Electrolyte imbalances are common among patients with traumatic brain injury tbi. We report a case of severe, symptomatic hyponatremia from siadh manifesting after a. Conversely, salt wasting syndromes can be easily fixed with. Syndrome of inappropriate antidiuretic hormone secretion siadh. Difference between diabetes insipidus and siadh description.
Normally, you would want to conserve sodium in this setting. Why does the differential diagnosis of hyponatremia when it comes to these 2 conditions matter so much. Cerebral salt wasting vs siadh pdf free serial pdf. Our case illustrates the diagnostic challenge presented to physicians when they manage hyponatremia in the setting of a central nervous system cns event.
The initial treatment consisted of intravenous fluid replacement with 0. Differentiating between siadh and csw using fractional. Pathophysiology of rsw and siadh and evolution of controversy on rarity of cerebral salt wasting. Conversely, salt wasting syndromes can be easily fixed with intravenous normal saline, which would make hyponatremia worse if the patient has siadh instead. In this condition, the kidney is functioning normally but excreting excessive sodium. In a followup of 102 consecutive patients, survivors of severe or. In addition, patients with siadh exhibit elevated adh levels and rarely develop urine sodium levels 100 meql. Differentiating the syndrome of inappropriate antidiuretic hormone and csw remains difficult and the pathophysiological mechanisms underlying csw are unclear. Our patient was given 2 salt tabs and a 2l infusion of 0. The patients serum sodium concentration upon discharge was 5 meql. Cerebral salt wasting csw should also be considered as a possible etiology, as it is also seen in the setting of subarachnoid hemorrhage, and its clinical management is different than siadh. Siadh vs cerebral salt wasting syndrome csws csws is usually associated with hypovolemia whereas patients with siadh are euvolemic.
He has a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. Silver rochester general hospital, rochester, university of rochester. Siadh and cerebral salt wasting syndrome csws in patients. It is important to differentiate between siadh and cerebral salt wasting syndrome csws, as the treatment of the two are diametrically opposite. Pdf differentiating siadh from cerebralrenal salt wasting. Differentiating siadh from cerebralrenal salt wasting. Cerebral salt wasting syndrome head injury, intracranial surgery, subarachnoid. The main diverential diagnosis is between syndrome of inappropriate adh secretion and cerebral salt wasting. The aetiology of hyponatremia below mmoll was siadh in 39 cases. But in many neuroscience patients, the cause of hyponatremia isnt siadh but a littleknown condition called cerebral salt wasting csw. Disorders of sodium balance after brain injury bja.
In siadh, the firstline intervention is fluid restriction, which will make matters worse in the volumecontracted patient with salt wasting. The proportion of patients with hyponatremia related to neurologic disease who have csw, as opposed to siadh or some other etiology of hypo natremia, is. Differentiation of siadh and cerebral salt wasting. Management of hyponatraemia in patients with acute. Hyponatremia is a common electrolyte disorder in the setting of central nervous system cns disease. Cerebral salt wasting syndrome csws, leading to renal sodium loss is. Department of nephrology and hypertension, cerebrovascular. However, after brain injury, hyponatraemia occurs most frequently because of the syndrome of inappropriate adh secretion siadh or the cerebral salt wasting syndrome csws. Following the haemorrhage, seven of nine animals developed hyponatraemia in association with natriuresis and negative salt balance. Cerebral salt wasting csw is another potential cause of hyponatremia in those with cns disease, particularly patients with subarachnoid hemorrhage. Cerebral salt wasting csw is another potential cause of hyponatremia in those. Cerbral salt wasting syndrome versus siadh in the context of cerebral diseases the two main mechanisms responsible for non iatrogenic causes of hyponatremia are cerebral salt wasting syndrome csw and inappropriate secretion of antidiuretic hormone siadh. 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. As such, it may be more appropriately termed renal salt wasting.
Differentiation includes cerebral salt wasting syndrome csw and syndrome of inappropriate antidiuretic hormone siadh. Cerebral salt wasting csw is a potential cause of hyponatremia in the. 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. Patients with csws usually have normal adh levels and often develop urine sodium levels 100 meql. Cerebral salt wasting polyuria phase of acute tubular necrosis high urine sodium this is a hyponatremia of increased renal losses. This is usually attributed to the syndrome of inappropriate secretion of antidiuretic hormone siadh.
Management of hyponatraemia in patients with acute cerebral insults a albanese, p hindmarsh, r stanhope abstract hyponatraemia is a common. Csw is characterized by hyponatremia and extracellular fluid depletion due to inappropriate sodium wasting in the urine 5. The main differential diagnosis is between syndrome of inappropriate adh secretion and cerebral salt wasting. Cerebral salt wasting csw is another potential cause of hyponatremia in those with the causes and diagnosis of hyponatremia, causes and treatment of siadh, and the general sivakumar v, rajshekhar v, chandy mj. Siadh is caused by infections and cancers while cerebral salt wasting is caused by brain trauma, injury, hematoma, and tumors all occurring in the brain.
Finally, inappropriate adh secretion can occur as a result of renal, adrenal, or thyroid dysfunction, and so those etiologies should be ruled out if. Aacn advanced critical care volume 23, number 3, pp. The initiation of rsw starts with the stimulation of a natriuretic factor that reduces sodium transport to induce rsw and extracellular volume ecv depletion, which in turn stimulates secretion of antidiuretic hormone adh, renin and aldosterone and decreases atrialbrain natriuretic peptide. If you are hypovolemic and hyponatremic, there is all the more reason to. Discuss the treatment and nursing management for cndi, siadh, and csws. Hyponatremia, especially cerebral salt wasting, occurring in the setting of stroke has been shown to worsen the prognosis of stroke, increase morbidity, short and long term mortality, and cause a poorer discharge disposition the purpose of this study is to observe the occurrence of siadh vs csw in the setting of stroke and. Cerebral salt wasting after traumatic brain injury. While fluid restriction is the treatment of choice in siadh, the treatment. Syndrome of inappropriate antidiuretic hormone secretion. Prolonged coexistent central diabetes insipidus and. In prognostic terms, it is very important to identify and appropriately treat these two entities. It is a medical condition or disorder of water and salt metabolism marked by heavy urination and intense thirst. Inappropriate antidiuretic hormone secretion and cerebral. However, cerebral salt wasting is a rare disorder that produces hyponatremia and can be difficult to distinguish from siadh.
Failure of the volume approach and need for a new approach to hyponatremia. Complexity of differentiating cerebralrenal salt wasting. This conundrum exists because of multiple overlapping clinical associations and laboratory abnormalities that characterize both. The underlying cause of the hyponatraemia should be identified and treated. List potential causes of central neurogenic diabetes insipidus cndi, syndrome of inappropriate secretion of antidiuretic hormone siadh, and cerebral salt wasting syndrome csws compare the signs, symptoms, and laboratory values for cndi, siadh, and csws. Central neurogenic diabetes insipidus, syndrome of. Cerebral salt wasting syndrome csws and the syndrome of inappropriate antidiuretic hormone secretion siadh are the most common causes of this disorder. Hyponatremia in a patient with cryptococcal meningitis. The differentiation of siadh from cerebral salt wasting syndrome csw or the preferred term, renal salt wasting rsw, represents one of the diagnostic conundrums that includes the fundamental question of the existence and prevalence of rsw 14. Cerebral saltwasting 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.
Syndrome of inappropriate antidiuretic hormone secretion siadh and cerebral saltwasting syndrome csws are the most common causes of hn in patients with neurological problems kalita et al. Like many clinicians, you might automatically suspect the syndrome of inappropriate antidiuretic hormone siadh in a patient who has hyponatremia. In this regard one could speculate that teleologically the development of renal salt wasting and resultant volume depletion in the setting of intracranial disease is a protective measure designed to limit extreme rises in intracranial pressure. Trimethoprimassociated hyponatremia american journal of. An 83yearold man admitted for weakness, lethargy, and mental status changes was found to have human immuno. The role that salt depletion played in the etiology of hyponatremia was well known to clinicians of that. Cerebral salt wasting csw is an electrolyte imbalance characterized by hyponatremia and hypovolemia. Cerebral salt wasting syndrome csw is defined as a renal loss of sodium during.
Differential diagnosis of cerebral salt wasting csw vs syndrome of inappropriate secretion of antidiuretic hormone siadh. The response to the treatment regimen supported our diagnosis of cerebral salt wasting csw. Cerebral salt wasting syndrome, hyponatremia, myeloproliferative. Cerebral salt wasting also known as renal salt wasting is a hyponatremic syndrome of unclear etiology. Pathophysiology of rsw and siadh and evolution of controversy on rarity of cerebral salt wasting the initiation of rsw starts with the stimulation of a natriuretic factor that reduces sodium transport to induce rsw and extracellular volume ecv depletion, which in turn stimulates secretion of antidiuretic hormone adh, renin and aldosterone and decreases atrialbrain natriuretic peptide abnp. Hydroelectrolytic abnormalities are reported in 15% 45% of children following intracranial surgery, with diabetes insipidus di, cerebral salt wasting syndrome csw, the syndrome of inappropriate secretion of antidiuretic hormone siadh and central adrenal insuf. Clarification of cerebral, or the more appropriate term, renal salt wasting rsw, vide infra, and its differentiation from siadh becomes critical. In addition, siadh and csws are two typical types of refractory hn, and the differential diagnosis between these two syndromes is difficult because of the overlapping signs, symptoms, and key laboratory data. Hyponatremia is a common electrolyte disorder in the setting of central nervous. Mcmanus, in a practice of anesthesia for infants and children sixth edition, 2019.
The treatment for salt wasting is to offset ongoing sodium losses with either saline solution infusions or salt tabs. Differentiating siadh from cerebral renal salt wasting. In siadh, hyponatremia can lead to an impaired level of consciousness, seizures, and worsening cerebral edema. Severe symptomatic hyponatremia due to syndrome of. Cerebral salt wasting in a patient with myeloproliferative neoplasm. Siadh means syndrome of inappropriate antidiuretic hormone secretion siadh. Hyponatraemia is a common finding in patients with acute cerebral insults. Cerebral salt wasting syndrome statpearls ncbi bookshelf. Siadh is frequently the cause of hyponatremia in a patient with a concurrent intracranial process. While fluid restriction is the treatment of choice in siadh, the treatment of csw. Most commonly recognized in neurosurgical patients, it is a primary natriuresis probably related to dysregulation of brain or atrial natriuretic peptides. Cerebral salt wasting an overview sciencedirect topics. Cerebral salt wasting syndrome csws cerebral salt wasting syndrome csws is a rare endocrine condition featuring a low blood sodium concentration and dehydration in response to traumainjury or the presence of tumors in or surrounding the brain. Syndrome of inappropriate antidiuretic hormone secretion siadh, is the most well.
Case report a 31year old hispanic man with no past medical history presented after a fall with witnessed seizure and altered mental status. Siadh is a known sequelae of neurosurgical procedures and cases of severe head trauma with associated clinical findings of injury 18. 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. Management of siadh is by fluid restriction while cerebral wasting is by frequent hydration. Cerebral salt wasting vanderbilt university medical center. Cerebral salt wasting syndrome csw is defined as a renal loss of sodium during intracranial disorders leading to hyponatremia and a decrease in extracellular fluid volume.
Siadh has a greater sodium urine concentration than cerebral salt wasting. Siadh vs cerebral salt wasting siadh is diagnosed by the combination of hyponatremia, low serum osmolality, inappropriately concentrated urine 100 osmkg h 2o, persistently high urinary sodium excre tion 20 mmoll, and hypouricemia. Failure to accurately diagnose these conditions and implement the correct treatment results in an increased mortality risk, a. Pathophysiology of rsw and siadh and evolution of controversy on rarity of cerebral. Distinction between these two syndromes is difficult and is based on the assessment of. Difference between siadh and cerebral salt wasting.
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