Background: CSWS usually devellops in the first week following brain insult and is defined by extracellular volume depletion due to excessive natriuresis in patients with intracranial disease; its duration is usually brief but it can last for several months
Case report: A 74 years old woman was admitted in ICU for polytrauma with multiple fractures (femoral, humeral, pelvic, rib fractures) and severe head trauma; the brain CT scan on admission showed subarachnoidal haemorrhage and temporal bone fracture At 3 p.o. days (femoral+humeral osteosynthesis) she developped progressive headaches, deteriorated consciousness and vomiting refractory to medical treatment.
Biochemical: Plasmatic Na level 98-102 mmol/l, glucose, blood urea, creatininenormal value, NT-proBNP 890 pg/ml, ADH< 2 ng/ml.
Urinary: Na level 180 mmol/l, osmolality 720 mosm/kgH2O, uric acid 399 mg/24 hours.
No hystory of hyponatremia, no medication-related hyponatremia, adrenal and thyroid functions tests-normal.
Clinically: Hypovolemia, high urinary output.
The diagnosis of CSWS was made; the clinical course was uneventful.
The treatment include NaCl molar (1 mmol/ml) supplementation, volume replacement therapy, methylprednisolon 32 mg/day.
Discharge day 62 with plasmatic Na 138 mmol/l, no i.v. Na supplementation. A second hit 2 weeks after discharge, conservative treatment with NaCl tablets, 1 gr NaCl each 4-6 hours.
Discussion: Traumatic brain injury may severely impair brain function; neuroendocrine dysfunction is an important complication Most TBI-associated hyponatremia are mild and asymptomatic, but in severe cases the differential diagnosis CSWS/SIADH, also difficult to make, is decisive for the treatment options.
1. 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
2. Vespa P. Cerebral salt wasting after traumatic brain injury: an important critical care treatment issue. Surg Neurol 2008;69(3):230-2
Learning points: The CSWS related hyponatremia had a prolonged and difficult recovery; till now there are few data concerning the therapeutic approach of chronic CSWS, requiring new research.© 2013 European Society of Anaesthesiology