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Observational Study
. 2024 May 1;52(5):752-763.
doi: 10.1097/CCM.0000000000006182. Epub 2024 Jan 11.

Sodium and Its Impact on Outcome After Aneurysmal Subarachnoid Hemorrhage in Patients With and Without Delayed Cerebral Ischemia

Homeyra Labib  1   2 , Maud A Tjerkstra  1   2 , Bert A Coert  1   2 , René Post  1   2 , W Peter Vandertop  1   2 , Dagmar Verbaan  1   2 , Marcella C A Müller  3
Affiliations
Observational Study

Sodium and Its Impact on Outcome After Aneurysmal Subarachnoid Hemorrhage in Patients With and Without Delayed Cerebral Ischemia

Homeyra Labib et al. Crit Care Med. .

Abstract

Objectives: To perform a detailed examination of sodium levels, hyponatremia and sodium fluctuations, and their association with delayed cerebral ischemia (DCI) and poor outcome after aneurysmal subarachnoid hemorrhage (aSAH).

Design: An observational cohort study from a prospective SAH Registry.

Setting: Tertiary referral center focused on SAH treatment in the Amsterdam metropolitan area.

Patients: A total of 964 adult patients with confirmed aSAH were included between 2011 and 2021.

Interventions: None.

Measurements and main results: A total of 277 (29%) developed DCI. Hyponatremia occurred significantly more often in DCI patients compared with no-DCI patients (77% vs. 48%). Sodium levels, hyponatremia, hypernatremia, and sodium fluctuations did not predict DCI. However, higher sodium levels were significantly associated with poor outcome in DCI patients (DCI onset -7, DCI +0, +1, +2, +4, +5, +8, +9 d), and in no-DCI patients (postbleed day 6-10 and 12-14). Also, hypernatremia and greater sodium fluctuations were significantly associated with poor outcome in both DCI and no-DCI patients.

Conclusions: Sodium levels, hyponatremia, and sodium fluctuations were not associated with the occurrence of DCI. However, higher sodium levels, hypernatremia, and greater sodium fluctuations were associated with poor outcome after aSAH irrespective of the presence of DCI. Therefore, sodium levels, even with mild changes in levels, warrant close attention.

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Conflict of interest statement

Dr. Labib disclosed work for hire. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
Daily sodium levels in patients with and without delayed cerebral ischemia (DCI). A, In patients with DCI, only sodium levels before the onset of DCI were used for analyzing group differences. For example, if a patient developed DCI on postbleed day (PBD) 4, only sodium levels on PBD 0, 1, 2, and 3 were included in the analysis. B, In patients with DCI, only sodium levels after the onset of DCI were used for analyzing group differences. For example, if a patient developed DCI on PBD 4, only sodium levels on PBD 5, 6, and so forth were included in the analysis. Days are presented as PBD with PBD 0 as the day of aneurysmal subarachnoid hemorrhage (aSAH) ictus. The number of available sodium measurements (n = x) per day are noted under the x-axis. *p < 0.05, **p < 0.001.
Figure 2.
Figure 2.
Daily sodium levels in: A, delayed cerebral ischemia (DCI) patients with poor and good outcome at 6 months after aneurysmal subarachnoid hemorrhage (aSAH). Days are centered around the day of DCI onset (DCI 0). B, Daily sodium levels in patients without DCI with poor and good outcome at 6 months after aSAH. Days are presented as postbleed days (PBD) with PBD 0 as the day of aSAH ictus. The number of available sodium measurements (n = x) per day are noted under the x-axis. *p < 0.05, **p < 0.001.
Figure 3.
Figure 3.
Median (interquartile range) sodium fluctuations (A) in delayed cerebral ischemia (DCI) patients with poor and good outcome, and (B) in patients without DCI with poor and good outcome. Sodium fluctuations were defined as the difference between the minimum and maximum sodium level in the concerning time interval. The number of available sodium fluctuation (n = x) per interval are noted under the x-axis. *p < 0.05, **p < 0.001.
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