Indian Journal of Critical Care Medicine

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 23 , ISSUE 12 ( December, 2019 ) > List of Articles

Original Article

Impact of Dysnatremia and Dyskalemia on Prognosis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study

Catherine WY Tam, Hoi-Ping Shum, WW Yan

Keywords : Clinical outcome, Hypernatremia, Hyponatremia, Subarachnoid hemorrhage

Citation Information : Tam CW, Shum H, Yan W. Impact of Dysnatremia and Dyskalemia on Prognosis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study. Indian J Crit Care Med 2019; 23 (12):562-567.

DOI: 10.5005/jp-journals-10071-23292

License: CC BY-NC 4.0

Published Online: 01-08-2014

Copyright Statement:  Copyright © 2019; The Author(s).


Background: Electrolyte disturbance is one of the complications of subarachnoid hemorrhage (SAH) and its prognostic value is not fully understood. The focus of this study is to evaluate the impact of dysnatremia and dyskalemia on functional outcomes in patients with aneurysmal SAH. Materials and methods: Patients with spontaneous aneurysmal SAH who were admitted to our intensive care unit (ICU) between 1st January 2011 and 31st December 2016 were included. Demographic data, biochemical parameters from days 1 to day 11 of ICU admission, disease severity, and clinical outcome were recorded. The prognosis was estimated using the Glasgow outcome scale (GOS) at 3 months after the initial insult. Results: A total of 244 patients were included in this study. There were 139 patients (57.0%) with hyponatremia (Na < 135 mmol/L) while 82 patients (33.6%) had hypernatremia (Na >146 mmol/L). Hyponatremia, hypernatremia, and sodium fluctuation >12 mmol/L were more commonly found in those patients with poor outcome. However, both hypokalemia and hyperkalemia were not shown to have a significant effect on the patient's prognosis. Logistic regression analysis identified the following independent predictors of poor outcome (GOS 1–3 at 3 months): age >55 years old, acute physiology and chronic health evaluation IV (APACHE IV) score >50, World Federation of Neurosurgical Societies (WFNS) grade >3, Fisher grade >2, presence of intracranial hemorrhage (ICH)/intraventricular hemorrhage (IVH), use of mannitol, use of loop diuretic aneurysms, involving posterior circulation, and hypernatremia >146 mmol/L. Conclusion: Hypernatremia, but not hyponatremia, in patients with aneurysmal SAH is associated with poor outcome. Both hypokalemia and hyperkalemia were not shown to have a significant effect on the patient's prognosis. Further studies are required to determine whether the treatment of dysnatremia can influence outcomes. Clinical significance: Dysnatremia and dyskalemia are common in patients with aneurysmal SAH, but only hypernatremia is associated with poor outcome. Further studies are required to determine whether the treatment of dysnatremia can influence outcomes.

  1. Rosengart AJ, Schultheiss KE, Tolentino J, Macdonald RL. Prognostic factors for outcome in patients with aneurysmal subarachnoid hemorrhage. Stroke 2007;38(8):2315–2321. DOI: 10.1161/STROKEAHA.107.484360.
  2. de Rooij NK, Linn FH, van der Plas JA, Algra A, Rinkel GJ. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry 2007;78(12):1365–1372. DOI: 10.1136/jnnp.2007.117655.
  3. Wong GK, Wun Tam YY, Zhu XL, Poon WS. Incidence and mortality of spontaneous subarachnoid hemorrhage in Hong Kong from 2002 to 2010: a Hong Kong hospital authority clinical management system database analysis. World Neurosurg 2014;81(3–4):552–556. DOI: 10.1016/j.wneu.2013.07.128.
  4. Naidech AM, Bendok BR, Tamul P, Bassin SL, Watts CM, Batjer HH, et al. Medical complications drive length of stay after brain hemorrhage: a cohort study. Neurocrit Care 2009;10(1):11–19. DOI: 10.1007/s12028-008-9148-x.
  5. Disney L, Weir B, Grace M, Roberts P. Trends in blood pressure, osmolality and electrolytes after subarachnoid hemorrhage from aneurysms. Can J Neurol Sci 1989;16(3):299–304. DOI: 10.1017/S0317167100029127.
  6. McGirt MJ, Blessing R, Nimjee SM, Friedman AH, Alexander MJ, Laskowitz DT, et al. Correlation of serum brain natriuretic peptide with hyponatremia and delayed ischemic neurological deficits after subarachnoid hemorrhage. Neurosurgery 2004;54(6):1369–1373. DOI: 10.1227/01.NEU.0000125016.37332.50.
  7. Bales J, Cho S, Tran TK, Korab GA, Khandelwal N, Spiekerman CF, et al. The effect of hyponatremia and sodium variability on outcomes in adults with aneurysmal subarachnoid hemorrhage. World Neurosurg 2016;96:340–349. DOI: 10.1016/j.wneu.2016.09.005.
  8. Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocrit Care 2005;2(2):110–118. DOI: 10.1385/NCC:2:2:110.
  9. Hijdra A, Brouwers PJ, Vermeulen M, van Gijn J. Grading the amount of blood on computed tomograms after subarachnoid hemorrhage. Stroke 1990;21(8):1156–1161. DOI: 10.1161/01.STR.21.8.1156.
  10. Purkayastha S, Sorond F. Transcranial Doppler ultrasound: technique and application. Semin Neurol 2012;32(4):411–420. DOI: 10.1055/s-0032-1331812.
  11. Compton JS, Redmond S, Symon L. Cerebral blood velocity in subarachnoid haemorrhage: a transcranial Doppler study. J Neurol Neurosurg Psychiatry 1987;50(11):1499–1503. DOI: 10.1136/jnnp.50.11.1499.
  12. Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;1(7905):480–484. DOI: 10.1016/S0140-6736(75)92830-5.
  13. van Gijn J, Rinkel GJ. Subarachnoid haemorrhage: diagnosis, causes and management. Brain 2001;124(Pt 2):249–278. DOI: 10.1093/brain/124.2.249.
  14. Kaminogo M, Yonekura M, Shibata S. Incidence and outcome of multiple intracranial aneurysms in a defined population. Stroke 2003;34(1):16–21. DOI: 10.1161/01.STR.0000046763.48330.AD.
  15. Mayberg MR, Batjer HH, Dacey R, Diringer M, Haley EC, Heros RC, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation 1994;90(5):2592–2605. DOI: 10.1161/01.CIR.90.5.2592.
  16. Lanzino G, Kassell NF, Germanson TP, Kongable GL, Truskowski LL, Torner JC, et al. Age and outcome after aneurysmal subarachnoid hemorrhage: why do older patients fare worse? J Neurosurg 1996;85(3):410–418. DOI: 10.3171/jns.1996.85.3.0410.
  17. Claassen J, Carhuapoma JR, Kreiter KT, Du EY, Connolly ES, Mayer SA. Global cerebral edema after subarachnoid hemorrhage: frequency, predictors, and impact on outcome. Stroke 2002;33(5):1225–1232. DOI: 10.1161/01.STR.0000015624.29071.1F.
  18. Lovelock CE, Rinkel GJ, Rothwell PM. Time trends in outcome of subarachnoid hemorrhage: population-based study and systematic review. Neurology 2010;74(19):1494–1501. DOI: 10.1212/WNL.0b013e3181dd42b3.
  19. Darkwah Oppong M, Gembruch O, Herten A, Frantsev R, Chihi M, Dammann P, et al. Intraventricular hemorrhage caused by subarachnoid hemorrhage: does the severity matter? World Neurosurg 2018;111:e693–e702. DOI: 10.1016/j.wneu.2017.12.148.
  20. Nieuwkamp DJ, Setz LE, Algra A, Linn FH, de Rooij NK, Rinkel GJ. Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis. Lancet Neurol 2009;8(7):635–642. DOI: 10.1016/S1474-4422(09)70126-7.
  21. Kim JT, Park MS, Choi KH, Kim BJ, Han MK, Park TH, et al. Clinical outcomes of posterior versus anterior circulation infarction with low National Institutes of Health Stroke Scale Scores. Stroke 2017;48(1): 55–62. DOI: 10.1161/STROKEAHA.116.013432.
  22. Wijdicks EF, Vermeulen M, Hijdra A, van Gijn J. Hyponatremia and cerebral infarction in patients with ruptured intracranial aneurysms: is fluid restriction harmful? Ann Neurol 1985;17(2):137–140. DOI: 10.1002/ana.410170206.
  23. Sherlock M, O'Sullivan E, Agha A, Behan LA, Rawluk D, Brennan P, et al. The incidence and pathophysiology of hyponatraemia after subarachnoid haemorrhage. Clin Endocrinol 2006;64(3):250–254. DOI: 10.1111/j.1365-2265.2006.02432.x.
  24. Gullans SR, Verbalis JG. Control of brain volume during hyperosmolar and hypoosmolar conditions. Annu Rev Med 1993;44:289–301. DOI: 10.1146/
  25. Takaku A, Shindo K, Tanaka S, Mori T, Suzuki J. Fluid and electrolyte disturbances in patients with intracranial aneurysms. Surg Neurol 1979;11(5):349–356.
  26. Beseoglu K, Etminan N, Steiger HJ, Hanggi D. The relation of early hypernatremia with clinical outcome in patients suffering from aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2014;123:164–168. DOI: 10.1016/j.clineuro.2014.05.022.
  27. Kumar AB, Shi Y, Shotwell MS, Richards J, Ehrenfeld JM. Hypernatremia is a significant risk factor for acute kidney injury after subarachnoid hemorrhage: a retrospective analysis. Neurocrit Care 2015;22(2): 184–191. DOI: 10.1007/s12028-014-0067-8.
  28. Eagles ME, Tso MK, Macdonald RL. Significance of fluctuations in serum sodium levels following aneurysmal subarachnoid hemorrhage: an exploratory analysis. J Neurosurg 2018;131(2): 420–425. DOI: 10.3171/2018.3.JNS173068.
  29. Alimohamadi M, Saghafinia M, Alikhani F, Danial Z, Shirani M, Amirjamshidi A. Impact of electrolyte imbalances on the outcome of aneurysmal subarachnoid hemorrhage: a prospective study. Asian J Neurosurg 2016;11(1):29–33. DOI: 10.4103/1793-5482.154978.
  30. Kamp MA, Dibue M, Schneider T, Steiger HJ, Hanggi D. Calcium and potassium channels in experimental subarachnoid hemorrhage and transient global ischemia. Stroke Res Treat 2012;2012:382146. DOI: 10.1155/2012/382146.
  31. Kimura H, Akutsu N, Shiomi R, Kohmura E. Subarachnoid hemorrhage caused by ruptured intracranial fusiform aneurysm associated with microscopic polyangiitis. Neurol Med Chir 2012;52(7):495–498. DOI: 10.2176/nmc.52.495.
  32. Roberts PA, Pollay M, Engles C, Pendleton B, Reynolds E, Stevens FA. Effect on intracranial pressure of furosemide combined with varying doses and administration rates of mannitol. J Neurosurg 1987;66(3):440–446. DOI: 10.3171/jns.1987.66.3.0440.
  33. Sakr Y, Dunisch P, Santos C, Matthes L, Zeidan M, Reinhart K, et al. Poor outcome is associated with less negative fluid balance in patients with aneurysmal subarachnoid hemorrhage treated with prophylactic vasopressor-induced hypertension. Ann Intensive Care 2016;6(1):25. DOI: 10.1186/s13613-016-0128-6.
  34. Li H, Pan R, Wang H, Rong X, Yin Z, Milgrom DP, et al. Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and meta-analysis. Stroke 2013;44(1):29–37. DOI: 10.1161/STROKEAHA.112.663559.
  35. Hoh BL, Topcuoglu MA, Singhal AB, Pryor JC, Rabinov JD, Rordorf GA, et al. Effect of clipping, craniotomy, or intravascular coiling on cerebral vasospasm and patient outcome after aneurysmal subarachnoid hemorrhage. Neurosurgery 2004;55(4):779–786. DOI: 10.1227/01.NEU.0000137628.51839.D5.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.