Hyponatraemia and head injury: just a coincidence or a case of cerebral salt wasting syndrome?

Chiara  Sciacovelli; Andrea Vercelli; Tommaso Sonnessa; Valentina Tinelli; Elvira Varrato; Erika Poggiali

doi:10.23750/abm.v95i2.15308

Hyponatraemia and head injury: just a coincidence or a case of cerebral salt wasting syndrome?

Authors

Chiara Sciacovelli Vita - Salute San Raffaele University and Emergency Department, San Raffaele IRCCS Hospital, Milan, Italy
Andrea Vercelli Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
Tommaso Sonnessa Vita - Salute San Raffaele University and Emergency Department, San Raffaele IRCCS Hospital, Milan, Italy
Valentina Tinelli Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
Elvira Varrato Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
Erika Poggiali Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy

DOI: https://doi.org/10.23750/abm.v95i2.15308

Keywords:

hyponatremia, cerebral salt wasting syndrome, head injury, sodium, orthostatic hypotension

Abstract

We report the case of an 81-year-old woman who presented to our attention complaining of headache, dizziness, gear insecurity with muscle weakness, and vomiting after a forward fall down the stairs with a minor head injury 15 days earlier and investigated with a brain computed tomography, that excluded fractures and haemorrhage. Laboratory tests showed severe hyponatraemia, that we immediately investigated with a diagnostic workup, that included urine tests, point-of-care ultrasound, and orthostatic hypotension with “supine-to-standing test”. Based on these results and the recent traumatic brain injury, cerebral salt wasting syndrome (CSWS) was diagnosed. The patient was treated with hypertonic saline infusion (3% NaCl), developing an initial osmotic demyelination syndrome due to the rapid correction of hyponatraemia, that completely solved stopping the infusion. CSWS is often misdiagnosed and commonly confused with the syndrome of inappropriate antidiuretic hormone secretion. CSWS can occur within the first 10 days following a neurosurgical procedure or acute neurological event (stroke, haemorrhage, and traumatic head injury). Since severe hyponatraemia is potentially life-threatening, emergency clinicians should always consider CSWS when evaluating hyponatraemic patients, particularly after a head injury.

References

Lindner G, Schwarz C, Haidinger M, Ravioli S. Hyponatraemia in the emergency department. Am J Emerg Med 2022;60:1-8. doi: 10.1016/j.ajem.2022.07.023.

Spasovski G, Vanholder R, Allolio B, et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Nephrol Dial Transplant 2014;29 Suppl 2:i1-i39. doi: 10.1093/ndt/gfu040.

Gankam Kengne F, Decaux G. Hyponatraemia and the Brain. Kidney Int Rep 2018;3(1):24-35. doi: 10.1016/j.ekir.2017.08.015.

Mustajoki S. Severe hyponatraemia (P-Na < 116 mmol/l) in the emergency department: a series of 394 cases. Intern Emerg Med 2023;18(3):781-789. doi: 10.1007/s11739-023-03221-y.

Refardt J, Kling B, Krausert K, et al. Impact of chronic hyponatraemia on neurocognitive and neuromuscular function. Eur J Clin Invest 2018;48(11):e13022. doi: 10.1111/eci.13022.

Pourmand A, Pyle M, Yamane D, Sumon K, Frasure SE. The utility of point-of-care ultrasound in the assessment of volume status in acute and critically ill patients. World J Emerg Med 2019;10(4):232-238. doi: 10.5847/wjem.j.1920-8642.2019.04.007.

Peters JP, Welt LG, Sims EA, Orloff J, Needham J. A salt-wasting syndrome associated with cerebral disease. Trans Assoc Am Physicians 1950;63:57-64. PMID: 14855556.

Tisdall M, Crocker M, Watkiss J, Smith M. Disturbances of sodium in critically ill adult neurologic patients: a clinical review. J Neurosurg Anesthesiol 2006;18(1):57-63. doi: 10.1097/01.ana.0000191280.05170.0f.

Sherlock M, O'Sullivan E, Agha A, et al. Incidence and pathophysiology of severe hyponatraemia in neurosurgical patients. Postgrad Med J 2009;85(1002):171-5. doi: 10.1136/pgmj.2008.072819.

Cerda-Esteve M, Cuadrado-Godia E, Chillaron JJ, et al. Cerebral salt wasting syndrome: review. Eur J Intern Med 2008;19(4):249-54. doi: 10.1016/j.ejim.2007.06.019.

Sherlock M, O'Sullivan E, Agha A, et al. The incidence and pathophysiology of hyponatraemia after subarachnoid haemorrhage. Clin Endocrinol (Oxf) 2006;64(3):250-4. doi: 10.1111/j.1365-2265.2006.02432.x.

Harrigan MR. Cerebral salt wasting syndrome: a review. Neurosurgery 1996;38(1):152-60. doi: 10.1097/00006123-199601000-00035.

Leonard J, Garrett RE, Salottolo K, et al. Cerebral salt wasting after traumatic brain injury: a review of the literature. Scand J Trauma Resusc Emerg Med 2015;23:98. doi: 10.1186/s13049-015-0180-5.

Nelson PB, Seif SM, Maroon JC, Robinson AG. Hyponatraemia in intracranial disease: perhaps not the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). J Neurosurg 1981;55(6):938-41. doi: 10.3171/jns.1981.55.6.0938.

Wijdicks EF, Vermeulen M, ten Haaf JA, Hijdra A, Bakker WH, van Gijn J. Volume depletion and natriuresis in patients with a ruptured intracranial aneurysm. Ann Neurol 1985;18(2):211-6. doi: 10.1002/ana.410180208.

Sivakumar V, Rajshekhar V, Chandy MJ. Management of neurosurgical patients with hyponatraemia and natriuresis. Neurosurgery 1994;34(2):269-74; discussion 274. doi: 10.1227/00006123-199402000-00010.

Levin ER, Gardner DG, Samson WK. Natriuretic peptides. N Engl J Med 1998;339(5):321-8. doi: 10.1056/NEJM199807303390507.

Berendes E, Walter M, Cullen P, et al. Secretion of brain natriuretic peptide in patients with aneurysmal subarachnoid haemorrhage. Lancet 1997;349(9047):245-9. doi: 10.1016/s0140-6736(96)08093-2.

Takahashi K, Totsune K, Sone M, et al. Human brain natriuretic peptide-like immunoreactivity in human brain. Peptides 1992;13(1):121-3. doi: 10.1016/0196-9781(92)90149-w.

Tomida M, Muraki M, Uemura K, Yamasaki K. Plasma concentrations of brain natriuretic peptide in patients with subarachnoid hemorrhage. Stroke 1998;29(8):1584-7. doi: 10.1161/01.str.29.8.1584.

Maesaka JK, Imbriano LJ, Grant C, Miyawaki N. New Approach to Hyponatraemia: High Prevalence of Cerebral/Renal Salt Wasting, Identification of Natriuretic Protein That Causes Salt Wasting. J Clin Med 2022;11(24). doi: 10.3390/jcm11247445.

Diringer MN, Zazulia AR. Hyponatraemia in neurologic patients: consequences and approaches to treatment. Neurologist 2006;12(3):117-26. doi: 10.1097/01.nrl.0000215741.01699.77.

Berkenbosch JW, Lentz CW, Jimenez DF, Tobias JD. Cerebral salt wasting syndrome following brain injury in three pediatric patients: suggestions for rapid diagnosis and therapy. Pediatr Neurosurg 2002;36(2):75-9. doi: 10.1159/000048356.

Baylis PH. Posterior pituitary function in health and disease. Clin Endocrinol Metab 1983;12(3):747-70. doi: 10.1016/s0300-595x(83)80063-2.

George JC, Zafar W, Bucaloiu ID, Chang AR. Risk Factors and Outcomes of Rapid Correction of Severe Hyponatraemia. Clin J Am Soc Nephrol 2018;13(7):984-992. doi: 10.2215/CJN.13061117.

Tandukar S, Sterns RH, Rondon-Berrios H. Osmotic Demyelination Syndrome following Correction of Hyponatraemia by =10 mEq/L per Day. Kidney360 2021;2(9):1415-1423. doi: 10.34067/KID.0004402021.

Oh H, Seo W. An Integrative Review of Cerebral Salt Wasting Syndrome. J Neurosci Nurs. 2020 Dec;52(6):289-294. doi: 10.1097/JNN.0000000000000548.

Warren AM, Grossmann M, Christ-Crain M, Russell N. Syndrome of Inappropriate Antidiuresis: From Pathophysiology to Management. Endocr Rev. 2023 Mar 28:bnad010. doi: 10.1210/endrev/bnad010.

Wijdicks EF, Vermeulen M, Hijdra A, van Gijn J. Hyponatraemia and cerebral infarction in patients with ruptured intracranial aneurysms: is fluid restriction harmful? Ann Neurol 1985;17(2):137-40. doi: 10.1002/ana.410170206.