Abstract
Hyponatremia post-neurosurgical intervention can be dangerous and potentially life-threatening. Two of its most common causes are cerebral salt wasting (CSW) and syndrome of inappropriate anti-diuretic hormone release (SIADH). CSW is proposed to be secondary not only to the elevated levels of circulating atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) but inhibition of steroidogenesis in the zona glomerulosa of the adrenal cortex, thus resulting in mineralocorticoid deficiency. We present a two-year-old male who had developed acute hyponatremia secondary to CSW on post-operative day two after a sub-total resection of a low-grade juvenile pilocytic astrocytoma (WHO grade I). Fludrocortisone was successfully used to manage the refractory hyponatremia and alleviated the need to use very large amounts of oral sodium supplementation.
Highlights
In the intensive care and neurosurgical setting, hyponatremia is both common and concerning
We present a two-year-old male who had developed acute hyponatremia secondary to cerebral salt wasting (CSW) on post-operative day two after a sub-total resection of a low-grade juvenile pilocytic astrocytoma (WHO grade I)
The pathophysiology of CSW is thought to be mediated by increased levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) which, are believed to be released after cerebral trauma [7,8]
Summary
In the intensive care and neurosurgical setting, hyponatremia is both common and concerning. Magnetic resonance imaging (MRI) obtained when the child was stabilized revealed a large multicystic hypothalamic optic chiasm tumor He underwent endoscopic cyst fenestration and subtotal resection of the mass. On post-operative day two, the child was noted to develop polyuria and hyponatremia with urinary output as high as 13 mL/kg/hour and a steep decline in the serum sodium from 135 mEq/L to 128 mEq/L over six hours. On post-operative day six, enteral sodium replacement as high as 13 mEq/kg/day was initiated to facilitate weaning off the hypertonic saline. The hypertonic saline was discontinued but serum sodium values on post-operative day nine decreased to 128 mEq/L, demonstrating that the child could not maintain serum sodium levels off intravenous supplementation. Two months post-operatively; the child continues on fludrocortisone 0.05mg twice a day and oral sodium chloride at 3 mEq/kg/day with normal serum sodium and potassium levels
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