Hyponatremia in neurologic intensive care: cerebral salt wasting syndrome and inappropriate antidiuretic hormone secretion

Hyponatraemia is a frequent complication in neurologically injured patients; it is a secondary cerebral injury. Hyponatraemia leads to consciousness problems, convulsions, worsening of the neurological status and thus the neurological evaluation. Hyponatraemia is secondary to free water retention (inappropriate ADH secretion) or to renal salt loss. The cerebral salt wasting syndrome (CSWS) has been described with head injury, subarachnoid haemorrhage and after several sorts of brain insults. It is characterised by an increased natriuresis and diuresis. Diagnosis is based on hyponatraemia, hypernatriuresis, increased diuresis and hypovolaemia. However, inappropriate ADH secretion and CSWS share several diagnostic criteria. The atrial natriuretic factor and the C-type natriuretic factors play a role in the development of the CSWS. The diagnostic approach and monitoring are based on the assessment of sodium and water losses. Therapy is based on correction of the circulating volume and natraemia. Speed of correction is a matter of debate: slow correction presents the risk of further neurological injury whereas rapid correction presents the risk of central pontine myelinosis.