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The Relationship Between Cerebral Salt Wasting Syndrome and Clinical ORIGINAL ARTICLE Bali Medical Journal (Bali Med J) 2020, Volume 9, Number 2: 489-492 P-ISSN.2089-1180, E-ISSN.2302-2914 The relationship between cerebral salt wasting ORIGINAL ARTICLE syndrome and clinical outcome in severe and moderate traumatic brain injury patient at Sanglah Published by DiscoverSys CrossMark Doi: http://dx.doi.org/10.15562/bmj.v9i2.1774 Hospital, Bali, Indonesia Nyoman Golden,1* Jeffrey Ariesta Putra,2 Wayan Niryana,1 Putu Eka Mardhika1 Volume No.: 9 ABSTRACT Issue: 2 Introduction: Intracranial and extracranial factors causing secondary injury. The relationship between variables was analyzed and using Traumatic Brain Injury (TBI) are the primary targets for medical Chi-square analysis. Data were analyzed using SPSS version 23 for intervention and preventing brain damage. One of the extracranial Windows. factors that worsen the prognosis of TBI is Cerebral Salt Wasting Results: Most of respondents are male (83.3%), severe head injury First page No.: 489 (CSW) syndrome. There are only a few articles that report CSW in TBI (73.3%), mild hyponatremia (90.0%), and negative fluid balance patients, and no studies are describing the relationship between CSW (100.0%) in CSW (+) group (Table 1). However, in CSW (-) group, and clinical outcome of head injury. This study aimed to determine the most of respondents are male (70.0%), moderate head injury (85.0%), P-ISSN.2089-1180 relationship between CSW and clinical outcome of TBI patients. normal serum natrium (80.0%), and positive fluid balance (60.0%). Methods: This was a prospective cohort study conducted from CSW increased the risk of unfavorable outcomes, 5.7 times in moderate October 2018 to May 2019. Data collection was carried out in a surgical and severe head injuries (95% CI=1.8 – 18.4; p=< 0.001). emergency and inpatient ward at Sanglah Hospital. The outcome was Conclusion: CSW syndrome increased the risk of unfavorable E-ISSN.2302-2914 assessed using the Glasgow Outcome Scale (GOS) 3 months after head outcomes in moderate and severe traumatic brain injury patients. Keywords: cerebral salt wasting, hyponatremia, outcome, traumatic brain injury. Cite This Article: Golden, N., Putra, J.A., Niryana, W., Mardhika, P.E. 2020. The relationship between cerebral salt wasting syndrome and clinical outcome in severe and moderate traumatic brain injury patient at Sanglah Hospital, Bali, Indonesia. Bali Medical Journal 9(2): 489-492. DOI:10.15562/bmj.v9i2.1774 1Department of Neurosurgery, INTRODUCTION to low osmolality. The death astrocytes will cause Faculty of Medicine, Universitas disturbance of the blood-brain barrier and cause Udayana, Sanglah General One of the extracranial factors that worsen the Hospital, Bali, Indonesia. brain edema and high intracranial pressure in prognosis of traumatic brain injury (TBI) patients is 6 2 the end. This study’s objective was to determine Department of Surgery, Faculty hyponatremia. Hyponatremia frequently happened of Medicine, Universitas Udayana, the relationship between cerebral salt wasting Sanglah General Hospital, Bali, in TBI patients because the central nervous system syndrome and clinical outcome of moderate and Indonesia. plays an important role in water and natrium severe traumatic brain injury patients. homeostasis.1 Sherlock et al.2 reported that hypona- tremia was experienced by 46.8% of TBI patients, 50.7% of subdural hematoma, 25% of epidural METHODS hematoma, 47.9% of cerebral contusion, and 50% of diffuse axonal injury patients. Albanese et al.3 This study was an observational analytic study also reported that hyponatremia in TBI patients using a prospective cohort design. This research increases mortality by up to 14.3%. begins by identifying subjects with risk factors and A traumatic brain injury could cause disturbance subjects without risk factors, followed up to the of natrium regulation by the kidney. Natriuresis time specified to assess outcomes. Data retrieval *Correspondence to: further caused hypovolemic status and developed was carried out in a surgical emergency instal- Nyoman Golden; Department of to Cerebral Salt Wasting (CSW) syndrome.4 CSW lation and inpatient ward at Sanglah Hospital. Neurosurgery, Faculty of Medicine, syndrome is a collection of symptoms as conse- Examination of serum sodium levels was carried Universitas Udayana, Sanglah General Hospital, Bali, Indonesia; quences of natrium and water regulation failure out at the Clinical Pathology Laboratory of Sanglah [email protected] because of brain disorder with normal kidney Hospital Denpasar. Whereas outcomes according function.5 This syndrome characterized by hypo- to the Glasgow outcome scale were assessed three Received: 2020-03-09 natremia associated with hypovolemia because of months after head injury when the patient was still Accepted: 2020-06-20 natriuresis. As hyponatremia occurs, it will cause being treated or polyclinic control. The time of Published: 2020-08-01 astrocyte apoptosis because of cell swelling due the study was carried out in the period of October Open access: www.balimedicaljournal.org and ojs.unud.ac.id/index.php/bmj 489 ORIGINAL ARTICLE 2018 - May 2019 or until the number of samples volume measured by a negative fluid balance was fulfilled. for 24 hours (with maintenance crystalloid fluid The target population in this study were therapy 16 drops per minute). The outcome was < 13 GCS head injury sufferers with age > 18 years. assessed with GOS-E. The unfavorable outcome This study’s affordable population was patients who was defined as GOS-E value shows a scale of 1 – suffered head injuries with GCS < 13 who were 2 and the outcome severe disability if the GOS-E diagnosed and hospitalized in the Sanglah Hospital value shows a scale of 3 – 4. Favorable outcome was Denpasar ward for the period October 2018 to May defined as score 5 – 8 in GOS-E value. The relation- 2019. ship between variables was analyzed and presented The research sample is part of an affordable using Chi-square to test the significance of the population that meets the inclusion and exclu- comparative hypothesis of two categorical samples sion criteria. The determination of samples is with the significance limits used were p < 0.05 and done by consecutive sampling, which is sampling 95% confidence intervals. Data analysis was carried sequentially during the period of the study until out using SPSS for Windows version 23.0. the required number of samples is fulfilled. The inclusion criteria for this study were adult patients RESULTS > 18 years old with GCS head injury < 13, agrees to participate in this study, followed by the signing of The characteristic of the sample can be seen in an agreement after explanation. Table 1. In this study, there were 70 patients with Patients with a history of brain tumors, moderate and severe TBI patients over 18 years old. cerebrovascular accident (hemorrhagic or non- Forty-two (60%) patients were classified as moder- hemorrhagic stroke), history of previous episodes ate TBI while the other 28 (40%) patients were of seizures or epilepsy, diabetes insipidus, thyroid classified as severe TBI. There were 30 moderate disorders, and kidney disorders were excluded and severe TBI patients (42.8%) who experienced from this study. Patients with a history of using CSW and 40 patients (57.2%) who did not expe- diuretics, who have performed trepanation surgery, rience CSW (Table 1). Most of respondents are and bilateral negative pupillary reflexes were also male (83.3%), severe head injury (73.3%), mild excluded from the study. hyponatremia (90.0%), and negative fluid balance The cerebral salt wasting syndrome was defined (100.0%) in CSW (+) group (Table 1). However, as a collection of symptoms characterized by in CSW (-) group, most of respondents are male hyponatremia findings and decreased extracellular (70.0%), moderate head injury (85.0%), normal volume. Hyponatremia was defined as blood sodium serum natrium (80.0%), and positive fluid balance levels through an examination of serum electrolytes (60.0%) (Table 1). at first arrival (24 hours) less than 136 meq/L before As we can see in Table 2, there is relationship receiving fluid therapy. A decrease in extracellular between the severity of the head injury and the presence of CSW syndrome. CSW syndrome tends Table 1 Baseline characteristics of the sample to present in more severe TBI patients (RR=4.12; 95%CI=2.14-7.92; p<0.001). CSW (+) CSW (-) Variable n = 30 n = 40 In Table 3, we can see that there is a significant relationship between the severity of hyponatremia Gender, n (%) and the clinical outcome of TBI patients (p=0.003). Male 25 (83.3) 28 (70.0) Most of patients with severe hyponatremia condi- Female 5 (16.7) 12 (30.0) tion was in the unfavorable outcome (66.67%) and Age 39.47±19.36 38.88±20.08 normal serum natrium levels was predominant in the favorable clinical outcome (96.9%) (Table 3). Severity of injury, n (%) Based on Table 4, it can be seen that the presence Moderate head injury 8 (26.7) 34 (85.0) of CSW increased the risk of unfavorable outcomes Severe head injury 22 (73.3) 6 (15.0) 5.7 times in moderate and severe TBI patients Serum natrium, n (%) significantly (95% CI=1.8 – 18.4; p<0.001). Normal 0 (0.0) 32 (80.0) Mild hyponatremia 27 (90.0) 8 (20.0) DISCUSSION Severe hyponatremia 3 (10.0) 0 (0.0) Although the incidence of CSW in head injuries Fluid balance, n (%) is unknown, the relationship between the two is Positive 0 (0.0) 24 (60.0) described by several case reports and case series. A study by Steelman et al.7 reported 5% to 10%
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