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Category: Volume 08 Issue 01 January 2020
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Title: Hyponatremia in Stroke: Cerebral Salt Wasting Versus Syndrome of Inappropriate Anti-Diuretic Hormone Secretion

Authors: Dr Babuanand M.D, Dr M. Ramesh M.D

 DOI: https://dx.doi.org/10.18535/jmscr/v8i1.63

Abstract

Hyponatremia is the most common electrolyte abnormality seen in hospitalised patients and is also the most common electrolyte imbalance seen in critically ill neurologic patients. It can significantly alter the morbidity, short and long term mortality of the underlying disease.

The causes of hyponatremia are varied, but in neurologically ill patients, are most commonly attributed to Syndrome of Inappropriate Anti-diuresis and Cerebral Salt Wasting. Both these entities are cerebral in origin but have distinct pathophysiology, prognosis and treatment options.

In stroke SIADH (euvolemichyponatremia) occurs due to AVP secretion inappropriate to the osmotic threshold. The suppressed proximal renal tubular transport in this condition can lead on to bicarbonaturia and hypouricemia. The effective treatment is fluid restriction. Hypertonic saline therapy is reserved for cases of severe hyponatremia.

CSW, on the other hand, is essentially a volume depleted state, which occurs due to the combined effects of decreased sympathetic outflow and increased natriuretic peptides. This resultant natriuresis leads to volume depletion and an appropriate AVP response. So the treatment for CSW includes an aggressive volume replacement regimen with isotonic saline or in severe cases, hypertonic saline.

Thus most CSW patients meet the criteria for SIADH and have elevated AVP levels but worsen with the treatment protocol given for SIADH. This observation lead to the description of CSW as a separate entity and widespread studies were carried out to distinguish the two entities.

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.

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Corresponding Author

Dr M. Ramesh M.D