTS During hospitalization, 118 patients (3.6%) died from all causes. Multivariable model adjusted for age, sex, baseline National Institutes of Health Stroke Scale score, serum sodium, and other potential covariates showed that hypochloremia was associated with a 2.43-fold increase in the risk of in-hospital mortality (hazard ratio [HR] 2.43; 95% confidence interval [CI], 1.41-4.19; P=.001). However, no significant association between hyponatremia (P=.905) and in-hospital mortality was observed. Moreover, the multivariable analysis found that serum chloride (HR=0.92, 95% CI 0.88-0.98; P=.004) but not serum sodium (P=.102) was significantly associated with in-hospital mortality. CONCLUSIONS Hypochloremia at admission was independently associated with in-hospital mortality in AIS patients.
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Affiliation(s)
- H.-Z. Bei
- Department of Neurology; Suzhou Clinical Research Center of Neurological Disease; The Second Affiliated Hospital of Soochow University; Suzhou China
- Department of Neurology; The Third Affiliated Hospital of Inner Mongolia Medical University; Baotou China
| | - S.-J. You
- Department of Neurology; Suzhou Clinical Research Center of Neurological Disease; The Second Affiliated Hospital of Soochow University; Suzhou China
| | - D. Zheng
- The George Institute for Global Health; The University of New South Wales; Sydney NSW Australia
| | - C.-K. Zhong
- Department of Epidemiology; School of Public Health; Medical College of Soochow University; Suzhou China
| | - H.-P. Du
- Department of Neurology; The Affiliated Wujiang Hospital of Nantong University; Suzhou China
| | - Y. Zhang
- Department of Neurology; Suzhou Clinical Research Center of Neurological Disease; The Second Affiliated Hospital of Soochow University; Suzhou China
| | - T.-S. Lu
- Department of Neurology; Changshu First People's Hospital; Suzhou China
| | - L.-D. Cao
- Department of Neurology; Zhangjiagang First People's Hospital; Suzhou China
| | - X.-F. Dong
- Department of Neurology; Suzhou Hospital Affiliated to Nanjing Medical University; Suzhou China
| | - Y.-J. Cao
- Department of Neurology; Suzhou Clinical Research Center of Neurological Disease; The Second Affiliated Hospital of Soochow University; Suzhou China
- Institutes of Neuroscience; Soochow University; Suzhou China
| | - C.-F. Liu
- Department of Neurology; Suzhou Clinical Research Center of Neurological Disease; The Second Affiliated Hospital of Soochow University; Suzhou China
- Institutes of Neuroscience; Soochow University; Suzhou China
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50
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Risk of Hyponatremia in Patients with Aneurysmal Subarachnoid Hemorrhage Treated with Exogenous Vasopressin Infusion. Neurocrit Care 2017; 26:182-190. [PMID: 27677909 DOI: 10.1007/s12028-016-0300-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Vasopressin is one of the vasopressors used to augment blood pressure in subarachnoid hemorrhage (SAH) patients with clinically significant vasospasm. The purpose of the present study was to determine whether the administration of vasopressin to a population of SAH patients was an independent predictor of developing hyponatremia. METHODS A retrospective review on the health records of 106 patients admitted to the University of Alberta Hospital Neurosciences ICU, Edmonton AB, Canada, with SAH from June 2013 to December 2015 was conducted. Serum sodium changes in patients receiving vasoactive drugs were compared. In addition, independent predictors for hyponatremia (Na < 135 mmol/L) were determined using a multivariate logistic regression model. RESULTS Patients treated with vasopressin in addition to other vasoactive drugs had significantly higher sodium changes compared to those treated with other vasoactive drugs (-4.7 ± 6 vs -0.1 ± 2.4 mmol/L, respectively, p value 0.001). Hyponatremia occurred in 14 patients (70 %) treated with vasopressin, 10 patients (44 %) treated with vasoactive drugs other than vasopressin (p value 0.081), and 24 patients (38 %) who did not receive any vasoactive drug (p value 0.013). In multivariate logistic regression analysis, when adjusting for disease severity, age, sex, aneurysm location, and treatment, vasopressin was associated with hyponatremia (OR 3.58, 95 % CI, 1.02-12.5, p value 0.046). CONCLUSIONS The results of the present study suggest that hyponatremia may be more common in SAH patients treated with exogenous vasopressin compared to those who did not receive it. Serum sodium should be monitored closely when vasopressin is being used in the SAH population. Further studies are needed to confirm the effect of exogenous vasopressin on serum sodium levels in SAH populations.
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