The two main mechanisms responsible for noniatrogenic hyponatremia are cerebral salt wasting csw syndrome and the syndrome of. 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. Cerebral salt wasting incidence 24% of neuro cases with hyponatremia potential pathophysiology sympathetic nervous system. Dialysis may be needed in severe acute or chronic kidney injury. Cerebral salt wasting csw syndrome is an important cause of hyponatremia in head injuries apart from syndrome of inappropriate antidiuretic hormone siadh. 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. Cerebral salt wasting syndrome how is cerebral salt wasting syndrome abbreviated.
Cerebral salt wasting seen in patients with intracranial disease. 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. Ppt siadh, di, cerebral salt wasting powerpoint presentation free to view id. Cerebral salt wasting syndrome definition of cerebral salt.
Change the layout of the slide to either blank of title. Cerebral salt wasting syndrome is a medical entity that leads to hyponatremia and hypovolemia due to dehydration, as a result of an acute or chronic and persistent underlying cns disorder, including trauma, tumors, and other pathologies. The two conditions may be indistinguishable at presentation, which can lead to underdiagnosis of csw in patients with cns disease. History hyponatremia and cerebral saltwasting syndrome as the decline in serum sodium concentration reduces serum osmolality, a tonicity gradient develops across the bloodbrain barrier that causes cerebral edema. Treatment early appropriate therapy of hyponatremia is important to prevent complications. Cerebral salt wasting syndrome csws was initially described in the early 1950s as a clinical condition in patients with a cerebral lesion who had hyponatremia, and an elevated concentration of urine sodium na. Difference between siadh and cerebral salt wasting. Primary polydipsia beer potomania n assess extracellular volume gi fluid loss adrenal insufficiency diuretics cerebral salt wasting burns and third space fluid loss marathon runners siadh glucocorticoid deficiency hypothyroidism reset osmostat nsaid edemaforming states heart failure cirrhosis nephrosis high low normal not avp mediated avp.
Its laboratory constellation resembles siadh closely, although the spot urinary sodium concentration is usually much greater than 30. Volume for volume replacement of urine na losses when dcd from hospital, most will still need oral na supplementation for a period of time 23. Cerebral salt wasting syndrome following head injury in a. We describe a patient with cerebral infarction who developed cerebral salt wasting syndrome in the course of. Cerebral saltwasting syndrome, or renal salt wasting, may be more common than siadh and may even occur in the absence of cerebral disease. Symptomatic vasospasm and asymptomatic vasospasm identified by tcd have been linked to hyponatremia.
Lp if hct, watch for siadh or cerebral salt wasting, monitor lytes and serum osmol q 6hrs, monitor abgs if on vent, prevent hyperglycemia 4 imaging. Hyponatremia develops in approximately 30% of cases as a result of either the cerebral salt wasting csw syndrome or the syndrome of inappropriate secretion of antidiuretic hormone siadh. Why does the differential diagnosis of hyponatremia when it comes to these 2 conditions matter so much. Cerebral saltwasting syndrome due to hemorrhagic brain.
Csws renal loss of sodium during intracranial disorders leading to hyponatremia and a decrease in extracellular fluid volume first described. Serum osmolality ranged between 260 and 268 mosmkgh2o in the first 15 h of the study. A rare differential diagnosis not mentioned in figure 1 is cerebral salt wasting csw, a condition sometimes seen on neurosurgical wards brookes and gould, 2003. 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 following traumatic brain injury in. Prophylactic management of excessive natriuresis with. In this condition, the kidney is functioning normally but excreting excessive sodium. Cerebral salt wasting syndrome is a condition featuring hyponatremia and dehydration caused by head injury, operation on the brain, subarachnoid hemorrhage, brain tumor and so on.
Specific attention is given to the use of hypertonic saline, the osmotic demyelination syndrome a. In this manuscript, we report the case of a sixyearold patient with cerebral salt wasting syndrome associ ated with subacute sclerosing panencephalitis. Syndrome of inappropriate antidiuretic hormone secretion siadh. Cerebral salt wasting syndrome csw is defined as a renal loss of sodium during intracranial disease leading to hyponatremia and a decrease in extracellular fluid volume. Cerebral salt wasting syndrome csws is often an unrecognized cause of hyponatremia that occurs in the setting of intracranial lesions. Sequential cerebral salt wasting complicating siadh in a patient. Nov 11, 2015 electrolyte imbalances are common among patients with traumatic brain injury tbi. Cerebral renal salt wasting syndrome is a rare condition which leads to a mildtomoderate hyponatraemia, and is commonly associated with intracranial bleeds subarachnoid haemorrhage, subdural haematomas, cerebral injury or brain tumours. Sodium can be lost through renal or nonrenal routes. In this article, 2 patients with the cerebral salt wasting syndrome are presented. Curriculum we will provide advanced training in general and neurocritical care, encompassing guidelines developed by the ucns, neurocritical care society, and society of critical care medicine. The adobe flash plugin is needed to view this content.
However, cerebral salt wasting is a rare disorder that produces hyponatremia and can be difficult to distinguish from siadh. Cerebral salt wasting explain cereberal salt wasting explain the pathophysiology and theories learn the different causes and risk factors correlate these concepts clinically to understand. The syndrome of inappropriate antidiuresis and cerebral salt wasting syndrome are similar yet discrete clinical entities, the main distinction being the absence or presence of volume depletion. Graduating fellows will be competent in managing complex patients with a broad spectrum critical and neurocritical care disorders within a collaborative. Siadh has a greater sodium urine concentration than cerebral salt wasting. Nov 11, 2015 initial search criteria phrases included cerebral salt wasting and traumatic brain injury or head trauma. Differential diagnosis between these two entities can be difficult due to considerable overlap in the laboratory findings and clinical situations. Cerebral salt wasting syndrome in brain injury patients. Normal saline may be useful for cases of mild hypovolemic hyponatremia, such as cerebral salt wasting. Salt wasting nephropathy causing hypovolemic hyponatremia renal disorders eg, interstitial nephropathy, medullary cystic disease, polycystic kidney disease, partial urinary obstruction with low salt intake. Differentiating the syndrome of inappropriate antidiuretic hormone and csw remains difficult and the pathophysiological mechanisms underlying csw are unclear.
Cerebral salt wasting csw is an uncommon cause of hyponatraemia and is particularly challenging to manage. The unit provides the full array of advanced respiratory support, including noninvasive positive pressure ventilation, highfrequency oscillatory ventilation, and. In literature, there are few reports about tuberculous. Cerebral saltwasting syndrome is a rare endocrine condition featuring a low blood sodium concentration and dehydration in response to injury or the presence of tumors in or surrounding the brain. As such, it may be more appropriately termed renal salt wasting. In siadh, the firstline intervention is fluid restriction, which will make matters worse in the volumecontracted patient with salt wasting. Brain natriuretic peptide and cerebral vasospasm in. Siadh, diabetes insipidus, and cerebral salt wasting presentation summary. Two main pathophysiologies of hyponatremia, excluding iatrogenic causes, are inappropriate secretion of antidiuretic hormone siadh and cerebral salt wasting csw syndrome. Cerebral salt wasting syndrome can be a result of intense neurohormonal activation resulting from subarachnoid haemorrhage. Definition cerebral saltwasting syndrome is defined by the development of extracellular volume depletion due to a renal na. However, some authorities contend that csw does not really exist and.
Furthermore, hyponatremia accompanied by cns disorders has shown to increase delayed cerebral ischemia and mortality rates. Whereas those patients with cerebral salt wasting syndrome have hyponatremia, the urine osmolarity is usually higher than it is in siadh because of the urinary sodium losses. The term cerebral salt wasting syndrome is commonly used due to its significant association with the. Create a new, blank presentation in powerpoint, or add a new, blank slide to an existing one. It has been reported in cases with subarachnoid haemorrhage, 8 infections, 7 head injury, 9 brain tumours, 10 transsphenoidal pituitary surgery, 11 and neurosurgery. Evolution and evolving resolution of controversy over. Syndrome of inappropriate antidiuretic hormone siadh see table 212 postoperative hyponatremia. A saltwasting syndrome associated with cerebral disease.
The clinical management of hyponatraemia postgraduate. 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. Case report article pdf available in neuro endocrinology letters 364. Disorders of sodium balance after brain injury bja. They have clinical signs of hypovolemia such as tachycardia and orthostatic changes in. Proper diagnosis and differentiation between these two entities are necessary for management as the treatment is quite opposite in both conditions. Failure to distinguish cerebral saltwasting syndrome from siadh in a patient with hyponatremia who has brain injury could lead to inappropriate. Cerebral salt wasting and siadh linkedin slideshare. A 4 to 6 meql increase in serum na concentration is sufficient to treat lifethreatening cerebral edema caused by.
Hyponatremia in asah may result from cerebral salt wasting or syndrome of inappropriate antidiuretic hormone secretion. Diagnostic value of urate determinations in hyponatremia. Siadh, diabetes insipidus, and cerebral salt wasting. Management of hyponatraemia in patients with acute. Several reports involving the investigation of cerebral salt wasting syndrome, however, have shown that the anp alone is unlikely to be responsible for hyponatremia in patients with sah. Singh s, bohn d, carlotti ap, cusimano m, rutka jt, halperin ml. This form of hyponatremia is called cerebral salt wasting csw, and 30% of patients with bleeding in the area between the brain and the membranes that cover the brain subarachnoid hemorrhage develop the problem, according to author m. Cerebral salt wasting after traumatic brain injury. Central pontine myelinolysis from rapid overcorrection.
Despite this evidence, some authors have not found a. Symptoms include lethargy, agitation, headache, altered consciousness, seizures,and coma. Cerebral salt wasting csw is a potential cause of hyponatremia in the setting of disease of the central nervous system cns. We also report on the high prevalence of rsw without cerebral disease in the general wards of the hospital. History hyponatremia and cerebral saltwasting syndrome as the decline in serum sodium concentration reduces serum osmolality, a tonicity. Avoidance of neurologic injury requires a clear understanding of why the serum sodium na concentration falls and why it rises, how the brain responds to a changing serum na concentration, and what the goals of therapy should be. Anaesthesia for endovascular management of cerebral aneurysm. Siadh diabetes insipidus and cerebral salt wasting powerpoint presentation presentation title. In this setting, crystalloids, colloids, 3% sodium chloride, and hypertonic sodium chloride solutions have all been shown to. Nov 28, 2015 cerebral salt wasting csw is potential cause of vna. Remove this presentation flag as inappropriate i dont like this i like this remember as a favorite. Cerebral salt wasting csw is another potential cause of hyponatremia in those with cns disease, particularly patients with subarachnoid.
Hypovolemic hyponatremia develops as sodium and free water are lost and replaced by inappropriately hypotonic fluids. With adequate free water intake, the increase in water reabsorption induces hyponatremia, plasma hypoosmolality, and a small degree of volume expansion, which along with increased atrial natriuretic peptide levels, decrease plasma renin and aldosterone. This neurohormonal activation is associated with consistently increased levels of both atrial natriuretic peptide anp and brain natriuretic peptide bnp. Seventeen 27% had siadh, 19 31% had a reset osmostat, 24 38% had. Fludrocortisone can help in managing csw where alone saline infusion does not work. Differential diagnosis between these two entities can be difficult due to considerable overlap in. Cerebral salt wasting csw is another potential cause of hyponatremia in those with cns disease, particularly patients with subarachnoid hemorrhage. High concentrations of sodium are found in the urine. Infusion of isotonic saline in cerebral salt wasting, since euvolemia will suppress the release of adh.
Bnp appeared to be the primary natriuretic peptide that caused salt wasting in patients with sah. Nov 27, 2014 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. Cerebral salt wasting syndrome is a disorder characterized by severe hyponatremia, volume depletion, and elevated brain natriuretic peptide but normal antidiuretic hormone levels. The cerebral salt wasting syndrome is thought to be caused by the secretion of brain and atrial natriuretic hormone, which leads to a negative sodium. Challenges still confront us as we attempt to differentiate rsw from siadh, ascertain the prevalence of rsw, and address reports of rsw. Cerebral salt wasting syndrome csws and the syndrome of inappropriate antidiuretic hormone siadh are both causes of hyponatremia in pediatric neurosurgical patients often with similar presenting symptoms. Cerebral salt wasting syndrome in a child with sspe ios press. May, 2020 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. Csw is characterized by hyponatremia and extracellular fluid depletion due to inappropriate sodium wasting in the urine 5.
Pdf cerebral salt wasting in tuberculous meningitis. 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 an electrolyte imbalance characterized by hyponatremia and hypovolemia. Critical care medicine physicians provide care for children with the full range of pediatric critical care illness including respiratory, cardiovascular, renal and liver dysfunction. 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. In the cerebral salt wasting syndrome, patients are hyponatremic. Cerebral salt wasting syndrome csw is defined as a. Disorders of sodium in the neurocritical care patient wfnn. Treatment of cerebral salt wasting is through frequent hydration to prevent dehydration plus medications. Powerpoint 2004 and earlier users can choose format slide layout, and apply the new layout within the relevant dialog box see figure 1 or task pane, or use the formatting palette.
However, there are a few reports of cerebral salt wasting syndrome caused by cerebral infarction. Electrolyte imbalances are common among patients with traumatic brain injury tbi. Case report a 31year old hispanic man with no past medical history presented after a fall with witnessed seizure and altered mental status. If so, share your ppt presentation slides online with. Treatment of hyponatremia in the neurocritical care unit. Recent findings we applied our new approach to hyponatremia by utilizing sound pathophysiologic criteria in 62 hyponatremic patients. Cerebral saltwasting syndrome csws is a rare endocrine condition featuring a low blood sodium concentration and dehydration in response to injury. Neuro powerpoint 9 neuroanesthesia icp flashcards quizlet. Hyponatremia is the most frequent electrolyte disorder in critically neurological patients. Siadh, diabetes insipidus, and cerebral salt wasting is the property of its rightful owner. The condition typically occurs in patients who are volumedepleted.
Cerebral salt wasting syndrome linkedin slideshare. The pathogenesis of this disorder is still not completely understood. Cerebral saltwasting syndrome how is cerebral saltwasting. The urinary sodium level is usually markedly elevated. Syndrome of inappropriate antidiuresis and cerebral salt. Hyponatremia occurs in 10% to 34% of patients after aneurysmal subarachnoid hemorrhage sah. Decision tree for the evaluation and management of hyponatremia in critically ill neurologic patients. We wanted to describe the diagnosis, treatment, and history of csw to provide clinicians with a better understanding of the differential diagnosis for. Cerebral angiogram is gold standard after diagnosis with hct or clinical presentation with xanthrochromia on lp, followed by daily tcds. Cerebral salt wasting syndrome in postoperative pediatric. Cerebral saltwasting syndrome clinical presentation. Cerebral salt wasting syndrome, subarachnoid haemorrhage, syndrome of inappropriate antidiuretic hormone secretion, hyponatraemia.
Cerebral salt wasting syndrome csws is characterized by severe natriuresis and volume depletion in the presence of cerebral pathology. Cerebral salt wasting syndrome in a patient with a pituitary. Cerebral salt wasting syndrome statpearls ncbi bookshelf. The primary defect in siadh is the euvolemic, inappropriate increase in plasma adh levels. If we talked about cerebral salt wasting, some of the primary interventions include giving fluid or salt back. Tuberculous menigitis tbm presents a major health burden around the world, especially in individuals with concomitant hiv infection, in whom mortality is nearly 50%. Nonrenal routes include gi losses, excessive sweating, third spacing of fluids e. Csws is characterized by renal loss of sodium resulting in polyuria, natriuresis, hyponatraemia, and hypovolaemia occurring as a result of a centrally mediated process. It is important to differentiate csws from the syndrome of inappropriate adh secretion, as this would alter the management of hyponatremia. Syndrome of inappropriate antidiuretic hormone siadh is frequently diagnosed in this clinical setting, but cerebral salt wasting csw is an important. Physiologic manifestations severe neurologic symptoms or cerebral edema, central pontine myelinolysis.