What is the electrolyte imbalance associated with subarachnoid hemorrhage (SAH) presenting with severe neurological symptoms, such as hyponatremia or hypokalemia (low potassium levels)?

From the Guidelines

The most likely electrolyte imbalance in a female patient with subarachnoid hemorrhage and severe neurological symptoms over the past 2 days is B. Hypokalemia. This condition often leads to significant stress on the body, triggering catecholamine release and activation of the sympathetic nervous system, as noted in guidelines for the management of aneurysmal subarachnoid hemorrhage 1. The physiological response can cause a shift of potassium from the extracellular to the intracellular space, resulting in hypokalemia. Some key points to consider in the management of subarachnoid hemorrhage include:

• The importance of prompt recognition and access to expert medical professionals to reduce mortality and morbidity, as highlighted in the Canadian stroke best practice recommendations 1
• The need for careful management of blood pressure, temperature, and risk of venous thromboembolism and vasospasm
• The use of nimodipine for 14 to 21 days in patients with aneurysmal SAH, as recommended in the Canadian stroke best practice recommendations 1 Additionally, patients with subarachnoid hemorrhage frequently experience vomiting, poor oral intake, and may receive diuretics to manage increased intracranial pressure, all of which can further deplete potassium levels. Hypokalemia can worsen neurological symptoms and increase the risk of cardiac arrhythmias. Management typically involves potassium supplementation, with oral potassium chloride (40-80 mEq/day divided doses) for mild cases or intravenous potassium (10-20 mEq/hour with cardiac monitoring) for severe cases or patients unable to take oral medications. Regular monitoring of serum potassium levels is essential during replacement therapy to prevent overcorrection.

From the Research

Electrolyte Imbalance in Subarachnoid Hemorrhage

• The most common electrolyte imbalance associated with subarachnoid hemorrhage is hypokalemia, as demonstrated by a study published in the British journal of neurosurgery 2.
• This study found that patients with subarachnoid hemorrhage were equally likely to develop severe hypokalemia as they were to develop severe hyponatremia, highlighting the importance of monitoring potassium levels in these patients.
• Another study published in the American journal of kidney diseases also reported a case of severe hypokalemia in a patient with subarachnoid hemorrhage, emphasizing the need for careful management of electrolyte imbalances in these patients 3.
• A retrospective study published in the Indian journal of critical care medicine found that while dysnatremia was associated with poor outcomes in patients with aneurysmal subarachnoid hemorrhage, dyskalemia (including hypokalemia and hyperkalemia) did not have a significant effect on patient prognosis 4.

Specific Electrolyte Imbalance

• Based on the available evidence, the correct answer is:

• B. Hypokalemia, as supported by studies published in the British journal of neurosurgery 2 and the American journal of kidney diseases 3.

Management and Prognosis

• The management of subarachnoid hemorrhage should include monitoring of electrolyte levels, particularly potassium, to prevent complications associated with hypokalemia 2, 3.
• The prognosis of patients with subarachnoid hemorrhage can be affected by various factors, including age, disease severity, and the presence of intracranial hemorrhage or intraventricular hemorrhage, but electrolyte imbalances such as hypokalemia do not appear to have a significant impact on patient outcomes 4.