J Korean Med Sci.  2005 Oct;20(5):866-869. 10.3346/jkms.2005.20.5.866.

Cerebral Salt Wasting Syndrome After Calvarial Remodeling in Craniosynostosis

• Byeon JH
• Yoo G

• KMID: 1781773
• DOI: http://doi.org/10.3346/jkms.2005.20.5.866

Abstract

Hyponatremia and increased urine output after calvarial remodeling have been noted in pediatric patients with craniosynostosis. If not treated properly, patients develop hypoosmotic conditions that can lead to cerebral edema, increased intracranial pressure, and collapsed circulation. Postoperative hyponatremia after central nervous system surgery is considered as the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Recently, however, cerebral salt wasting syndrome (CSWS) instead of SIADH has been reported frequently. CSWS is associated with a decreased serum sodium level, increased urinary sodium level, increased urine output, decreased ECF volume, increased atrial natriuretic peptide (ANP) level, and increased brain natriuretic peptide (BNP) level. We experienced nine patients with craniosynostosis who underwent calvarial remodeling. By postoperative day 1, the ANP and BNP levels increased by 3-6 folds compared with the preoperative levels. They returned to the normal levels by postoperative day 5. The ADH level was within the normal range even after operation. The urinary sodium level increased in all patients by postoperative day 1 and 3. But the serum sodium level, and serum and urine osmolarity were normal due to appropriate replacement of sodium and fluid. After calvarial remodeling, the potential development of CSWS should be considered and distinguished from SIADH. The patients with CSWS require normal saline resuscitation and should prophylactically receive normal saline.

Keyword

Hyponatremia; Natriuresis; Inappropriate ADH Syndrome; Craniosynostoses; Atrial Natriuretic Factor; Natriuretic Peptide, Brain

MeSH Terms

Child
Child, Preschool
Craniosynostoses/complications/*surgery
Craniotomy/*adverse effects
Diagnosis, Differential
Female
Humans
Hyponatremia/*diagnosis/*etiology
Inappropriate ADH Syndrome/*diagnosis/*etiology
Infant
Male
Reconstructive Surgical Procedures/adverse effects
Research Support, Non-U.S. Gov't
Skull/*surgery

Figure

• 

  Fig. 1 Changes of electrolyte values and osmolarity in the patients at preoperative and postoperative 1st-5th day. PNa+, Plasma level of Na+; UNa+, Urine level of Na+; Posm, Plasma osmolarity; Uosm, Urine osmolarity.

• 

  Fig. 2 Changes of atrial natriuretic peptides (ANP), brain natriuretic peptide (BNP) and antidiuretic hormones (ADH) in the patients at preoperative and postoperative 1st through 5th day.

Reference

1. Peters JP, Welt LG, Sims EA, Orloff J, Needham J. A salt wasting syndrome associated with cerebral disease. Trans Assoc Am Physicians. 1950. 63:57–64.

2. Schwartz WB, Bennett W, Curelop S, Bartter FC. A syndrome of renal sodium loss and hyponatremia probably resulting from inappropriate secretion of antidiuretic hormone. Am J Med. 1957. 23:529–542.

3. Nelson PB, Seif SM, Maroon JC, Robinson AG. Hyponatremia in intracranial disease: Perhaps not the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). J Neurosurg. 1981. 55:938–941.

4. Ganong CA, Kappy MS. Cerebral salt wasting in children. Am J Dis Child. 1993. 147:167–169.

5. Betjes MG. Hyponatremia in acute brain disease: the cerebral salt wasting syndrome. Eur J Intern Med. 2002. 13:9–14.

6. Berger TM, Kistler W, Berendes E, Raufhake C, Walter M. Hyponatremia in a pediatric stroke patient: Syndrome of inappropriate antidiuretic hormone secretion or cerebral salt wasting? Crit Care Med. 2002. 30:792–795.

7. Levin JP, Stelnicki E, Weiner HL, Bradley JP, McCarthy JG. Hyponatremia in the postoperative craniofacial pediatric patient population: a connection to cerebral salt wasting syndrome and management of the disorder. Plast Reconstr Surg. 2001. 108:1501–1508.

8. Palmer BF. Hyponatremia in patients with central nervous system disease: SIADH versus CSW. TRENDS in Endocrinology and Metabolism. 2003. 14:182–187.

9. Roca-Ribas F, Ninno JE, Gasperin A, Lucas M, Llubia C. Cerebral salt wasting syndrome as a postoperative complication after surgical resection of acoustic neuroma. Otol Neurotol. 2002. 23:992–995.

10. Albanese A, Hindmarsh P, Stanhope R. Management of hyponatremia in patients with acute cerebral insults. Arch Dis Child. 2001. 85:246–251.

11. Lee SJ, Huh EJ, Byeon JH. Two cases of cerebral salt wasting syndrome developing after cranial vault remodeling in craniosynostosis in children. J Korean Med Sci. 2004. 19:627–630.