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Hyponatremia after aneurysmal subarachnoid hemorrhage

Hyponatremia is the most common electrolyte abnormality in patients with aneurysmal subarachnoid hemorrhage (aSAH), occurring in one-third of aneurysmal subarachnoid hemorrhage (aSAH) patients.

This is secondary to Syndrome of inappropriate antidiuretic hormone secretion (SIADH) or Cerebral salt wasting syndrome (CSW).

Distinguishing between these two entities can be difficult because they have similar manifestations, including hyponatremia, serum hypoosmolality, and high urine osmolality.

SIADH is much more common than CSW in patients with aSAH. Anterior circulation aneurysms may be associated with a higher rate of SIADH than posterior circulation aneurysms 1).


Hyponatremia and dehydration due to natriuresis after subarachnoid hemorrhage are related to symptomatic vasospasm. Therefore, most institutions are currently targeting euvolemia and eunatremia in subarachnoid hemorrhage patients to avoid complications 2).

Current evidence from a Systematic Review does not demonstrate a benefit of preventative treatment with mineralocorticoids in clinically important outcomes, although a difference cannot be ruled out due to imprecision. Larger well-designed trials are needed to establish the impact of mineralocorticoids and fluid and sodium supplementation strategies on clinically relevant outcomes in the prevention and treatment of hyponatremia in patients with SAH 3).

CSW occurs from increased natriuretic peptide secretion and causes hyponatremia with diuresis and natriuresis, reduces total blood volume and increases risk of vasospasm. SIADH manifests as euvolemic hyponatremia with concentrated urine from excessive ADH secretion. CSW is managed by administering isotonic fluids and fludrocortisone while SIADH is corrected with fluid restriction. Severe and refractory hyponatremia may warrant hypertonic saline administration. Other electrolyte disturbances in these patients include hypomagnesemia, hypokalemia and hypocalcemia 4).

Hoffman H, Ziechmann R, Gould G, Chin LS. The Impact of Aneurysm Location on Incidence and Etiology of Hyponatremia Following Subarachnoid Hemorrhage. World Neurosurg. 2017 Nov 21. pii: S1878-8750(17)31981-2. doi: 10.1016/j.wneu.2017.11.058. [Epub ahead of print] PubMed PMID: 29162524.
Uozumi Y, Mizobe T, Miyamoto H, Ashida N, Katsube T, Tatsumi S, Nakamura M, Kohmura E. Decreased serum sodium levels predict symptomatic vasospasm in patients with subarachnoid hemorrhage. J Clin Neurosci. 2017 Dec;46:118-123. doi: 10.1016/j.jocn.2017.08.037. Epub 2017 Sep 5. PubMed PMID: 28887070.
Shah K, Turgeon RD, Gooderham PA, Ensom MHH. Prevention and Treatment of Hyponatremia in Patients with Subarachnoid Hemorrhage: A Systematic Review. World Neurosurg. 2018 Jan;109:222-229. doi: 10.1016/j.wneu.2017.09.182. Epub 2017 Oct 5. Review. PubMed PMID: 28987848.
Rose MJ. Aneurysmal subarachnoid hemorrhage: An update on the medical complications and treatments strategies seen in these patients. Curr Opin Anaesthesiol. 2011;24:500–7.
hyponatremia_after_aneurysmal_subarachnoid_hemorrhage.txt · Last modified: 2018/01/01 17:59 by administrador