title: Marathon related death due to brainstem herniation in rehydration-related hyponatraemia: a case report.
abstract: BACKGROUND
  Identifying marathon runners at risk of neurological deterioration at the end of the race (within a large cohort complaining of exhaustion, dehydration, nausea, headache, dizziness, etc.) is challenging. Here we report a case of rehydration-related hyponatraemia with ensuing brain herniation.
  
  
  METHODS
  We report the death of runner in his 30's who collapsed in the recovery area following a marathon. Following rehydration he developed a respiratory arrest in the emergency room. He was found to be hyponatraemic (130 mM). A CT brain scan showed severe hydrocephalus and brain stem herniation. Despite emergency insertion of an extraventricular drain, he was tested for brainstem death the following morning. Funduscopy demonstrated an acute-on-chronic papilledema; CSF spectrophotometry did not reveal any trace of oxyhemoglobin or bilirubin, but ferritin levels were considerably raised (530 ng/mL, upper reference value 12 ng/mL), consistent with a previous bleed. Retrospectively it emerged that the patient had suffered from a thunderclap headache some months earlier. Subsequently he developed morning headaches and nausea. This suggests that he may have suffered from a subarachnoid haemorrhage complicated by secondary hydrocephalus. This would explain why in this case the relatively mild rehydration-related hyponatremia may have caused brain swelling sufficient for herniation.
  
  
  CONCLUSIONS
  Given the frequency of hyponatraemia in marathon runners (serum Na <135 mM in about 13%), and the non-specific symptoms, we discuss how a simple screening test such as funduscopy may help to identify those who require urgent neuroimaging.
authors.affiliation: The Tavistock Intensive Care Unit, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK. a.petzold@ion.ucl.ac.uk.
authors.forename: Axel
authors.initials: A
authors.lastname: Petzold
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Keir
authors.forename: Ian
authors.initials: I
authors.lastname: Appleby