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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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Baba M, Alsbrook D, Williamson S, Soman S, Ramadan AR. Approach to the Management of Sodium Disorders in the Neuro Critical Care Unit. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00723-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Determinants of hyponatremia following a traumatic brain injury. Neurol Sci 2022; 43:3775-3782. [DOI: 10.1007/s10072-022-05894-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 01/12/2022] [Indexed: 10/19/2022]
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Eisinger RS, Sorrentino ZA, Lucke-Wold B, Zhou S, Barlow B, Hoh B, Maciel CB, Busl KM. Severe headache trajectory following aneurysmal subarachnoid hemorrhage: the association with lower sodium levels. Brain Inj 2022; 36:579-585. [PMID: 35353644 PMCID: PMC9177668 DOI: 10.1080/02699052.2022.2055146] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A clinical hallmark of aneurysmal SAH (aSAH) is headache. Little is known about post-aSAH headache factors which may point to underlying mechanisms. In this study, we aimed to characterize the severity and trajectory of headaches in relation to clinical features of patients with aSAH. METHODS This is a retrospective longitudinal study of adult patients admitted to an academic tertiary care center between 2012 and 2019 with aSAH who could verbalize pain scores. Factors recorded included demographics, aneurysm characteristics, analgesia, daily morning serum sodium concentration, and occurrence of vasospasm. Group-based trajectory modeling was used to identify headache pain trajectories, and clinical factors were compared between trajectories. RESULTS Of 91 patients included in the analysis, mean age was 57 years and 20 (22%) were male. Headache score trajectories clustered into two groups: patients with mild-moderate and moderate-severe pain. Patients in the moderate-severe pain group were younger (P<0.05), received more opioid analgesia (P<0.001), and had lower sodium concentrations (P<0.001) than patients in the mild-moderate pain group. CONCLUSION We identified two distinct post-aSAH headache pain trajectory cohorts and identified an association with age, analgesia, and sodium levels. Future prospective studies considering sodium homeostasis and volume status under standardized analgesic regimens are warranted.
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Affiliation(s)
- Robert S Eisinger
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sonya Zhou
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brooke Barlow
- Department of Pharmacy, University of Florida Shands Hospital, Gainesville, Florida, USA
| | - Brian Hoh
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Carolina B Maciel
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, Florida USA
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Katharina M Busl
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, Florida USA
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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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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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Abstract
Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.
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Cui H, He G, Yang S, Lv Y, Jiang Z, Gang X, Wang G. Inappropriate Antidiuretic Hormone Secretion and Cerebral Salt-Wasting Syndromes in Neurological Patients. Front Neurosci 2019; 13:1170. [PMID: 31780881 PMCID: PMC6857451 DOI: 10.3389/fnins.2019.01170] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 10/16/2019] [Indexed: 12/13/2022] Open
Abstract
The differential diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt-wasting syndrome (CSWS) in patients with neurological disorders has been a perplexing clinical controversy. The purpose of this review is to summarize the characteristics and risk factors of patients with different types of neurological disorders complicated by hyponatremia (HN) and review various methods to distinguish SIADH from CSWS. Common neurological disorders with high rates of HN include subarachnoid hemorrhage (SAH), traumatic brain injuries, stroke, cerebral tumors, central nervous system (CNS) infections, and Guillain-Barré syndrome (GBS), which have their own characteristics. Extracellular volume (ECV) status of patients is a key point to differentiate SIADH and CSWS, and a comprehensive assessment of relevant ECV indicators may be useful in differentiating these two syndromes. Besides, instead of monitoring the urinary sodium excretion, more attention should be paid to the total mass balance, including Na+, K+, Cl-, and extracellular fluid. Furthermore, the dynamic detection of fractional excretions (FE) of urate before and after correction of HN and a short-term infusion of isotonic saline solution may be useful in identifying the etiology of HN. As for brain natriuretic peptide (BNP) or N-terminal prohormone of BNP (NT-proBNP), more prospective studies and strong evidence are needed to determine whether there is a pertinent and clear difference between SIADH and CSWS.
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Affiliation(s)
- Haiying Cui
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Guangyu He
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Shuo Yang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - You Lv
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Zongmiao Jiang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Xiaokun Gang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
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Abstract
Sodium perturbations are a common complication after pituitary surgery, with hyponatremia being the most frequent. Postoperative assessments should be tailored to the early and late periods, and monitoring sodium perturbations is recommended. Cerebral salt wasting is rare after pituitary surgery, and diagnosis and management can be challenging. Providing patient counseling and close postoperative follow-up is important to effectively manage diabetes insipidus and reduce hospital readmissions due to sodium perturbations.
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Affiliation(s)
- Kevin C J Yuen
- Department of Neuroendocrinology, Barrow Pituitary Center, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, University of Arizona College of Medicine and Creighton School of Medicine, 124 W Thomas Road, Suite 300, Phoenix, AZ 85013, USA.
| | - Adnan Ajmal
- Department of Internal Medicine and Endocrinology, St. Joseph's Hospital and Medical Center, Creighton University School of Medicine, 500 W Thomas Road, Suite 900B Phoenix, AZ 85013, USA
| | - Ricardo Correa
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Phoenix Veterans Administration Medical Center, University of Arizona College of Medicine, Creighton School of Medicine and Mayo School of Medicine, 650 E Indian School Road, Building 21, Suite 117, Phoenix, AZ 85014, USA
| | - Andrew S Little
- Department of Neurosurgery, Barrow Pituitary Center, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, University of Arizona College of Medicine, 300 W Thomas Road, Phoenix, AZ 85013, USA
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Tang AM, Bakhsheshian J, Ding L, Jarvis CA, Yuan E, Strickland B, Giannotta SL, Amar A, Attenello FJ, Mack WJ. Nonindex Readmission After Ruptured Brain Aneurysm Treatment Is Associated with Higher Morbidity and Repeat Readmission. World Neurosurg 2019; 130:e753-e759. [PMID: 31284063 DOI: 10.1016/j.wneu.2019.06.214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) requires complex multidisciplinary care. After initial treatment (index hospital), readmission to a different hospital (nonindex) can compromise quality of care, resulting in increased morbidity. We aimed to evaluate factors associated with nonindex readmission and evaluate association of nonindex hospital readmission on outcomes in patients with ruptured aneurysm. METHODS Readmissions within 90 days after aSAH treatment were identified in the 2010-2014 Nationwide Readmissions Database. Multivariable logistic regression identified patient and hospital characteristics associated with nonindex readmission. Separate multivariable models determined increased morbidity or risk of second readmission for nonindex readmissions. RESULTS A total of 9254 patients who underwent treatment of ruptured aneurysms from 2010 to 2014 were identified. Of these, 1985 (21.5%) were readmitted within 90 days. Three hundred and fifty-five of these readmissions (17.9%) occurred to nonindex hospitals. Patients that were discharged to a skilled nursing or other facility (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.27-2.28]) had higher odds of nonindex readmission, whereas patients with private insurance were associated with lower odds of nonindex readmission (OR, 0.65; 95% CI, 0.46-0.92). Patients readmitted to a nonindex (vs. index) hospital were associated with increased likelihood of major complications (OR, 1.71; 95% CI, 1.18-2.48) and second readmissions (OR, 1.51; 95% CI, 1.17-1.96). CONCLUSIONS After treatment of a ruptured cerebral aneurysm, 17.9% of readmissions occurred at a nonindex hospital. These patients were at increased risk for major complications or subsequent readmissions, which may be because of care fragmentation. Interventions aimed at improving continuity of care may reduce higher morbidity associated with nonindex readmission.
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Affiliation(s)
- Austin M Tang
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
| | - Joshua Bakhsheshian
- Department of Neurological, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Li Ding
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Casey A Jarvis
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Edith Yuan
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ben Strickland
- Department of Neurological, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Steven L Giannotta
- Department of Neurological, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Arun Amar
- Department of Neurological, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Frank J Attenello
- Department of Neurological, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - William J Mack
- Department of Neurological, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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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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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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Hoffman H, Ziechmann R, Gould G, Chin LS. In Reply to “Hyponatremia Following Aneurysmal Subarachnoid Hemorrhage”. World Neurosurg 2018; 115:482. [DOI: 10.1016/j.wneu.2018.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 04/02/2018] [Indexed: 10/28/2022]
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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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