Hydrocortisone vs. dexamethasone in the prophylaxis of post-subarachnoid hemorrhage cerebral salt wasting syndrome
Leander Steger (Münster), Benoit Liquet (Sydney / AU), Keving Agyemang (Sydney / AU), Moritz Freistühler (Münster), Antonio Di Ieva (Sydney / AU), Christian Ertmer (Münster), Walter Stummer (Münster), Eric Suero Molina (Münster; Sydney / AU)
Cerebral salt wasting syndrome (CSW) leads to hyponatremia and is frequently observed in aneurysmal subarachnoid hemorrhage (SAH) patients. Although standards for the diagnosis "CSW" are controversial, it is known that CSW leads to excessive natriuresis and decreased extracellular fluids that result in hyponatremia and hypovolemia. The administration of corticosteroids to SAH patients has proven to be an effective prophylactic treatment. Dexamethasone has been used in patients as a prophylactic deterrent to possible brain swelling. Previous studies that investigated the effect of corticosteroids on hyponatremia development after non-traumatic SAH showed effective prevention by using Hydrocortisone. In this retrospective study, we compare Hydrocortisone and Dexamethasone for the prophylaxis of CSW-associated hyponatremia after non-traumatic SAH.
We analyzed data from 510 non-traumatic SAH patients who had been admitted to the University Hospital of Münster, Germany, from October 2009 to December 2019. During treatment, hyponatremia was defined as blood sodium levels <130mmol/L. The cohorts included patients treated with Dexamethasone (Dexa) (N=188) and Hydrocortisone (Hydro) (N=322). We compared the administrated dose and the length of the treatment among both cohorts. Criteria for CSW diagnosis were defined as blood sodium levels <135 mmol/L and a simultaneous negative fluid balance of the same day. We utilized Poisson and Negative Binomial models with explanatory variables to analyze hyponatremia events, employing a log link function and a Generalized Linear Mixed Model with random slope for Bernoulli trials to account for dependence in observations across time for each patient.
In total, 87 patients (N=47, 25% Dexa patients and N=40, 12.4% Hydro patients) developed hyponatremia (Na(s) <130 mmol/L). Patients received Dexa for a median of 9 days (IQR: 5-15) and Hydro for a median of 10 days (IQR: 8-12.75) with an average dose of 9.21 mg (± 4.32) Dexa per day and 114.27 mg (± 81.88) Hydro per day. Of 510 patients, 210 (41.2%), 95 Dexa patients (50.5% of the Dexa group), and 115 Hydro patients (35.7% of the Hydro group) showed simultaneous negative fluid balance and sodium levels <135 mmol/L.
Our findings demonstrate that Hydro is a highly effective drug for the prophylactic treatment of CSW-associated hyponatremia development following non-traumatic SAH and demonstrate its effectiveness and superiority to Dexa.
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