Hyponatraemia occurs in up to 10% of patients following a traumatic brain injury and is associated with a worse prognosis even in mild cases. Pathophysiology, diagnosis, and treatment cerebral salt wasting csw is a syndrome of hypovolemic. Cerebral salt wasting syndrome in tuberculous meningitis. The syndrome of inappropriate secretion of antidiuretic hormone siadh is a disorder of impaired water excretion caused by the inability to suppress the secretion of antidiuretic hormone adh 1. After the description of siadh in 1957, such patients were. The mechanisms underlying csw have not been precisely delineated, although existing. It is a true hyponatremia, first described by peters et al as a cerebral disease causing natriuresis and diuresis 19. Cerebral saltwasting syndrome caused by minor head injury. Fludrocortisone can help in managing csw where alone saline infusion does not work. Previous studies have shown an increased risk of symptomatic cerebral vasospasm or delayed cerebral ischemia dci in patients with hyponatremia and or the cerebral salt wasting syndrome csw. A 52yearold man with a history of diabetes and hiv was admitted for headache and found to have cryptococcal meningitis.
Exceptionally, cerebral saltwasting syndrome csws has also been claimed as the cause of hyponatraemia after pituitary surgery, but few cases have been reported in the last 20 years 35. Cerebral salt wasting csw, or renal salt wasting rsw, has evolved from a misrepresentation of the syndrome of inappropriate secretion of antidiuretic hormone siadh to acceptance as a distinct entity. Aacn advanced critical care volume 23, number 3, pp. Cerebral salt wasting csw is an electrolyte imbalance characterized by hyponatremia and hypovolemia. Nov 28, 2015 cerebral salt wasting csw is potential cause of vna. Cerebral salt wasting syndrome csws is a rare endocrine condition featuring a low blood sodium concentration and dehydration in response to injury trauma or the presence of tumors in or surrounding the brain. Differentiating the syndrome of inappropriate antidiuretic hormone and csw remains difficult and the pathophysiological mechanisms underlying csw are unclear. Cerebral saltwasting syndrome, or renal salt wasting, may be more common than siadh and may even occur in the absence of cerebral disease. Syndrome of inappropriate antidiuretic hormone siadh is frequently diagnosed in this clinical setting, but cerebral salt wasting csw is an important diagnosis to consider. Cerebral salt wasting csw is a disorder characterized by ecf depletion and hyponatremia.
Cerebral salt wasting csw is potential cause of vna. The mechanisms underlying csw have not been precisely delineated, although existing evidence strongly implicates abnormal elevations in circulating natriuretic peptides. The importance of distinguishing both lies in the fact that the therapy indicated for one if used for the other, can be deleterious. The diagnosis of csw requires a high index of suspicion. Cerebral salt wasting csw is another potential cause of hyponatremia in those with cns disease, particularly patients with subarachnoid hemorrhage.
Challenges still confront us as we attempt to differentiate rsw from siadh, ascertain the prevalence of rsw, and address reports of rsw occurring without cerebral disease. Cerebral salt wasting incidence 24% of neuro cases with hyponatremia potential pathophysiology sympathetic nervous system. This twoyearold child with a lowgrade juvenile pilocytic astrocytoma who grade i developed significant hyponatremia on postoperative day two. Central neurogenic diabetes insipidus cndi, syndrome of inappropriate secretion of antidiuretic hormone siadh, and cerebral saltwasting syndrome csws all affect both sodium and water balance. Hyponatremia is a common electrolyte disorder in the setting of central nervous system cns disease. Proper diagnosis and differentiation between these two entities are necessary for management as the treatment is quite opposite in both conditions. Develop an evidencebased treatment strategy for neurocritical care patients that will optimize patient outcomes and reduce the risk of adverse drug effects and drug interactions. Although the diagnosis of cerebral saltwasting syndrome is thought to be controversial by some, it should be considered a discrete clinical entity. He was also found to have asymptomatic hyponatremia. Cerebral salt wasting syndrome statpearls ncbi bookshelf. Cerebral saltwasting syndrome constitutes a medical condition characterized by hypovolemia and hyponatremia, secondary to various pathologies affecting the central nervous system cns.
Failure to accurately diagnose these conditions and implement the correct treatment results in an increased. The pathophysiology is still not yet understood, vhowe er there are two proposed mechanisms. The causes and diagnosis of hyponatremia, causes and treatment of. The syndrome of inappropriate antidiuretic hormone siadh and cerebral salt wasting csw are characterized by hyponatremia and can be difficult to differentiate. He had associated polyuria and significant natriuresis, favoring the diagnosis of cerebral salt wasting syndrome over siadh. Cerebral salt wasting csw is another potential cause of. We also revise the aetiology, mechanisms, differential diagnosis and treatment of hyponatraemia after pituitary surgery. Hyponatremia was defined if 2 consecutive serum sodium levels were and hypernatremia if 145 meql. Natriuresis with polyuria is common after aneurysmal subarachnoid hemorrhage asah. Previous studies have shown an increased risk of symptomatic cerebral vasospasm or delayed cerebral ischemia dci in patients with hyponatremia andor the cerebral salt wasting syndrome csw. Cerebral salt wasting after traumatic brain injury. Causes include vomiting, diarrhea, intense exercise sweating, blood loss, diuretic use, and adrenal insufficiency. Csw is characterized by hyponatremia and extracellular fluid depletion due to inappropriate sodium wasting in the urine 5.
In this condition, the kidney is functioning normally but excreting excessive sodium. Management of hyponatraemia in patients with acute. Nov 11, 2015 electrolyte imbalances are common among patients with traumatic brain injury tbi. Hyponatremia was defined if 2 consecutive serum sodium levels were 145 meql. Oct, 2015 natriuresis with polyuria is common after aneurysmal subarachnoid hemorrhage asah. Objectives introduction definition pathophysiology etiology epidemiology history physical examination workup diagnosis differential diagnosis treatment prognosis summary 3. In conclusion, based on our experience, we propose that mineralocorticoid supplementation is a safe and effective treatment of cerebral salt wasting syndrome. Treatment requires volume replacement and maintenance of a positive salt balance. What is the pathophysiology of cerebral saltwasting. Cerebral salt wasting following traumatic brain injury in. Electrolyte imbalances are common among patients with traumatic brain injury tbi. Among various causes of hyponatremia, the diagnosis of the syndrome of inappropriate antidiuretic hormone secretion siadh and cerebral salt wasting syndrome csw is still confusing due to many similarities between the siadh and csw. Cerebral salt wasting csw is a disorder of sodium and water handling that occurs as a result of cerebral disease in the setting of normal kidney function. Apr 01, 2012 central neurogenic diabetes insipidus, syndrome of inappropriate secretion of antidiuretic hormone, and cerebral salt wasting syndrome are secondary events that affect patients with traumatic brain injury.
Polyuria and cerebral vasospasm after aneurysmal subarachnoid. Read more about symptoms, diagnosis, treatment, complications, causes and prognosis. It can be caused either by the syndrome of inappropriate secretion of antidiuretic hormone or by the cerebral saltwasting syndrome csws. This case represents the first illustration of severe hyponatremia related to cerebral salt wasting syndrome caused by a minor head injury. It should also be considered in patients without cerebral disease. Cerebral salt wasting is the most common cause of hyponatremia in stroke article in journal of stroke and cerebrovascular diseases.
The human body is 60% to 70% water, with approximately 30% of that water as extracellular fluid and sodium chloride as the major electrolyte 5145 meql. Leading theories for the pathophysiology of cerebral salt wasting. Apr 27, 2018 first described by peters et al in 1950, cerebral salt wasting syndrome is defined by the development of extracellular volume depletion due to a renal sodium transport abnormality in patients with intracranial disease and normal adrenal and thyroid function. Rather the evidence of negative salt balance and reductions in both plasma and total blood volume in these patients is more consistent with a diagnosis of cerebral salt wasting. Differential diagnosis between these two entities can be difficult due to considerable overlap in the laboratory findings and clinical situations. However, natriuresis may occur in the absence of hyponatremia or hypovolemia and it is not known whether the.
Cerebral saltwasting syndrome cerebral salt wasting syndrome. Cerebral salt wasting csw is seen with intracranial disorders, such as subarachnoid hemorrhage, carcinomatous or infectious meningitis, and metastatic carcinoma, but. The mechanism by which cerebral disease leads to renal salt wasting is not well understood. Cerebral salt wasting syndrome and systemic lupus erythematosus. The pathophysiology of csw is thought to be mediated by increased levels of. Cerebral saltwasting syndrome was proposed by peters and associates in 1950 280 as an explanation for the natriuresis and hyponatremia that sometimes accompanies intracranial disease, particularly subarachnoid hemorrhage, in which up to one third of patients develop hyponatremia. Syndrome of inappropriate antidiuretic hormone secretion and. Cerebral saltwasting csw, or renal saltwasting rsw, has evolved from a misrepresentation of the syndrome of inappropriate secretion of antidiuretic hormone siadh to acceptance as a distinct entity. In patients with severe symptomatic hyponatremia, the rate of sodium correction should be 6 to 12 meq per l in the first 24 hours and 18 meq per l. Making the diagnosis rapidly is vital as its treatment requires volume resuscitation and sodium restoration rather than the water restriction used for the more commonly observed siadh.
Inappropriate antidiuresis and cerebral salt wasting. Hyponatraemia may occur early during the first 24 h after surgery or at a later stage. What is the pathophysiology of cerebral salt wasting. Cureus successful use of fludrocortisone in a child with. Kojima et al have described an animal model of cerebral saltwasting syndrome that may allow better clarification of the conditions etiology. Cerebral salt wasting is a form of hypovolemic hypoosmolality that is usually related to a central nervous system cns disorder or neurosurgery. Differentiating between siadh and csw using fractional. This case represents the first illustration of severe hyponatremia related to cerebral saltwasting syndrome caused by a minor head injury. Distinguishing it from siadh is essential to enable prompt treatment in order to prevent severe. The incidence and pathophysiology of hyponatraemia after subarachnoid haemorrhage. Hyponatraemia is a common finding in patients with acute cerebral insults.
However, some authorities contend that csw does not really exist and. Diagnosis and treatment of cerebral salt wasting syndrome. Both these entities are cerebral in origin but have distinct pathophysiology, prognosis and treatment options. First described by peters et al in 1950, cerebral saltwasting syndrome is defined by the development of extracellular volume depletion due to a renal sodium transport abnormality in patients with intracranial disease and normal adrenal and thyroid function. Cerebral salt wasting csw is a syndrome of hypovolemic hyponatremia caused by natriuresis and diuresis. Both diagnosis approach and monitoring are based on the. Mar 01, 2015 in patients with severe symptomatic hyponatremia, the rate of sodium correction should be 6 to 12 meq per l in the first 24 hours and 18 meq per l or less in 48 hours.
As such, it may be more appropriately termed renal salt wasting. This is usually attributed to the syndrome of inappropriate secretion of antidiuretic hormone siadh. Cerebral saltwasting syndrome cerebral salt wasting. Hormone and cerebral salt wasting in critically ill patients amanda zomp, pharmd, bcps earnest alexander, pharmd serum sodium levels in critically ill patients can be altered by many factors. Differential diagnosis between these two entities can be difficult due to considerable overlap in. Cerebral salt wasting csw resulting in hyponatremia is also. Central neurogenic diabetes insipidus, syndrome of inappropriate secretion of antidiuretic hormone, and cerebral saltwasting syndrome are secondary events that affect patients with traumatic brain injury.
We wanted to describe the diagnosis, treatment, and history of csw to provide clinicians with a better understanding of the differential diagnosis for. Two main pathophysiologies of hyponatremia, excluding iatrogenic causes, are inappropriate secretion of antidiuretic hormone siadh and cerebral salt wasting csw syndrome. Cerebral saltwasting syndrome an overview sciencedirect. Causes of hyponatremia, such as cerebral salt wasting csw and syndrome of inappropriate secretion of antidiuretic hormone siadh, were based on predefined criteria. Body weight decreased in proportion to the decrease in serum sodium. Sodium imbalances are among the most common electrolyte abnormalities encountered in the acute care setting. The main differential diagnosis is between syndrome of inappropriate adh secretion and cerebral salt wasting. It is important to distinguish cerebral salt wasting csw from the two other major disturbances of water metabolism seen following cns injury ie, siadh and diabetes insipidus, because incorrect diagnosis and treatment could greatly increase morbidity in csw.
Jan 22, 2015 among various causes of hyponatremia, the diagnosis of the syndrome of inappropriate antidiuretic hormone secretion siadh and cerebral salt wasting syndrome csw is still confusing due to many similarities between the siadh and csw. Cerebral salt wasting csw syndrome is an important cause of hyponatremia in head injuries apart from syndrome of inappropriate antidiuretic hormone siadh. Central neurogenic diabetes insipidus, syndrome of. Definition cerebral saltwasting syndrome is defined by the development of extracellular volume depletion due to a renal na. Apr 27, 2018 although the diagnosis of cerebral salt wasting syndrome is thought to be controversial by some, it should be considered a discrete clinical entity and may be more common than perceived. Cerebral saltwasting syndrome clinical presentation. He had signs of hypovolemia, such as orthostatic hypotension, dry mucosa, decreased skin turgor, hemoconcentration, contraction alkalosis. Cerebral salt wasting csw is an uncommon cause of hyponatraemia and is particularly challenging to manage. The key in diagnosis of csw lies in distinguishing it from the more common syndrome of inappropriate secretion of.
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