Refractory polyuria secondary to cerebral salt wasting successfully treated with DDAVP and hypertonic saline

Abstract

Background: Cerebral salt wasting (CSW) is a complication in patients with aneurysmal subarachnoid hemorrhage (aSAH) and other neurological conditions. It results in hyponatremia and hypovolemia due to unregulated natriuresis and loss of extracellular fluid volume. A lesser recognized mechanism of dysregulation of volume and sodium in aSAH patients is due to varying levels of antidiuretic hormone (ADH) following the injury to the anterior communicating artery and/or internal carotid arteries. Dysregulation of ADH can make the degree of sodium and volume changes even more difficult to treat in aSAH patients with CSW. Case description: A 55-year-old presented to an emergency department with headache and nausea for 5 days. She was found to have aSAH due to a ruptured anterior communicating artery aneurysm (ACOM). Hospital course was complicated by refractory polyuria from CSW and likely dysregulation of ADH secretion managed with intravenous 1-deamino-8-D-arginine vasopressin (DDAVP) concordantly with hypertonic saline. This combination maintained euvolemia and her serum sodium level. Follow up imaging showed pituitary stalk hyperintensity in the magnetic resonance imaging secondary to ischemic insult. Conclusion: Transient ADH deficiency may occur in patients with aSAH from ruptured ACOM aneurysm. ADH deficiency if coexistent with CSW, can result in hyponatremia and refractory polyuria. It is possibly due to vasospasm of anteromedial central and hypophyseal arteries or hypothalamic ischemia. DDAVP in combination with hypertonic saline can be safely used to treat polyuria in this setting.

Keywords

• Cerebral salt wasting
• Polyuria
• Antidiuretic hormone
• Hypothalamic injury
• Hypophyseal arteries
• Subarachnoid hemorrhage