Effect of fludrocortisone acetate in patients with subarachnoid hemorrhage

Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

The neurointensive care management of patients with aneurysmal subarachnoid hemorrhage (aSAH) is one of the most critical components contributing to short-term and long-term patient outcomes. Previous recommendations for the medical management of aSAH comprehensively summarized the evidence based on consensus conference held in 2011. In this report, we provide updated recommendations based on appraisal of the literature using the Grading of Recommendations Assessment, Development, and Evaluation methodology.

METHODS

The Population/Intervention/Comparator/Outcome (PICO) questions relevant to the medical management of aSAH were prioritized by consensus from the panel members. The panel used a custom-designed survey instrument to prioritize clinically relevant outcomes specific to each PICO question. To be included, the study design qualifying criteria were as follows: prospective randomized controlled trials (RCTs), prospective or retrospective observational studies, case-control studies, case series with a sample larger than 20 patients, meta-analyses, restricted to human study participants. Panel members first screened titles and abstracts, and subsequently full text review of selected reports. Data were abstracted in duplicate from reports meeting inclusion criteria. Panelists used the Grading of Recommendations Assessment, Development, and Evaluation Risk of Bias tool for assessment of RCTs and the "Risk of Bias In Nonrandomized Studies - of Interventions" tool for assessment of observational studies. The summary of the evidence for each PICO was presented to the full panel, and then the panel voted on the recommendations.

RESULTS

The initial search retrieved 15,107 unique publications, and 74 were included for data abstraction. Several RCTs were conducted to test pharmacological interventions, and we found that the quality of evidence for nonpharmacological questions was consistently poor. Five PICO questions were supported by strong recommendations, one PICO question was supported by conditional recommendations, and six PICO questions did not have sufficient evidence to provide a recommendation.

CONCLUSIONS

These guidelines provide recommendations for or against interventions proven to be effective, ineffective, or harmful in the medical management of patients with aSAH based on a rigorous review of the available literature. They also serve to highlight gaps in knowledge that should guide future research priorities. Despite improvements in the outcomes of patients with aSAH over time, many important clinical questions remain unanswered.

Prevention and Correction of Dysnatremia After Aneurysmal Subarachnoid Hemorrhage

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.

Cerebral Salt Wasting Syndrome Following Right Occipital Craniotomy in a Patient With Metastatic Lung Adenocarcinoma

Cerebral salt wasting syndrome (CSW) is characterized by excessive natriuresis leading to hyponatremia and hypovolemia. It is commonly encountered among patients who have undergone brain trauma or subarachnoid hemorrhage. The occurrence of CSW after neurosurgical procedures has been frequently reported in the pediatric age group; however, it is a rare phenomenon in adults. We describe the case of a 59-year-old female who developed symptoms of polyuria and polydipsia after a right occipital craniotomy.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

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.

Anti-Inflammatory Drug Therapy in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis of Prospective Randomized and Placebo-Controlled Trials

Emerging evidence suggests that neuroinflammation may play a potential role in aneurysmal subarachnoid hemorrhage (aSAH). We aim to analyze the influence of anti-inflammatory therapy on survival and outcome in aSAH. Eligible randomized placebo-controlled prospective trials (RCTs) were searched in PubMed until March 2023. After screening the available studies for inclusion and exclusion criteria, we strictly extracted the main outcome measures. Dichotomous data were determined and extracted by odds ratio (OR) with 95% confidence intervals (CIs). Neurological outcome was graded using the modified Rankin Scale (mRS). We created funnel plots to analyze publication bias. From 967 articles identified during the initial screening, we included 14 RCTs in our meta-analysis. Our results illustrate that anti-inflammatory therapy yields an equivalent probability of survival compared to placebo or conventional management (OR: 0.81, 95% CI: 0.55-1.19, p = 0.28). Generally, anti-inflammatory therapy trended to be associated with a better neurologic outcome (mRS ≤ 2) compared to placebo or conventional treatment (OR: 1.48, 95% CI: 0.95-2.32, p = 0.08). Our meta-analysis showed no increased mortality form anti-inflammatory therapy. Anti-inflammatory therapy in aSAH patients tends to improve the neurological outcome. However, multicenter, rigorous, designed, prospective randomized studies are still needed to investigate the effect of fighting inflammation in improving neurological functioning after aSAH.

Suspected Cerebral Salt Wasting Syndrome with Cervical Spinal Lesion in a Domestic Shorthair Cat

A 12-year-old spayed female domestic short cat was presented with tetraplegia. The cat also showed signs of hyponatremia and dehydration, which were rapidly corrected by intravenous fluid infusion. Based on thorough physical and neurological examinations, the patient was suspected of having an intracranial disease. MRI revealed a high-signal T2 image of the bilateral parietal cerebral cortical gray matter junction, which is associated with fast electrolyte calibration, and a high-signal T2 image of the C2 spinal cord ventral area, which is associated with ischemic myelopathy. The cat reappeared three days later due to anorexia. Laboratory examinations revealed that the cat was clinically dehydrated and exhibited hyponatremia. Other causes of hyponatremia were excluded through history-taking, laboratory examination, imaging, and therapeutic response to fluid therapy, except for cerebral salt-wasting syndrome (CSWS). The cat was discharged 3 days after the start of fludrocortisone therapy with electrolytes within the normal range. Magnetic resonance imaging (MRI) was performed again 1 month after hospitalization, and the cerebral lesion disappeared, but the spinal cord lesion worsened compared to the previous image. The patient was euthanized due to the progression of the spinal lesion, with a poor prognosis and poor quality of life. This is the first case of suspected CSWS with a cervical spinal lesion in a cat.

Fludrocortisone evaluation in aneurysmal subarachnoid hemorrhage patients with cerebral salt wasting (Flush Salt)

OBJECTIVE

Cerebral salt wasting is a condition that can occur in patients with aneurysmal subarachnoid hemorrhage and is characterized by excessive natriuresis, resulting in hyponatremia and hypovolemia. Fludrocortisone is a mineralocorticoid that facilitates retention of sodium and water. Guideline recommendations are weak regarding fludrocortisone use in this patient population due to mixed clinical effectiveness in prior studies. The purpose of this study was to evaluate the clinical effectiveness of fludrocortisone for cerebral salt wasting in patients with aneurysmal subarachnoid hemorrhage.

METHODS

This single-site, retrospective study evaluated data from March 29th, 2014 through August 31st, 2021. Patients were included if they were admitted for aneurysmal subarachnoid hemorrhage and received fludrocortisone. Patients were excluded if they were less than 18 years old, pregnant, or received fludrocortisone for less than 48 h. Patients served as their own control and endpoints compared baseline data (24 h prior to fludrocortisone) to a run-in period (0-24-hour post fludrocortisone) and a steady-state period (24-48-hour post fludrocortisone). The primary endpoint was fluid balance, determined by urine output and net daily intake. Secondary endpoints included 3 % hypertonic saline (or equivalent) intake and median serum sodium.

RESULTS

There were 110 patients included in this study. Daily doses of fludrocortisone over the 48-hour period varied from 100 mcg to 500 mcg, with 48 % of patients receiving between 200 mcg and 300 mcg daily. Median 24-hour urine output was reduced over the course of the study period (8232 mL at baseline, 8464 mL during 24-hour run-in, and 7080 mL during steady-state timeframe); p = 0.014. There was a 18 % reduction in net volume intake (p = 0.001), including a 38 % reduction in 3 % hypertonic saline (or equivalent) required during the study period; p = 0.025).

CONCLUSION

Fludrocortisone was associated with decreased urine output and subsequently, decreased volume intake, to maintain euvolemia in patients with aneurysmal subarachnoid hemorrhage and cerebral salt wasting.

Korean Society of Nephrology 2022 recommendations on controversial issues in diagnosis and management of hyponatremia

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.

Systemic inflammatory markers of persistent cerebral edema after aneurysmal subarachnoid hemorrhage

Background

Cerebral edema (CE) at admission is a surrogate marker of ‘early brain injury’ (EBI) after subarachnoid hemorrhage (SAH). Only recently has the focus on the changes in CE after SAH such as delayed resolution or newly developed CE been examined. Among several factors, an early systemic inflammatory response has been shown to be associated with CE. We investigate inflammatory markers in subjects with early CE which does not resolve, i.e., persistent CE after SAH.

Methods

Computed tomography scans of SAH patients were graded at admission and at 7 days after SAH for CE using the 0–4 ‘subarachnoid hemorrhage early brain edema score’ (SEBES). SEBES ≤ 2 and SEBES ≥ 3 were considered good and poor grade, respectively. Serum samples from the same subject cohort were collected at 4 time periods (at < 24 h [T1], at 24 to 48 h [T2]. 3–5 days [T3] and 6–8 days [T4] post-admission) and concentration levels of 17 cytokines (implicated in peripheral inflammatory processes) were measured by multiplex immunoassay. Multivariable logistic regression analyses were step-wisely performed to identify cytokines independently associated with persistent CE adjusting for covariables including age, sex and past medical history (model 1), and additional inclusion of clinical and radiographic severity of SAH and treatment modality (model 2).

Results

Of the 135 patients enrolled in the study, 21 of 135 subjects (15.6%) showed a persistently poor SEBES grade. In multivariate model 1, higher Eotaxin (at T1 and T4), sCD40L (at T4), IL-6 (at T1 and T3) and TNF-α (at T4) were independently associated with persistent CE. In multivariate model 2, Eotaxin (at T4: odds ratio [OR] = 1.019, 95% confidence interval [CI] = 1.002–1.035) and possibly PDGF-AA (at T4), sCD40L (at T4), and TNF-α (at T4) was associated with persistent CE.

Conclusions

We identified serum cytokines at different time points that were independently associated with persistent CE. Specifically, persistent elevations of Eotaxin is associated with persistent CE after SAH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-022-02564-1.

Korean Society of Nephrology 2022 Recommendations on controversial issues in diagnosis and management of hyponatremia

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.

Fludrocortisone Induces Aortic Pathologies in Mice

BACKGROUND AND OBJECTIVE

In an experiment designed to explore the mechanisms of fludrocortisone-induced high blood pressure, we serendipitously observed aortic aneurysms in mice infused with fludrocortisone. The purpose of this study was to investigate whether fludrocortisone induces aortic pathologies in both normocholesterolemic and hypercholesterolemic mice.

METHODS AND RESULTS

Male adult C57BL/6J mice were infused with either vehicle (85% polyethylene glycol 400 (PEG-400) and 15% dimethyl sulfoxide (DMSO); n = 5) or fludrocortisone (12 mg/kg/day dissolved in 85% PEG-400 and 15% DMSO; n = 15) for 28 days. Fludrocortisone-infused mice had higher systolic blood pressure, compared to mice infused with vehicle. Fludrocortisone induced aortic pathologies in 4 of 15 mice with 3 having pathologies in the ascending and aortic arch regions and 1 having pathology in both the ascending and descending thoracic aorta. No pathologies were noted in abdominal aortas. Subsequently, we infused either vehicle (n = 5/group) or fludrocortisone (n = 15/group) into male ApoE -/- mice fed a normal laboratory diet or LDL receptor -/- mice fed either normal or Western diet. Fludrocortisone increased systolic blood pressure, irrespective of mouse strain or diet. In ApoE -/- mice infused with fludrocortisone, 2 of 15 mice had ascending aortic pathologies, but no mice had abdominal aortic pathologies. In LDL receptor -/- mice fed normal diet, 5 had ascending/arch pathologies and 1 had pathologies in the ascending, arch, and suprarenal aortic regions. In LDL receptor -/- mice fed Western diet, 2 died of aortic rupture in either the descending thoracic or abdominal region, and 2 of the 13 survived mice had ascending/arch aortic pathologies. Aortic pathologies included hemorrhage, wall thickening or thinning, or dilation. Only ascending aortic diameter in LDLR -/- mice fed Western diet reached statistical significance, compared to their vehicle.

CONCLUSION

Fludrocortisone induces aortic pathologies independent of hypercholesterolemia. As indicated by the findings in mouse studies, people who are taking or have taken fludrocortisone might have an increased risk of aortic pathologies.

Cerebral Salt Wasting Syndrome (CSW): An unusual cause of hypovolemia after spontaneous cerebral hemorrhage successfully treated with fludrocortisone

Our objective is to demonstrate the interest of thinking about Cerebral salt wasting syndrome (CSW) in front of hyponatremia with severe hypovolemia after a brain injury, and at the same time the interest to differentiate between Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) and Cerebral salt wasting syndrome (CSW) as two etiologies to be evoked in front of a hyponatremia with brain injury.

Case report: We report the case of a 63-year-old patient with a recent history of hemorrhagic stroke admitted for severe hypovolemic shock in whom the investigations find a very deep hypotonic hyponatremia secondary to a cerebral salt wasting syndrome successfully treated with fludrocortisone.

Discussion: CWS is characterized by hypotonic hyponatremia associated with cerebral associated with hypovolemia, the difficulty of the diagnosis is explained by the points of convergences with SIADH which is also presented with hyponatremia. The treatment is based on filling with saline, if the symptoms are severe, hypertonic saline has its place. Fludrocortisone has proven its effectiveness in the correction of refractory hyponatremia in CWS.

Conclusion: It is essential to differentiate between hyponatremia in CWS and hyponatremia in SIADH because the medical care is categorically different.

Vasopressin-Induced Hyponatremia in Patients With Aneurysmal Subarachnoid Hemorrhage: A Case Series and Literature Review

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.

An overview of pharmacotherapy for cerebral vasospasm and delayed cerebral ischemia after subarachnoid hemorrhage

Introduction: Survival from aneurysmal subarachnoid hemorrhage has increased in the past few decades. However, functional outcome after subarachnoid hemorrhage is still suboptimal. Delayed cerebral ischemia (DCI) is one of the major causes of morbidity.Areas covered: Mechanisms underlying vasospasm and DCI after aneurysmal subarachnoid hemorrhage and pharmacological treatment are summarized in this review.Expert opinion: Oral nimodine, an L-type dihydropyridine calcium channel blocker, is the only FDA-approved drug for the prevention and treatment of neurological deficits after aneurysmal subarachnoid hemorrhage. Fasudil, a potent Rho-kinase inhibitor, has also been shown to improve the clinical outcome and has been approved in some countries for use in patients with aneurysmal subarachnoid hemorrhage. Although other drugs, including nicardipine, cilostazol, statins, clazosentan, magnesium and heparin, have been expected to have beneficial effects on DCI, there has been no convincing evidence supporting the routine use of those drugs in patients with aneurysmal subarachnoid hemorrhage in clinical practice. Further elucidation of the mechanisms underlying DCI and the development of effective therapeutic strategies for DCI, including combination therapy, are necessary to further improve the functional outcome and mortality after subarachnoid hemorrhage.

Mechanism, spectrum, consequences and management of hyponatremia in tuberculous meningitis

Hyponatremia is the commonest electrolyte abnormality in hospitalized patients and is associated with poor outcome. Hyponatremia is categorized on the basis of serum sodium into severe (< 120 mEq/L), moderate (120-129 mEq/L) and mild (130-134mEq/L) groups. Serum sodium has an important role in maintaining serum osmolality, which is maintained by the action of antidiuretic hormone (ADH) secreted from the posterior pituitary, and natriuretic peptides such as atrial natriuretic peptide and brain natriuretic peptide. These peptides act on kidney tubules via the renin angiotensin aldosterone system. Hyponatremia <120mEq/L or a rapid decline in serum sodium can result in neurological manifestations, ranging from confusion to coma and seizure. Cerebral salt wasting (CSW) and syndrome of inappropriate secretion of ADH (SIADH) are important causes of hyponatremia in tuberculosis meningitis (TBM). CSW is more common than SIADH. The differentiation between CSW and SIADH is important because treatment of one may be detrimental for the other; evidence of hypovolemia in CSW and euvolemia or hypervolemia in SIADH is used for differentiation. In addition, evidence of dehydration, polyuria, negative fluid balance as assessed by intake output chart, weight loss, laboratory evidence and sometimes central venous pressure are helpful in the diagnosis of these disorders. Volume contraction in CSW may be more protracted than hyponatremia and may contribute to border zone infarctions in TBM. Hyponatremia should be promptly and carefully treated by saline and oral salt, while 3% saline should be used in severe hyponatremia with coma and seizure. In refractory patients with hyponatremia, fludrocortisone helps in early normalization of serum sodium without affecting polyuria or functional outcome. In SIADH, V2 receptor antagonist conivaptan or tolvaptan may be used if the patient is not responding to fluid restriction. Fluid restriction in SIADH has not been found to be beneficial in TBM and should be avoided.

Mechanism, spectrum, consequences and management of hyponatremia in tuberculous meningitis

Hyponatremia is the commonest electrolyte abnormality in hospitalized patients and is associated with poor outcome. Hyponatremia is categorized on the basis of serum sodium into severe (< 120 mEq/L), moderate (120-129 mEq/L) and mild (130-134mEq/L) groups. Serum sodium has an important role in maintaining serum osmolality, which is maintained by the action of antidiuretic hormone (ADH) secreted from the posterior pituitary, and natriuretic peptides such as atrial natriuretic peptide and brain natriuretic peptide. These peptides act on kidney tubules via the renin angiotensin aldosterone system. Hyponatremia <120mEq/L or a rapid decline in serum sodium can result in neurological manifestations, ranging from confusion to coma and seizure. Cerebral salt wasting (CSW) and syndrome of inappropriate secretion of ADH (SIADH) are important causes of hyponatremia in tuberculosis meningitis (TBM). CSW is more common than SIADH. The differentiation between CSW and SIADH is important because treatment of one may be detrimental for the other; evidence of hypovolemia in CSW and euvolemia or hypervolemia in SIADH is used for differentiation. In addition, evidence of dehydration, polyuria, negative fluid balance as assessed by intake output chart, weight loss, laboratory evidence and sometimes central venous pressure are helpful in the diagnosis of these disorders. Volume contraction in CSW may be more protracted than hyponatremia and may contribute to border zone infarctions in TBM. Hyponatremia should be promptly and carefully treated by saline and oral salt, while 3% saline should be used in severe hyponatremia with coma and seizure. In refractory patients with hyponatremia, fludrocortisone helps in early normalization of serum sodium without affecting polyuria or functional outcome. In SIADH, V2 receptor antagonist conivaptan or tolvaptan may be used if the patient is not responding to fluid restriction. Fluid restriction in SIADH has not been found to be beneficial in TBM and should be avoided.

Intracranial Vascular Procedures

Anesthesia for intracranial vascular procedures is complex because it requires a balance of several competing interests and potentially can result in significant morbidity and mortality. Frequently, periods of ischemia, where perfusion must be maintained, are combined with situations that are high risk for hemorrhage. This review discusses the basic surgical approach to several common pathologies (intracranial aneurysms, arteriovenous malformations, and moyamoya disease) along with the goals for anesthetic management and specific high-yield recommendations.

Is cerebral salt wasting related to sympathetic dysregulation in tuberculous meningitis?

BACKGROUND

Cerebral Salt wasting (CSW) is common in Tuberculous Meningitis (TBM) and is suggested to be due to sympathetic dysregulation of renal blood supply but has not been proven.

OBJECTIVE

To evaluate plasma Catecholamines in TBM patients with CSW and correlate with the markers of stress.

MATERIALS AND METHODS

The diagnosis of TBM was based on clinical, CSF and MRI criteria. Catecholamines level was measured by LC-MS on admission, at the time of hyponatremia and on correction of hyponatremia. Catecholamine levels were correlated with clinical and laboratory markers of stress, hyponatremia and severity of CSW using pre-defined criteria.

RESULTS

There were 24 patients with TBM (12 with CSW) and 12 controls. The median age of patients was 31 (18-75) years and 12 (50 %) were females. TBM patients with CSW had significantly higher levels of catecholamines compared to controls (p < 0.001). TBM patients with CSW had higher levels of norepinephrine than those without CSW (p = 0.034). Sequential studies revealed that dopamine and epinephrine increased at the time of hyponatremia and declined on its correction. Severity of TBM was related to dopamine (p = 0.04) and severity of CSW was related to epinephrine (p = 0.016).

CONCLUSION

CSW in TBM seems to be related to catecholamine dysregulation.

Mineralocorticoid Dysfunction during Critical Illness: A Review of the Evidence

The recent demonstration of the significant reduction in mortality in patients with septic shock treated with adjunctive glucocorticoids combined with fludrocortisone and the effectiveness of angiotensin II in treating vasodilatory shock have renewed interest in the role of the mineralocorticoid axis in critical illness. Glucocorticoids have variable interactions at the mineralocorticoid receptor. Similarly, mineralocorticoid receptor-aldosterone interactions differ from mineralocorticoid receptor-glucocorticoid interactions and predicate receptor-ligand interactions that differ with respect to cellular effects. Hyperreninemic hypoaldosteronism or selective hypoaldosteronism, an impaired adrenal response to increasing renin levels, occurs in a subgroup of hemodynamically unstable critically ill patients. The suggestion is that there is a defect at the level of the adrenal zona glomerulosa associated with a high mortality rate that may represent an adaptive response aimed at increasing cortisol levels. Furthermore, cross-talk exists between angiotensin II and aldosterone, which needs to be considered when employing therapeutic strategies.

Pharmacotherapy of sodium disorders in neurocritical care

PURPOSE OF REVIEW

To describe the pathophysiology and pharmacotherapy of dysnatremia in neurocritical care patients.

RECENT FINDINGS

Sodium disorders may affect approximately half of the neurocritical care patients and are associated with worse neurological outcome and increased risk of death. Pharmacotherapy of sodium disorders in neurocritical care patients may be challenging and is guided by a careful investigation of water and sodium balance.

SUMMARY

In case of hyponatremia, because of excessive loss of sodium, fluid challenge with isotonic solution, associated with salt intake is the first-line therapy, completed with mineralocorticoids if needed. In case of hyponatremia because of SIADH, fluid restriction is the first-line therapy followed by urea if necessary. Hypernatremia should always be treated with hypotonic solutions according to the free water deficit, associated in case of DI with desmopressin. The correction speed should take into consideration the symptoms associated with dysnatremia and the rapidity of the onset.

Inappropriate Antidiuretic Hormone Secretion and Cerebral Salt-Wasting Syndromes in Neurological Patients

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.

Safety and Efficacy of Fludrocortisone in the Treatment of Cerebral Salt Wasting in Patients With Tuberculous Meningitis: A Randomized Clinical Trial

Importance

Tuberculous meningitis is associated with high frequency of cerebral salt wasting. There is a paucity of objective information regarding the best method of treatment of this condition.

Objective

To evaluate the efficacy and safety of fludrocortisone in the treatment of cerebral salt wasting in patients with tuberculous meningitis.

Design, Setting, and Participants

This is a single-center, open-label, randomized clinical trial conducted from October 2015 to April 2017 in India. Patients were randomized in a 1:1 ratio to arms receiving saline only or saline plus fludrocortisone, in addition to a standard treatment of 4 antitubercular drugs, prednisolone, and aspirin. The 2 arms were matched for demographic, clinical, and magnetic resonance imaging findings. The patients were followed up for at least 6 months.

Interventions

Patients were randomized to a 0.9% solution of intravenous saline with 5 to 12 g per day of oral salt supplementation, with or without the addition of 0.1 to 0.4 mg of fludrocortisone per day.

Main Outcomes and Measures

The primary end point was the time needed to correct serum sodium levels; secondary end points were in-hospital deaths, disability at 3 months, disability at 6 months, occurence of stroke, and serious adverse reactions.

Results

Ninety-three patients with suspected tuberculous meningitis were recruited; 12 did not meet the inclusion criteria, including 4 with alternate diagnoses. A total of 37 patients with cerebral salt wasting were eligible for the study. One refused to participate, and therefore 36 patients were included, with 18 randomized to each group. The median (range) age was 30 (20-46) years, and 19 were male (52.8%). Those receiving fludrocortisone regained normal serum sodium levels after 4 days, significantly earlier than those receiving saline only (15 days; P = .004). In an intention-to-treat analysis, hospital mortality, disability at 3 months, and disability at 6 months did not differ significantly, but fewer infarcts occurred in the deep border zone in the group receiving fludrocortisone (1 of 18 [6%]) vs those in the control arm (6 of 18 [33%]; P = .04). Fludrocortisone was associated with severe hypokalemia and hypertension in 2 patients each, and pulmonary edema occurred in 1 patient. These adverse reactions necessitated discontinuation of fludrocortisone in 2 patients.

Conclusions and Relevance

Fludrocortisone results in earlier normalization of serum sodium levels, but did not affect outcomes at 6 months. Fludrocortisone had to be withdrawn in 2 patients because of severe adverse effects. This study provides class II evidence on the role of fludrocortisone in treatment of hyponatremia associated with cerebral salt wasting in patients with tuberculous meningitis.

Trial Registration

Clinical Trials Registry of India (ctri.nic.in) Identifier: CTRI/2017/10/010255.

Predictive Value of Cerebral Autoregulation Impairment for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis

OBJECTIVE

Delayed cerebral ischemia (DCI) happens in about 30% of patients with aneurysmal subarachnoid hemorrhage (SAH) and is related to higher mortality and disability. Some studies have shown cerebral autoregulation impairment can be a predictor of DCI in aneurysmal SAH. We conducted this meta-analysis to evaluate the predictive value of cerebral autoregulation impairment for DCI based on the current literature.

METHODS

A systematic literature search was performed in PubMed and Embase. According to inclusion and exclusion criteria, 2 authors screened the records and extracted data from the included studies. Pooled sensitivity, specificity, and their 95% confidence intervals (CIs) were obtained. To investigate the overall accuracy, a summary receiver operating characteristic (SROC) curve was built and the area under SROC curve was calculated. Deeks' linear regression was used to assess the publication bias. All statistical analyses were performed with Stata 14.0.

RESULTS

A total of 7 studies were finally included in this meta-analysis. The pooled sensitivity and specificity values of impaired cerebral autoregulation for DCI prediction were 0.79 (95% CI, 0.65-0.88) and 0.85 (95% CI, 0.615-0.96). Moreover, the area under the SROC curve of cerebral autoregulation impairment for DCI prediction was 0.87 (95% CI, 0.835-0.89). No obvious publication bias was found in Deeks' linear regression (P = 0.99).

CONCLUSIONS

Cerebral autoregulation impairment can be a helpful predictor of DCI in aneurysmal SAH. Its accuracy for DCI prediction should be verified by more studies in the future.

Hypovolemia due to cerebral salt wasting may contribute to stroke in tuberculous meningitis

BACKGROUND

Both stroke and cerebral salt wasting (CSW) are common in tuberculous meningitis (TBM), but there is paucity of studies evaluating their combined effect.

AIM

The present study has been undertaken to evaluate the spectrum of stroke in TBM and its relation to CSW.

DESIGN

Hospital-based prospective cohort study.

METHODS

Eighty-one patients with TBM diagnosed on the basis of clinical, cerebrospinal fluid and magnetic resonance imaging (MRI) criteria were prospectively included. Stroke was diagnosed on the basis of clinical, MRI findings or both. Stroke risk factors were noted. Patients with hyponatremia were categorized into CSW and other causes. Three and 6 months outcome was defined using modified Rankin Scale (mRS) as good (<2) or poor (≥2).

RESULTS

Out of 81 patients with TBM, 32 (39.5%) had ischemic stroke. CSW was the commonest cause of hyponatremia and occurred in 34 (42%) patients. Stroke occurred in tubercular zone in 10, ischemic zone in 15 and both in 7 patients. The patients with ischemic zone infarction were older and had stroke risk factors such as diabetes mellitus, hypertension and hyperlipidemia. Out of 16 (47%) patients with CSW, 10 (62.5%) had stroke during the polyuric phase. The patients with CSW had more frequent deep white matter infarcts (P = 0.01) which were in internal border zone in 4 (40%).

CONCLUSION

In TBM, stroke occurred in 39.5% of the patients, 50% of whom had CSW. Volume contraction due to CSW may contribute to stroke.

Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

Prevention and Treatment of Hyponatremia in Patients with Subarachnoid Hemorrhage: A Systematic Review

BACKGROUND

Current guidelines for the management of hyponatremia in patients with subarachnoid hemorrhage (SAH) are not based on a systematic assessment of the literature. We evaluated published studies on the efficacy and safety of current preventative and treatment strategies for hyponatremia in patients with SAH.

METHODS

We searched the Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PubMed for relevant studies. Primary outcomes of interest included neurologic functional outcomes, symptomatic vasospasm, and others. Secondary outcomes included measures of sodium and volume status.

RESULTS

We included 5 out of 117 identified studies: 1 before-and-after observational trial (using fludrocortisone) and 4 randomized controlled trials (2 using fludrocortisone; 2 using hydrocortisone). All 5 trials had a high risk of bias in at least 1 domain. We could not perform a meta-analysis of functional outcomes; however, individual studies did not demonstrate statistically significant differences. Mineralocorticoid use did not statistically significantly reduce the incidence of symptomatic vasospasm (relative risk, 0.60; 95% confidence interval, 0.35-1.03; I² = 0%). The studies did not report other primary outcomes. In the 4 RCTs, mineralocorticoid use reduced natriuresis and volume contraction.

CONCLUSIONS

Current evidence does not demonstrate a benefit of preventative treatment with mineralocorticoids in clinically important outcomes, although a difference cannot be ruled out due to imprecision. Larger well-designed trials are needed to establish the impact of mineralocorticoids and fluid and sodium supplementation strategies on clinically relevant outcomes in the prevention and treatment of hyponatremia in patients with SAH.

Management of delayed cerebral ischemia after subarachnoid hemorrhage

For patients who survive the initial bleeding event of a ruptured brain aneurysm, delayed cerebral ischemia (DCI) is one of the most important causes of mortality and poor neurological outcome. New insights in the last decade have led to an important paradigm shift in the understanding of DCI pathogenesis. Large-vessel cerebral vasospasm has been challenged as the sole causal mechanism; new hypotheses now focus on the early brain injury, microcirculatory dysfunction, impaired autoregulation, and spreading depolarization. Prevention of DCI primarily relies on nimodipine administration and optimization of blood volume and cardiac performance. Neurological monitoring is essential for early DCI detection and intervention. Serial clinical examination combined with intermittent transcranial Doppler ultrasonography and CT angiography (with or without perfusion) is the most commonly used monitoring paradigm, and usually suffices in good grade patients. By contrast, poor grade patients (WFNS grades 4 and 5) require more advanced monitoring because stupor and coma reduce sensitivity to the effects of ischemia. Greater reliance on CT perfusion imaging, continuous electroencephalography, and invasive brain multimodality monitoring are potential strategies to improve situational awareness as it relates to detecting DCI. Pharmacologically-induced hypertension combined with volume is the established first-line therapy for DCI; a good clinical response with reversal of the presenting deficit occurs in 70 % of patients. Medically refractory DCI, defined as failure to respond adequately to these measures, should trigger step-wise escalation of rescue therapy. Level 1 rescue therapy consists of cardiac output optimization, hemoglobin optimization, and endovascular intervention, including angioplasty and intra-arterial vasodilator infusion. In highly refractory cases, level 2 rescue therapies are also considered, none of which have been validated. This review provides an overview of current state-of-the-art care for DCI management.

A review in the treatment of oncologic emergencies

AIM

Oncologic emergencies are often categorized as a group of metabolic abnormalities associated with the diagnosis of cancer or the initiation of chemotherapy for treatment. These syndromes often arise in the acute setting, demanding an accurate knowledge of the associated condition and current treatment. In this review, we evaluate five oncologic emergencies: tumor lysis syndrome, hypercalcemia, hyponatremia, spinal cord compression, and disseminated intravascular coagulation.

SUMMARY

Oncologic emergencies are often diverse in etiology and are often associated with the initiation of chemotherapy. Tumor lysis syndrome presents as severe electrolyte abnormalities that need to be addressed urgently, sometimes prior to initiation of chemotherapy. Hypercalcemia of malignancy is treated with aggressive rehydration, furosemide, and intravenous bisphosphonates. If a patient with cancer presents with normovolemic hyponatremia, syndrome of inappropriate antidiuretic hormone should be suspected. Malignant spinal cord compression happens when cancer cells grow in, or near to, the spine and press on the spinal cord and nerves. This causes swelling and a reduction in the blood supply to the spinal cord and nerve roots. Disseminated intravascular coagulation is characterized by systemic activation of blood coagulation, which results in generation and deposition of fibrin, leading to microvascular thrombi in various organs and contributing to multiple organ dysfunction syndrome.

CONCLUSION

Knowledge of oncology emergencies is critical to the understanding of these emergent syndromes in oncology patients. Each of these disease states requires careful evaluation of the patient's symptoms, monitoring parameters for conditions and supportive care measures and interventions.

Small Cell Lung Cancer Patient with Profound Hyponatremia and Acute Neurological Symptoms: An Effective Treatment with Fludrocortisone

Hyponatremia is a frequent electrolyte abnormality in patients with small cell lung cancer (SCLC). Being usually asymptomatic, hyponatremia may cause symptoms like nausea, fatigue, disorientation, headache, muscle cramps, or even seizures, particularly if severe and rapid decrease of serum sodium levels occurs. Here we report a case of SCLC patient with severe hyponatremia and acute neurological symptoms that developed 2 days after the first course of second-line chemotherapy, most probably due to the release of antidiuretic hormone (ADH, also known as arginine vasopressin) during lysis of the tumour cells. Initial treatment consisted of continuous administration of hypertonic saline that resulted in improvement of patient's neurological status. However, to obtain a persistent increase in serum sodium level, pharmacological intervention with oral fludrocortisone 0.1 mg twice daily was needed. We can therefore conclude that mineralocorticoids may be used to correct hyponatremia in SCLC patients when appropriate.

Diagnosis and Management of Hyponatremia in Patients with Aneurysmal Subarachnoid Hemorrhage

Hyponatremia is the most common, clinically-significant electrolyte abnormality seen in patients with aneurysmal subarachnoid hemorrhage. Controversy continues to exist regarding both the cause and treatment of hyponatremia in this patient population. Lack of timely diagnosis and/or providing inadequate or inappropriate treatment can increase the risk of morbidity and mortality. We review recent literature on hyponatremia in subarachnoid hemorrhage and present currently recommended protocols for diagnosis and management.

Virology, immunology and pathology of human rabies during treatment

BACKGROUND

Rabies is an acute fatal encephalitis caused by all members of the Lyssavirus genus. The first human rabies survivor without benefit of prior vaccination was reported from Milwaukee in 2005. We report a second unvaccinated patient who showed early recovery from rabies and then died accidentally during convalescence, providing an unparalleled opportunity to examine the histopathology as well as immune and virological correlates of early recovery from human rabies.

METHODS

Case report, rapid fluorescent focus inhibition test, enzyme-linked immunosorbent assay, indirect and direct fluorescent antibody assays, reverse-transcriptase polymerase chain reaction, phylogenetic reconstruction, isolation in tissue culture, pathology and immunohistochemistry.

RESULTS

The 9 year old died 76 days after presenting with rabies of vampire bat phylogeny transmitted by cat bite. Antibody response in serum and cerebrospinal fluid was robust and associated with severe cerebral edema. No rabies virus was cultured at autopsy. Rabies virus antigen was atypical in size and distribution. Rabies virus genome was present in neocortex but absent in brainstem.

CONCLUSIONS

Clinical recovery was associated with detection of neutralizing antibody and clearance of infectious rabies virus in the central nervous system by 76 days but not clearance of detectable viral subcomponents such as nucleoprotein antigen or RNA in brain.

Increase in urinary sodium excretion in spinal cord injury patients in the emergency department

OBJECTIVE

Spinal cord injury (SCI) is a pathological condition known to produce hyponatremia. The aim of this study was to elucidate the dynamics of urinary sodium excretion in patients with spinal cord injury.

METHODS

SCI patients undergoing intensive care management were enrolled in this study. These patients were divided into two groups: those with Frankel Grade A spinal cord injury manifesting complete, severe motor disorders (FA group) and those with incomplete spinal cord injury (non-FA group). The occurrence of episode of hyponatremia (serum sodium <135 mmol/L), hypotension, and bradycardia during the first 14 hospital days was counted and fractional excretion of sodium (FENa) was calculated on the 1st, 7th, and 14th hospital days.

RESULTS

Thirty-four patients (FA group, n = 9; non-FA group, n = 25) were included. Eight patients (88.9 %) in the FA group and three patients (12 %) in the non-FA group experienced at least one episode of hyponatremia during the first 14 hospital days. In the FA group, the FENa was significantly increased on the 7th and 14th hospital days compared to the 1st hospital day. FENa on the 14th hospital day was a significant independent predictor of hyponatremic episodes. Hypotension and bradycardia as the symptoms of sympathetic blockade differed significantly as independent predictors of increased FENa on the 14th hospital day.

CONCLUSION

Urinary sodium excretion calculated by FENa increased in patients with severe spinal cord injury. Sympathetic blockade due to SCI may increase urine sodium excretion and lead to hyponatremia.

How we do it: acute management of subarachnoid hemorrhage

OBJECTIVES

Acute subarachnoid hemorrhage (SAH) is a neurological emergency with significant potential for long-term morbidity and mortality. We review our management of acute SAH and some of the evidence base supporting our practices.

METHODS

We reviewed our standardized and multi-disciplinary approach to the management of SAH.

RESULTS

Management of SAH treatment can be divided into acute, aneurysmal, waiting, and post-waiting phases. Acute issues upon presentation include hemodynamic and respiratory stability, prevention of rebleeding, and treatment of hydrocephalus. The aneurysm must then be secured through endovascular or microsurgical methods. Observation for signs and symptoms of vasospasm must be closely undertaken. Prevention of subsequent medical complications must also be undertaken. Weaning from cerebrospinal fluid diversion and possible shunting is the final step.

DISCUSSION

Standardized multi-modality management of rebleeding, hydrocephalus, aneurysmal obliteration, vasospasm, cerebral salt wasting, and other medical complications during these phases, is critical.

Hormonal dysfunction in neurocritical patients

PURPOSE OF REVIEW

Acute brain injury results in widespread systemic endocrine dysfunction and affects how we care for patients. We review the existing literature on incidence, type and duration of endocrine dysfunction with special focus on the pituitary dependent function.

RECENT FINDINGS

Acute studies document widespread alterations of the hypothalamic-pituitary-adrenal axis, disruption of the anterior hypothalamus related hormones, and alteration of regulation of sodium and fluid balance. Diagnostic testing and therapeutic intervention are outlined in this review. Relative adrenal insufficiency and cerebral salt wasting are the two main forms of endocrine dysfunction in neurocritical care patients.

SUMMARY

Surveillance for endocrine dysfunction and early treatment with hormonal replacement may be life-saving in neurologic critically ill patients.

Randomized, double-blind trial of the effect of fluid composition on electrolyte, acid-base, and fluid homeostasis in patients early after subarachnoid hemorrhage

BACKGROUND

Hyper- and hyponatremia are frequently observed in patients after subarachnoidal hemorrhage, and are potentially related to worse outcome. We hypothesized that the fluid regimen in these patients is associated with distinct changes in serum electrolytes, acid-base disturbances, and fluid balance.

METHODS

Thirty-six consecutive patients with SAH were randomized double-blinded to either normal saline and hydroxyethyl starch dissolved in normal saline (Voluven(®); saline) or balanced crystalloid and colloid solutions (Ringerfundin(®) and Tetraspan(®); balanced, n = 18, each) for 48 h. Laboratory samples and fluid balance were evaluated at baseline and at 24 and 48 h.

RESULTS

Age [57 ± 13 years (mean ± SD; saline) vs. 56 ± 12 years (balanced)], SAPS II (38 ± 16 vs. 34 ± 17), Hunt and Hess [3 (1-4) (median, range) vs. 2 (1-4)], and Fischer scores [3.5 (1-4) vs. 3.5 (1-4)] were similar. Serum sodium, chloride, and osmolality increased in saline only (p ≤ 0.010, time-group interaction). More patients in saline had Cl >108 mmol/L [16 (89 %) vs. 8 (44 %); p = 0.006], serum osmolality >300 mosmol/L [10 (56 %) vs. 2 (11 %); p = 0.012], a base excess <-2 [12 (67 %) vs. 2 (11 %); p = 0.001], and fluid balance >1,500 mL during the first 24 h [11 (61 %) vs. 5 (28 %); p = 0.046]. Hyponatremia and hypo-osmolality were not more frequent in the balanced group.

CONCLUSIONS

Treatment with saline-based fluids resulted in a greater number of patients with hyperchloremia, hyperosmolality, and positive fluid balance >1,500 mL early after SAH, while administration of balanced solutions did not cause more frequent hyponatremia or hypo-osmolality. These results should be confirmed in larger studies.

Managing subarachnoid hemorrhage in the neurocritical care unit

Patients with aneurysmal subarachnoid hemorrhage who survive the initial hemorrhage require complex interventions to occlude the aneurysm, typically followed by a prolonged intensive care unit and hospital course to manage the complications that follow. Much of the morbidity and mortality from this disease happens in delayed fashion in the neurocritical care unit. Despite progress made in the last decades, much remains to be understood about this disease and how to best manage these patients. This article provides a review of current evidence and the authors' experience, aimed at providing practical aid to those caring for patients with this disease.

Clinical trials in cardiac arrest and subarachnoid hemorrhage: lessons from the past and ideas for the future

Introduction. Elevated intracranial pressure that occurs at the time of cerebral aneurysm rupture can lead to inadequate cerebral blood flow, which may mimic the brain injury cascade that occurs after cardiac arrest. Insights from clinical trials in cardiac arrest may provide direction for future early brain injury research after subarachnoid hemorrhage (SAH). Methods. A search of PubMed from 1980 to 2012 and clinicaltrials.gov was conducted to identify published and ongoing randomized clinical trials in aneurysmal SAH and cardiac arrest patients. Only English, adult, human studies with primary or secondary mortality or neurological outcomes were included. Results. A total of 142 trials (82 SAH, 60 cardiac arrest) met the review criteria (103 published, 39 ongoing). The majority of both published and ongoing SAH trials focus on delayed secondary insults after SAH (70%), while 100% of cardiac arrest trials tested interventions within the first few hours of ictus. No SAH trials addressing treatment of early brain injury were identified. Twenty-nine percent of SAH and 13% of cardiac arrest trials showed outcome benefit, though there is no overlap mechanistically. Conclusions. Clinical trials in SAH assessing acute brain injury are warranted and successful interventions identified by the cardiac arrest literature may be reasonable targets of the study.