Diagnosis and Management of Combined Central Diabetes Insipidus and Cerebral Salt Wasting Syndrome After Traumatic Brain Injury

A Review of Electrolyte, Mineral, and Vitamin Changes After Traumatic Brain Injury

INTRODUCTION

Despite the prevalence of traumatic brain injury (TBI) in both civilian and military populations, the management guidelines developed by the Joint Trauma System involve minimal recommendations for electrolyte physiology optimization during the acute phase of TBI recovery. This narrative review aims to assess the current state of the science for electrolyte and mineral derangements found after TBI.

MATERIALS AND METHODS

We used Google Scholar and PubMed to identify literature on electrolyte derangements caused by TBI and supplements that may mitigate secondary injuries after TBI between 1991 and 2022.

RESULTS

We screened 94 sources, of which 26 met all inclusion criteria. Most were retrospective studies (n = 9), followed by clinical trials (n = 7), observational studies (n = 7), and case reports (n = 2). Of those, 29% covered the use of some type of supplement to support recovery after TBI, 28% covered electrolyte or mineral derangements after TBI, 16% covered the mechanisms of secondary injury after TBI and how they are related to mineral and electrolyte derangements, 14% covered current management of TBI, and 13% covered the potential toxic effects of the supplements during TBI recovery.

CONCLUSIONS

Knowledge of mechanisms and subsequent derangements of electrolyte, mineral, and vitamin physiology after TBI remains incomplete. Sodium and potassium tended to be the most well-studied derangements after TBI. Overall, data involving human subjects were limited and mostly involved observational studies. The data on vitamin and mineral effects were limited, and targeted research is needed before further recommendations can be made. Data on electrolyte derangements were stronger, but interventional studies are needed to assess causation.

Permanent central diabetes insipidus after traumatic brain injury. Case report and literature review

The authors report permanent central diabetes insipidus (CDI) in a patient after severe traumatic brain injury (TBI) in traffic accident. A 16-year-old boy entered to a medical facility in coma (GCS score 6) with the following diagnosis: acute TBI, severe cerebral contusion, subarachnoid hemorrhage, depressed comminuted cranial vault fracture, basilar skull fracture, visceral contusion. CDI was diagnosed in 3 days after injury considering polyuria and hypernatremia (155 mmol/l). Desmopressin therapy was initiated through a feeding tube. Thirst appeared when a patient came out of the coma after 21 days despite ongoing desmopressin therapy. Considering persistent thirst and polyuria, we continued desmopressin therapy in a spray form. Under this therapy, polyuria reduced to 3-3.5 liters per a day. Symptoms of CDI persisted in long-term period (2 years after TBI) while function of adenohypophysis was intact. This case demonstrates a rare development of permanent diabetes insipidus after TBI. CDI manifested only as polyuria and hypernatremia in coma. Thirst joined after recovery of consciousness. Probable causes of CDI were damage to neurohypophysis and partially injury of pituitary stalk because of extended basilar skull fracture and/or irreversible secondary lesion of hypothalamus following diffuse axonal damage after TBI.

Concurrent central diabetes insipidus and cerebral salt wasting disease in a post-operative case of craniopharyngioma: a case report

BACKGROUND

Water and electrolyte disorders commonly encountered in children post-surgery involving hypothalamus and posterior pituitary, are central diabetes insipidus, syndrome of inappropriate secretion of anti-diuretic hormone and cerebral salt wasting disease. Delayed diagnosis and inadequate management of such cases may lead to worsened neurological outcomes with a high mortality rate.

CASE PRESENTATION

Here we report the case of a 7-year-old girl who underwent surgical resection of a craniopharyngioma, following which she initially developed central diabetes insipidus. However, later on in the course of her illness she developed symptomatic hyponatremia with natriuresis which was diagnosed to be due to cerebral salt wasting disease. This combination of central diabetes insipidus and cerebral salt wasting syndrome is a rare occurrence and poses a diagnostic challenge. Diagnosis and management can be even more difficult when these conditions precede or coexist with each other.

CONCLUSION

In such cases development of hyponatremia should always prompt consideration of unusual causes like cerebral salt wasting disease in addition to the classically described syndrome of inappropriate secretion of anti-diuretic hormone. Hence, a thorough knowledge of these disorders along with intensive monitoring of fluid and sodium status is critical for timely diagnosis and management of these patients.

Clinical case of combined diabetes insipidus and cerebral salt-wasting syndrome in a patient with craniocerebral and spinal injury

Introduction. Cerebral salt-wasting syndrome and diabetes insipidus are serious complications of craniocerebral injury and spinal cord injuries. Each of the syndromes in some cases causes a life-threatening condition. This determines the importance of timely diagnosis and emergency intensive care measures. In the literature, there are only single descriptions of combinations of these symptoms in one patient.Clinical case report. A victim with craniocerebral injury and cervical spinal cord injury underwent, according to emergency indications, emptying and drainage of a tense subgaleal hematoma of the fronto-parieto-occipital region, spinal cord decompression, and stabilization of the spine. Postoperative follow-up and intensive care: on the 1st day the rate of diuresis was 2.5 mL/kg/h, blood glucose level – 14.18 mmol/L, and sodium level – 148–158 mmol/L. The patient was diagnosed with diabetes insipidus, and a therapy with desmopressin at a dose of 0.6 mg/day, restoration of fluid volume with hypotonic solutions, and correction of hyperglycemia was started. On the 4th day blood sodium level was 133 mmol/L, and blood glucose level – 8.67 mmol/L. On the 5th day, hyponatremia of 126–115 mmol/L was noted with a diuresis rate of 4 mL/kg/h and glicemya level of 7.86 mmol/L. The development of cerebral salt-wasting syndrome was diagnosed, and the infusion of hydrocortisone 400 mg/day and of 10% NaCl solution was started. On the 6th day glucose level returned to normal. On the 9th day of follow-up, an increase in the volume of diuresis was again observed, and desmopressin therapy was continued. Stable normalization of water-electrolyte balance, urine output, and glucose levels were observed on the 16th day of follow-up.Conclusion. Monitoring of fluid balance and electrolyte composition of blood serum, and adequate replacement therapy were the conditions for successful treatment of a rare combination of diabetes insipidus and cerebral salt-wasting syndrome in patients with concomitant craniocerebral and spinal cord injuries.

Coexisting Cerebral Salt Wasting Syndrome and Central Diabetes Insipidus in a Patient with Posterior Cerebrovascular Infarction: A Case Report

<b><i>Background:</i></b> Disorders of sodium balance are common in critically ill neurologic patients. However, the coexisting of cerebral salt wasting syndrome (CSW) and central diabetes insipidus (CDI) in such patients is rare. Early recognition of such conditions is challenging, thus making the prognosis ominous. <b><i>Case Presentation:</i></b> A 50-year-old male patient presented with acute posterior cerebrovascular infarction complicated by several attacks of disturbed sodium homeostasis. The first attack manifested as hypernatremia (up to 161 mmol/L) and polyuria with high urine sodium (188 mmol/L) could only be explained by CSW on top of CDI. Especially the patient was not receiving any hyperosmolar or sodium-containing fluids. Serum sodium was corrected by desmopressin acetate. Later, the patient developed 2 attacks of hyponatremia (down to 119 mmol/L) diagnosed as CSW that was treated with fludrocortisone. Finally, he developed hypernatremia (up to 165 mmol/L) diagnosed as CDI and was treated with desmopressin acetate. <b><i>Conclusion:</i></b> Sodium hemostasis disorders require full consideration of serum electrolytes, intravascular volume state, and urine electrolytes in view of the clinical condition. Early diagnosis and administration of the proper treatment are the cornerstones of successful management.

Diabetes exacerbates brain pathology following a focal blast brain injury: New role of a multimodal drug cerebrolysin and nanomedicine

Blast brain injury (bBI) is a combination of several forces of pressure, rotation, penetration of sharp objects and chemical exposure causing laceration, perforation and tissue losses in the brain. The bBI is quite prevalent in military personnel during combat operations. However, no suitable therapeutic strategies are available so far to minimize bBI pathology. Combat stress induces profound cardiovascular and endocrine dysfunction leading to psychosomatic disorders including diabetes mellitus (DM). This is still unclear whether brain pathology in bBI could exacerbate in DM. In present review influence of DM on pathophysiology of bBI is discussed based on our own investigations. In addition, treatment with cerebrolysin (a multimodal drug comprising neurotrophic factors and active peptide fragments) or H-290/51 (a chain-breaking antioxidant) using nanowired delivery of for superior neuroprotection on brain pathology in bBI in DM is explored. Our observations are the first to show that pathophysiology of bBI is exacerbated in DM and TiO₂-nanowired delivery of cerebrolysin induces profound neuroprotection in bBI in DM, not reported earlier. The clinical significance of our findings with regard to military medicine is discussed.

Gradient washout and secondary nephrogenic diabetes insipidus after brain injury in an infant: a case report

Background

Disorders of water and sodium balance can occur after brain injury. Prolonged polyuria resulting from central diabetes insipidus and cerebral salt wasting complicated by gradient washout and a type of secondary nephrogenic diabetes insipidus, however, has not been described previously, to the best of our knowledge. We report an unusual case of an infant with glioblastoma who, after tumor resection, was treated for concurrent central diabetes insipidus and cerebral salt wasting complicated by secondary nephrogenic diabetes insipidus.

Case presentation

A 5-month-old Hispanic girl was found to have a large, hemorrhagic, suprasellar glioblastoma causing obstructive hydrocephalus. Prior to mass resection, she developed central diabetes insipidus. Postoperatively, she continued to have central diabetes insipidus and concurrent cerebral salt wasting soon after. She was managed with a vasopressin infusion, sodium supplementation, fludrocortisone, and urine output replacements. Despite resolution of her other major medical issues, she remained in the pediatric intensive care unit for continual and aggressive management of water and sodium derangements. Starting on postoperative day 18, her polyuria began increasing dramatically and did not abate with increasing vasopressin. Nephrology was consulted. Her blood urea nitrogen was undetectable during this time, and it was thought that she may have developed a depletion of inner medullary urea and osmotic gradient: a “gradient washout.” Supplemental dietary protein was added to her enteral nutrition, and her fluid intake was decreased. Within 4 days, her blood urea nitrogen increased, and her vasopressin and fluid replacement requirements significantly decreased. She was transitioned soon thereafter to subcutaneous desmopressin and transferred out of the pediatric intensive care unit.

Conclusions

Gradient washout has not been widely reported in humans, although it has been observed in the mammalian kidneys after prolonged polyuria. Although not a problem with aquaporin protein expression or production, gradient washout causes a different type of secondary nephrogenic diabetes insipidus because the absence of a medullary gradient impairs water reabsorption. We report a case of an infant who developed complex water and sodium imbalances after brain injury. Prolonged polyuria resulting from both water and solute diuresis with low enteral protein intake was thought to cause a urea gradient washout and secondary nephrogenic diabetes insipidus. The restriction of fluid replacements and supplementation of enteral protein appeared adequate to restore the renal osmotic gradient and efficacy of vasopressin.

Low brain endocannabinoids associated with persistent non-goal directed nighttime hyperactivity after traumatic brain injury in mice

Traumatic brain injury (TBI) is a frequent cause of chronic headache, fatigue, insomnia, hyperactivity, memory deficits, irritability and posttraumatic stress disorder. Recent evidence suggests beneficial effects of pro-cannabinoid treatments. We assessed in mice levels of endocannabinoids in association with the occurrence and persistence of comparable sequelae after controlled cortical impact in mice using a set of long-term behavioral observations in IntelliCages, motor and nociception tests in two sequential cohorts of TBI/sham mice. TBI mice maintained lower body weights, and they had persistent low levels of brain ethanolamide endocannabinoids (eCBs: AEA, OEA, PEA) in perilesional and subcortical ipsilateral brain tissue (6 months), but rapidly recovered motor functions (within days), and average nociceptive responses were within normal limits, albeit with high variability, ranging from loss of thermal sensation to hypersensitivity. TBI mice showed persistent non-goal directed nighttime hyperactivity, i.e. they visited rewarding and non-rewarding operant corners with high frequency and random success. On successful visits, they made more licks than sham mice resulting in net over-licking. The lower the eCBs the stronger was the hyperactivity. In reward-based learning and reversal learning tasks, TBI mice were not inferior to sham mice, but avoidance memory was less stable. Hence, the major late behavioral TBI phenotype was non-goal directed nighttime hyperactivity and "over-licking" in association with low ipsilateral brain eCBs. The behavioral phenotype would agree with a "post-TBI hyperactivity disorder". The association with persistently low eCBs in perilesional and subcortical regions suggests that eCB deficiency contribute to the post-TBI psychopathology.

Clinical Approach to Sodium Homeostasis Disorders in Children with Pituitary-Suprasellar Tumors

Children with pituitary-suprasellar tumors are at high risk of developing sodium metabolism disorders since the tumoral mass itself or surgical and medical treatment can damage AVP release circuits. Additional risk factors are represented by the use of hypotonic fluids, the young age, total parenteral nutrition, and obstructive hydrocephalus secondary to tumor pathology. The most frequent hyponatremic disorders related to AVP in these patients are the syndrome of inappropriate ADH secretion and the cerebral/renal salt wasting syndrome, while hypernatremic conditions include central diabetes insipidus (CDI) and adipsic CDI. The main challenge in the management of these patients is to promptly distinguish the AVP release disorder at the base of the sodium imbalance and treat it correctly by avoiding rapid sodium fluctuations. These disorders can coexist or follow each other in a few hours or days; therefore, careful clinical and biochemical monitoring is necessary, especially during surgery, the use of chemotherapeutic agents, or radiotherapy. This monitoring should be performed by experienced healthcare professionals and should be multidisciplinary, including pediatric endocrinologists, neurosurgeons, and oncologists since maintaining sodium homeostasis also plays a prognostic role in terms of disease survival, therapeutic response, hospitalization rate, and mortality. In this review, we analyze the management of sodium homeostasis disorders in children with pituitary-suprasellar tumors and discuss the main challenges in the diagnosis and treatment of these conditions based on literature data and over 30 years of clinical experience at our Department of Pediatric Endocrinology.

A challenging coexistence of central diabetes insipidus and cerebral salt wasting syndrome: a case report

BACKGROUND

Combined central diabetes insipidus and cerebral salt wasting syndrome is a rare clinical finding. However, when this happens, mortality is high due to delayed diagnosis and/or inadequate treatment.

CASE PRESENTATION

A 42-year-old white man was referred to neurosurgery due to a non-functional pituitary macroadenoma. He underwent a partial resection of the tumor on July 2, 2015. On the day following surgery he presented polyuria with sodium 149 mEq/L, plasma osmolality 301 mOsm/kg, and urine osmolality 293 mOsm/kg. He started nasal desmopressin 0.05 mg/day with good response. He was already on dexamethasone 4 mg and levothyroxine 75 mcg due to hypopituitarism after surgery. On July 9 he became confused. Cerebral computed tomography was performed with no significant changes. His natremia dropped to 128 mEq/L with development of polyuria despite maintenance of desmopressin dose. His hemoglobin and hematocrit rose from 9.1 g/L to 11.6 g/L and 27.5 to 32.5, respectively. His thyroid function was normal and he was on hydrocortisone 30 mg/day. At 12 p.m. 150 mg/hydrocortisone infusion was initiated, but sodium did not increase. Plasma and urine osmolality were 264 mOsm/kg and 679 mOsm/kg, respectively. At 4 p.m. hydrocortisone was increased and hypertonic saline replacement started. Two hours later he was dehydrated with polyuria and vomiting, and natremia of 124 mEq/L. Hyponatremia was very resistant to treatment despite hypertonic saline replacement, hence desmopressin was suspended. The following day, urine spot analysis showed that natriuresis was 63 mEq/L with serum sodium 132 mEq/L. This was interpreted as a cerebral salt wasting syndrome and control was achieved with aggressive hypertonic saline replacements and fludrocortisone 0.1 mg/three times a day.

CONCLUSIONS

We present a rare case of a patient with diabetes insipidus and cerebral salt wasting syndrome, who was successfully treated. Hyponatremia in a patient with diabetes insipidus may erroneously be interpreted as inadequate diabetes insipidus control or as syndrome of inappropriate antidiuretic hormone secretion, leading to therapeutic errors. Thus, all clinical and analytical data should be evaluated together for early and correct diagnosis.

Concurrence of Inappropriate Antidiuretic Hormone Secretion and Cerebral Salt Wasting Syndromes after Traumatic Brain Injury

Syndrome of inappropriate antidiuretic hormone (SIADH) and cerebral salt wasting syndrome (CSWS) as the two most common neuroendocrine diseases, have been recognized and understood by many neurologists. Although SIADH and CSWS are the common causes of central hyponatremia after traumatic brain injury (TBI), a few cases are mixed, with the coexistence of the two pathological pathomechanism. However, the mixed type of both SIADH and CSWS has not been clearly reported in any literature. Here, we present the first description of the concurrent syndrome of SIADH and CSWS after TBI in four patients who underwent standard diagnostic procedures, treatment and follow up. Our findings further support that this rare neuroendocrine disease may exist in clinical practice, in which the traditional-conventional treatment shows poor efficacy.