Case scenario for fluid management after subarachnoid hemorrhage in the neuro-intensive care unit

Subarachnoid hemorrhage is a cerebrovascular emergency that has potential for a prolonged and complicated hospital course, carrying high rates of morbidity and mortality. The most common cause of spontaneous subarachnoid hemorrhage is aneurysm rupture. Most patients with aneurysmal subarachnoid hemorrhage will need to be monitored closely in an intensive care unit after treatment of the ruptured aneurysm to monitor and prevent potential neurological and medical complications. Neurological complications include seizures, hydrocephalus, high intracranial pressure, cerebral vasospasm, and delayed cerebral ischemia, all of which can worsen outcome of postsubarachnoid hemorrhage. Medical complications that can occur in these patients include hyponatremia, which is commonly caused by either cerebral salt wasting syndrome or syndrome of inappropriate antidiuretic hormone secretion. Close monitoring of the extracellular fluid status and accurately diagnosing the etiology of hyponatremia is important in order to provide the appropriate management and avoid its potential sequelae such as hypovolemia, cerebral edema, and secondary symptomatic cerebral vasospasm.