In the acute period after SAH, hypernatremia is associated with adverse cardiac outcomes and death. SAH patients with hypernatremia should be monitored for evidence of cardiac dysfunction.

Diastolic dysfunction is common after SAH. It is associated with history of hypertension and older age and may explain the development of pulmonary edema in many SAH patients.

Surgical and endovascular aneurysm therapies were associated with similar risks of cardiac injury and dysfunction after SAH. The presence of neurocardiogenic injury should not affect aneurysm treatment decisions.

No abstract

that hyponatremia would be associated with cardiac injury and dysfunction after SAH, as both findings may be related to excessive activation of the sympathetic nervous system.The primary aim of the parent research study was to define the prevalence, reversibility, and pathogenesis of cardiac injury after SAH and its central results have been published elsewhere. We do believe the methods describe our attempts to define which patients received sodium supplementation, and we acknowledge that dehydration plays a role in some cases. We believe that Diabetes Insipidus is rare in this setting. We also believe that the cohorts' clinical characteristics, as described, are quite typical for SAH populations. The lack of association between vasospasm and mortality may be explained by recent advances in the medical and interventional management of vasospasm after SAH; the references provided by Dr. Lazaridis et al are notably more than 13 years old.The study's clear limitations, such as its observational design and inability to describe the patients' volume status, are evident. We believe that this work is hypothesis-generating and agree that more work need to be done in this area. Our central conclusion, is that hypernatremia which is a marker for poor outcome, is germane. We are fully aware of the need to supplement sodium in patients with cerebral salt wasting and as in all quality neurointensive care units surveillance, and mitigation of hyponatremia is a daily consideration. We have not observed a concern by family members about sodium supplementation; on the contrary we explain its necessity to the families as part of our routine communications. We trust that readers would use proper judgement in considering the clinical implications of this work.