pituitrin and Intracranial-Aneurysm

Autosomal dominant polycystic kidney disease (ADPKD), which frequently leads to end-stage renal disease, currently has no specific drug therapies. Better understanding of its pathogenesis and recent clinical trials have led to more accurate diagnosis of the disease and its manifestations, as well as to promising new approaches to treatment.

Topics: Drug Discovery; Humans; Hypertension; Intracranial Aneurysm; Pain; Polycystic Kidney, Autosomal Dominant; Signal Transduction; TOR Serine-Threonine Kinases; Urinary Tract Infections; Vasopressins

Craniotomy for resection of cerebral arterial venous malformation has been associated with postoperative hypertension, which necessitates administration of large doses of antihypertensive medications to control blood pressure. Controlling blood pressure is essential because hypertensive episodes can lead to postoperative cerebral hemorrhage with increases in morbidity and mortality. We measured vasoactive peptide and catecholamine release in 13 patients who underwent resection of an arterial venous malformation and in a control group of 6 patients who presented for clipping of unruptured cerebral aneurysms. Plasma renin activity, angiotensin I and II, vasopressin, aldosterone, epinephrine, and norepinephrine levels were measured intraoperatively and for 36 h postoperatively. Analysis of variance was used to assess sample and group effects. A significant interaction between sample and groups was found for norepinephrine (p < 0.001) and renin (p = 0.002). Our data suggest that elevated plasma renin and norepinephrine levels are in part responsible for postoperative hypertension in patients undergoing resection of arterial venous malformations. Blocking the release of these hormones may help control blood pressure after surgery for removal of arterial venous malformations.

Topics: Adult; Aldosterone; Angiotensins; Catecholamines; Epinephrine; Female; Humans; Intracranial Aneurysm; Intracranial Arteriovenous Malformations; Intraoperative Period; Male; Vasoactive Intestinal Peptide; Vasopressins

A 38-year-old Japanese man who had undergone clipping surgery for a ruptured aneurysm of the anterior communicating artery 2 days prior, suddenly developed refractory hypernatremia (serum sodium (Na) 156 - 162 mmol/L). Symptoms included low plasma vasopressin, fluctuating urine osmolality (120 - 710 mOsm/kg) and lack of thirst, all suggesting adipsic diabetes insipidus (ADI). Hypernatremia was corrected by scheduled water intake with desmopressin administration. During 1-year follow-up after the surgery, his serum Na level normalized despite the suspension of desmopressin, but neither thirst nor osmolality-dependent vasopressin release recovered. Meanwhile, his urine osmolality shifted to a constant high level. The present case suggests that renal compensatory adaptation, apparently independent of the circulating vasopressin level, plays a major role in water handling in longitudinal ADI.
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Topics: Adaptation, Physiological; Adult; Aneurysm, Ruptured; Body Water; Diabetes Insipidus; Humans; Intracranial Aneurysm; Kidney; Male; Vasopressins

Hemodynamic augmentation is utilized as a treatment in the setting of symptomatic cerebral vasospasm. This approach includes the use of vasopressors to induce hypertension with the aim of improved cerebral blood flow. Agents with potent alpha-1 antagonism properties, including clozapine, can inhibit or blunt the response of several vasopressor agents.. Case report.. A 54-year-old schizophrenic male with an aneurysmal subarachnoid hemorrhage required hemodynamic augmentation in which several vasopressor trials resulted in no or poor response. The addition of epinephrine resulted in a decrease of mean arterial pressure. Vasopressin initiation demonstrated an immediate vasopressor effect.. Vasopressors are an important treatment modality in symptomatic cerebral vasospasm. This case highlights the potential for clozapine to blunt the effects of vasopressors; or in the case of epinephrine, it causes a reversal effect. Vasopressin may be considered an agent of choice in patients who have recently taken clozapine and require hemodynamic augmentation.

Topics: Clozapine; Drug Interactions; Epinephrine; GABA Antagonists; Humans; Hypertension; Intracranial Aneurysm; Male; Middle Aged; Schizophrenia; Subarachnoid Hemorrhage; Vasoconstrictor Agents; Vasopressins; Vasospasm, Intracranial

Labetalol is an effective antihypertensive medication frequently used to treat systemic hypertension in acute care settings, including the management of hypertension associated with a subarachnoid hemorrhage. We present a case of profound hypotension, refractory to inotropic and vasopressor therapy following an iv infusion of labetalol.. Initiation of an iv labetalol infusion resulted in good blood pressure control in a patient suffering from a Fisher grade 3 subarachnoid hemorrhage with an initial Glascow coma scale of 14/15 and mild hydrocephalus. Progressive deterioration of neurological symptoms and evidence of worsening hydrocephalus preceded the sudden development of profound hypotension (60/35 mmHg) and bradycardia with a minimum heart rate of 40 beats.min(-1). Initial resuscitative efforts included administration of intravascular fluid, hypertonic saline, atropine, adrenalin (more than 10 mg in divided doses) and noradrenalin. These measures restored the blood pressure to 80/45 with a HR of 98 beats.min(-1). Intraoperative placement of an intraventricular drain released cerebrospinal fluid under pressure with an initial intracranial pressure of 15 cm H(2)O. A combination of adrenalin, noradrenalin, dopamine and vasopressin infusions were required to restore the blood pressure to 130/65 mmHg after an additional two hours. All inotropic and vasopressor support was weaned off after the 14th hr (about two drug half-lives). The patient was awake and responsive the following day, with no obvious neurological consequences. No evidence of neurological injury, drug administration error or myocardial dysfunction was documented.. The episode of profound hypotension which occurred after initiating a labetolol infusion required maximal combined vasopressor therapy to restore the blood pressure suggesting that this patient demonstrated an extreme sensitivity to labetalol. Combination therapy with adrenergic and nonadrenergic agonists may be required for optimal treatment of profound hypotension associated with labetalol-induced vasoplegia.

Topics: Antihypertensive Agents; Bradycardia; Cardiotonic Agents; Dopamine; Epinephrine; Female; Humans; Hypotension; Intracranial Aneurysm; Labetalol; Middle Aged; Norepinephrine; Subarachnoid Hemorrhage; Time Factors; Vasoconstrictor Agents; Vasopressins

We present a case to illustrate the importance of emphasizing elementary physiology to deduce the basis for the acute onset of polyuria and hypernatremia. An imaginary consultation with Professor McCance is utilized to illustrate how a clinician-physiologist would have explained why these abnormalities developed and how they should have been treated. His approach began with a consideration of the most impressive abnormality. His analysis relied heavily on deductions and the anticipation of the expected responses to a stimulus in quantitative terms. The goals of therapy became evident after he performed mass balance calculations. Professor McCance would not understand why modern clinicians abandoned this form of analysis.

Topics: Adult; Female; Humans; Hypernatremia; Intracranial Aneurysm; Polyuria; Urination; Vasopressins; Water-Electrolyte Imbalance

To determine how mild hypothermia (34 degrees C) affects the hemodynamic and the stress hormonal responses intraoperatively and during extubation in patients undergoing cerebral aneurysm surgery.. After induction, anesthesia was maintained with 1.2% isoflurane and 50% nitrous oxide. For the normothermia and the hypothermia groups, the body temperature was maintained at 36.9 +/- 0.3 degrees C and 34.2 +/- 0.2 degrees C respectively up to the recovery room. Hemodynamic changes were recorded continuously. Stress hormones comprising epinephrine, norepinephrine, ADH, ACTH, and cortisol were measured at the awake control, intraoperative, and extubation periods.. Vital signs of the intraoperative and postextubation time periods were not significantly different between the normothermia and hypothermia groups except for a statistically lower pulse rate intraoperatively in the hypothermia group (P <0.05). In the control awake state, all five hormonal concentrations were similar between the two groups. Intraoperatively, all of the hormonal levels tended to be lower in the hypothermia group compared to the normothermia group, but only the epinephrine level decreased sufficiently to reach statistical significance (P <0.05). During extubation, all stress hormone concentrations, except norepinephrine, were lower in the hypothermia group (epinephrine: P <0.05; ADH: P <0.05; ACTH: P <0.05; cortisol: P <0.05).. Our data suggest that intraoperative mild hypothermia neither significantly affects the blood pressure response nor increases the concentrations of stress hormones intraoperatively. Furthermore, mild hypothermia significantly decreased the plasma concentrations of stress hormones during the extubation period.

Topics: Adrenocorticotropic Hormone; Adult; Aged; Epinephrine; Female; Hemodynamics; Humans; Hydrocortisone; Hypothermia, Induced; Intracranial Aneurysm; Male; Middle Aged; Norepinephrine; Vasopressins

We report a 45 y old male patient with severe hypodipsia, but intact vasopressin secretion and maximal renal response to vasopressin. The patient presented during hot summer days, 18 months after a frontal lobe hemorrhage due to a ruptured aneurysm, with severe hypernatremia (171 mmol/L) and a plasma osmolality of 348 mosm/kg. He was awake and had no interest in fluid intake. After initial correction, a thirst test for 36 hours was performed. Plasma osmolality rose from 295 to 320, urine osmolality rose from 220 to 700 mosm/kg, while plasma vasopressin levels increased more than 3-fold. Throughout the test the patient did not exhibit appreciable thirst. The intact osmoregulation of vasopressin as evidenced by the plasma levels and the elicited renal response, indicates that a selective acquired disturbance of thirst is present. Whether the thirst center is destroyed or/and thirst recognition (frontal lobe affection) is disturbed primarily, can not be decided.

Topics: Aneurysm, Ruptured; Brain Mapping; Cerebral Hemorrhage; Frontal Lobe; Humans; Hypernatremia; Intracranial Aneurysm; Magnetic Resonance Imaging; Male; Middle Aged; Perceptual Disorders; Postoperative Complications; Thirst; Vasopressins; Water-Electrolyte Balance

Hyponatremia following subarachnoid hemorrhage (SAH) occurs due to the inappropriate secretion of antidiuretic hormone (SIADH). However, this condition is also sometimes associated with certain dehydration states.. To clarify the pathogenesis, daily values of urine volume, water balance, and sodium balance (Na Bal) were correlated with plasma levels of atrial natriuretic peptide (ANP), antidiuretic hormone (ADH), and plasma renin activity (PRA) in 31 cases of SAH.. Na Bal was markedly negative on days 2 and 3. Cumulative Na Bal showed continuous negative values until day 10 following SAH. ANP values showed a consistent elevation, while ADH showed only an initial surge. PRA, as the gross indicator of circulatory volume, showed a lack of suppression, indicating no increase in the circulatory volume.. Hyponatremia following SAH therefore appears to be the result of increased natriuresis, due to the inappropriate elevation of ANP rather than SIADH. In this situation, water restriction should not be recommended, since the circulatory volume is decreased.

Topics: Adult; Aged; Aneurysm, Ruptured; Atrial Natriuretic Factor; Body Water; Dehydration; Female; Humans; Hyponatremia; Intracranial Aneurysm; Male; Middle Aged; Natriuresis; Renin; Subarachnoid Hemorrhage; Vasopressins

The relationship between plasma atrial natriuretic peptide (ANP) and antidiuretic hormone (ADH) both of which show high values after subarachnoid hemorrhage and cerebral vasospasm was studied. The subjects were 23 patients who were admitted because of aneurysmal subarachnoid hemorrhage during three years from March, 1989 to March, 1992 and in whom plasma ANP and ADH levels could be determined over time. Cerebral vasospasm was evaluated by the finding of cerebral angiography, clinical symptoms, and presence or not of low density areas on CT. Hyponatremia was defined as the serum sodium level of 130 mEq/l or less for two days or more. Angiographical vasospasm was found in 17 patients (85%), symptomatic vasospasm in 15 patients (65.2%), low density areas on CT in 9 patients (40.9%) and hyponatremia in 8 patients (34.8%). Symptomatic vasospasm was noted in 7 of the 8 patients (87.5%) with hyponatremia, low density areas on CT in 4 patients (50%), the detection rate being high. The plasma ANP and ADH levels were 76.7 +/- 32.1 pg/ml and 2.2 +/- 0.7 pg/ml respectively in the patients with symptomatic vasospasm against 38.3 +/- 21.3 pg/ml and 2.4 +/- 0.6 pg/ml respectively without symptomatic vasospasm, the plasma ANP level being significantly high in the patients with symptomatic vasospasm (p < 0.01). The plasma ANP and ADH were 71.2 +/- 33.8 pg/ml and 2.0 +/- 1.1 pg/ml respectively in the patients with low density areas on CT against 51.2 +/- 31.3 pg/ml and 1.8 +/- 0.5 pg/ml respectively without low density areas on CT.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Atrial Natriuretic Factor; Humans; Hyponatremia; Intracranial Aneurysm; Ischemic Attack, Transient; Rupture, Spontaneous; Subarachnoid Hemorrhage; Vasopressins

Topics: Blood Proteins; Cardenolides; Digoxin; Humans; Hyponatremia; Intracranial Aneurysm; Plasma Volume; Renin; Saponins; Sodium-Potassium-Exchanging ATPase; Subarachnoid Hemorrhage; Vasopressins

The authors describe a case of subarachnoid hemorrhage with hyponatremia accompanied by elevation of plasma atrial natriuretic peptide (ANP). The early phase of hyponatremia was classified as the syndrome of inappropriate secretion of antidiuretic hormone (ADH) due to subarachnoid hemorrhage. However, in the later phase, hyponatremia and natriuresis were accompanied by suppression of ADH while plasma ANP remained elevated. The patient was effectively treated with demeclocycline and hypertonic saline. The significance of ANP in the pathophysiology of increased natriuresis is discussed.

Topics: Aged; Atrial Natriuretic Factor; Demeclocycline; Female; Humans; Hyponatremia; Inappropriate ADH Syndrome; Intracranial Aneurysm; Natriuresis; Saline Solution, Hypertonic; Subarachnoid Hemorrhage; Vasopressins

Measurement of plasma alpha-humanANP (ANP) and antidiuretic hormone (ADH) in 28 cases with aneurysmal subarachnoid haemorrhage (SAH) was carried out, and then compared with control subjects who were infused with hypertonic saline. In cases with hyponatremia (HN), statistical correlation between control subjects and cases without HN was not evident with regards to ANP and plasma osmolality (Posm), excreted fraction of filtrated sodium (FENa) and urinary Na/K. Furthermore, they secreted supernumerarilly in spite of HN. Cases with HN were further subdivided into two groups, they were those cases with negative total sodium balance at the time of appearance of HN, and those cases without total negative sodium balance. In the former, central venous pressure had a tendency to decrease, however, secretion of ANP and ADH was statistically not different in either groups. It appears that ANP regulated urinary sodium excretion against an osmotic or sodium load acts as a maintenance of homeostasis as an osmotic regulator. Cases with HN in which secretion of ADH was physiological, ANP secreted supernumerarilly in spite of hypoosmonaemia and hypovolaemia. Our findings may contribute to a better understanding of the pathophysiological processes leading to hyponatremia in cases with cerebral disorders, and may help to improve the treatment possibilities.

Topics: Adult; Aged; Atrial Natriuretic Factor; Female; Humans; Hyponatremia; Intracranial Aneurysm; Male; Middle Aged; Peptide Fragments; Rupture, Spontaneous; Subarachnoid Hemorrhage; Vasopressins

Diurnal changes in vasopressin and oxytocin levels in cerebrospinal fluid were investigated under normal diurnal conditions. The patients examined had ruptured intracranial aneurysms, and underwent neck-clipping operations and continuous drainage from the basal cistern. All of the patients recovered consciousness without signs of neurological deficit. The investigations were conducted for 2 days starting 5-9 days after the neck-clipping operations were performed. The oxytocin concentration decreased as night fell, remained low during this period and then increased during the day. The vasopressin level demonstrated no definite rhythmic tendency. No correlation was revealed between the changes in the concentrations of either vasopressin or oxytocin in the cerebrospinal fluid and the osmolality.

Topics: Adult; Circadian Rhythm; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Osmolar Concentration; Oxytocin; Postoperative Period; Vasopressins

The cases of diabetes insipidus (DI) after surgery of intracranial aneurysms were reported and discussed. 1. Of 112 patients operated on for intracranial arterial aneurysm (microsurgical approach), four patients (3.6%) showed DI in the postoperative period. In 3 cases of these 4, the aneurysms located on the anterior communicating artery and the remaining one was the posterior inferior cerebellar artery. 2. The exact mechanism of occurrence of DI is obscure. We suppose that not only vascular spasm of branches of the anterior cerebral and anterior communicating arteries supplying to the paraventricular and preoptic nucleus, but also surgical trauma with direct tissue injury might explain the symptoms. 3. All patients showed a monophasic type of DI which started 1 to 4 days after surgery and lasted from 6 up to 9 days. 4. Two patients with DI showed decreased plasma ADH values below 0.6 microunits/ml in the few days prior to the appearance of abnormally large amount of urinary output. Therefore, once the diagnosis of postoperative DI is made, the patients should be managed promptly with the replacement therapy of Aqueous pitressin. 5. A slow continuous infusion of Aqueous pitressin in the range of 1 to 1.5 IU/hr effectively reduce the polyuria which were not controlled by intermittent intramuscular injections.

Topics: Adult; Aged; Aldosterone; Diabetes Insipidus; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Postoperative Complications; Radioimmunoassay; Vasopressins

Clinical aspects with disturbances in fluid and electrolytes metabolism in brain diseases were discussed reviewing 41 cases experienced in our department. These 41 cases were found in 377 patients with diseases of the central nervous system in our hospital during recent 14 months. Hyponatremia was found in 19 cases and aneurysms of A-C, A1 and A2 had the majority of the cases. The cerebral angiography suggested an unstable blood supply to the anterior portion of the hypothalamus, for instance, showing remarkable shift, spasm or obstruction A-C, A1 or A2. The duration of hyponatremia was transient and mostly less than 2 weeks after the last attack of subarachnoid hemorrhage. On the contrary, hypernatremia was seen in 9 cases and 6 of them were found in cases of tumors in the pineal region and A-C, A1 and A2 were intact angiographically. The hypernatremia was continuous and did not response to V-P shunt or any kinds of infusion therapy. The hypernatremia due to cerebral disease is thought to be a result of destruction of the supraoptic and paraventricular nuclei or adjacent area in the anterior potion of the hypothalamus in most of presumed these cases. It might be that the decreased blood supply to the anterior position of the hypothalamus offers an information not of hypoosmolarity but of hypovolemic state, and this information increases the secretion of ADH. This mechanism of hyponatremia could play an important role in S.I.A.D.H.

Topics: Adolescent; Adult; Aged; Brain Diseases; Brain Neoplasms; Child; Female; Humans; Hypernatremia; Hyponatremia; Infant; Intracranial Aneurysm; Male; Middle Aged; Pinealoma; Postoperative Complications; Vasopressins

Topics: Brain Edema; Carotid Artery Diseases; Cerebral Arterial Diseases; Circle of Willis; Dexamethasone; Diabetes Insipidus; Humans; Intracranial Aneurysm; Postoperative Complications; Potassium; Sodium; Thirst; Trimethaphan; Vasopressins; Water-Electrolyte Balance

Topics: Aged; Female; Humans; Hypokalemia; Hyponatremia; Intracranial Aneurysm; Vasopressins

Topics: Adult; Female; Humans; Hyponatremia; Hypothalamo-Hypophyseal System; Intracranial Aneurysm; Male; Middle Aged; Rupture, Spontaneous; Subarachnoid Hemorrhage; Vasopressins; Water-Electrolyte Balance