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Vlad RM, Albu AI, Nicolaescu ID, Dobritoiu R, Carsote M, Sandru F, Albu D, Păcurar D. An Approach to Traumatic Brain Injury-Related Hypopituitarism: Overcoming the Pediatric Challenges. Diagnostics (Basel) 2023; 13:diagnostics13020212. [PMID: 36673021 PMCID: PMC9857786 DOI: 10.3390/diagnostics13020212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/30/2022] [Accepted: 01/01/2023] [Indexed: 01/09/2023] Open
Abstract
Traumatic brain injury (TBI)-related hypopituitarism is a rare polymorphic complication of brain injury, with very little data, particularly concerning children and teenagers. This is a comprehensive review of the literature regarding this pathology, starting from a new pediatric case. The research was conducted on PubMed and included publications from the last 22 years. We identified nine original studies on the pediatric population (two case reports and seven studies; only four of these seven were prospective studies). TBI-related hypopituitarism is associated with isolated hormonal deficits ranging from 22.5% to 86% and multiple hormonal deficiencies from 5.9% to 50% in the studied pediatric population. Growth hormone (GH) deficiency is most often found, including the form with late occurrence after TBI; it was described as persistent in half of the studies. Thyroid-stimulating hormone (TSH) deficiency is identified as a distant complication following TBI; in all three studies, we identified this complication was found to be permanent. Adrenocorticotropic hormone (ACTH) deficiency did not relate to a certain type of brain trauma, and it was transient in reported cases. Hyperprolactinemia was the most frequent hormonal finding, also occurring late after injury. Central diabetes insipidus was encountered early post-TBI, typically with a transient pattern and did not relate to a particular type of injury. TBI-related hypopituitarism, although rare in children, should be taken into consideration even after a long time since the trauma. A multidisciplinary approach is needed if the patient is to safely overcome any acute condition.
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Affiliation(s)
- Raluca Maria Vlad
- Department of Pediatrics, “Grigore Alexandrescu” Emergency Children’s Hospital, 011743 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence: (R.M.V.); (A.I.A.); Tel.: +40-722451462 (R.M.V.); +40-723886967 (A.I.A.)
| | - Alice Ioana Albu
- Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “Elias” Emergency Clinical Hospital, 011461 Bucharest, Romania
- Correspondence: (R.M.V.); (A.I.A.); Tel.: +40-722451462 (R.M.V.); +40-723886967 (A.I.A.)
| | | | - Ruxandra Dobritoiu
- Department of Pediatrics, “Grigore Alexandrescu” Emergency Children’s Hospital, 011743 Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “C. I. Parhon” National Institute of Endocrinology, 011863 Bucharest, Romania
| | - Florica Sandru
- Department of Dermatovenerology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “Elias” University Emergency Hospital, 011461 Bucharest, Romania
| | - Dragos Albu
- 2nd Clinical Department Obstetrics Gynecology, Faculty of Dentistry, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Daniela Păcurar
- Department of Pediatrics, “Grigore Alexandrescu” Emergency Children’s Hospital, 011743 Bucharest, Romania
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
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Rachfalska N, Putowski Z, Krzych ŁJ. Distant Organ Damage in Acute Brain Injury. Brain Sci 2020; 10:E1019. [PMID: 33371363 PMCID: PMC7767338 DOI: 10.3390/brainsci10121019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 02/07/2023] Open
Abstract
Acute brain injuries pose a great threat to global health, having significant impact on mortality and disability. Patients with acute brain injury may develop distant organ failure, even if no systemic diseases or infection is present. The severity of non-neurologic organs' dysfunction depends on the extremity of the insult to the brain. In this comprehensive review we sought to describe the organ-related consequences of acute brain injuries. The clinician should always be aware of the interplay between central nervous system and non-neurological organs, that is constantly present. Cerebral injury is not only a brain disease, but also affects the body as whole, and thus requires holistic therapeutical approach.
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Affiliation(s)
| | | | - Łukasz J. Krzych
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland; (N.R.); (Z.P.)
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Bensalah M, Donaldson M, Labassen M, Cherfi L, Nebbal M, Haffaf EM, Abdennebi B, Guenane K, Kemali Z, Ould Kablia S. Prevalence of hypopituitarism and quality of life in survivors of post-traumatic brain injury. Endocrinol Diabetes Metab 2020; 3:e00146. [PMID: 32704567 PMCID: PMC7375098 DOI: 10.1002/edm2.146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 04/08/2020] [Accepted: 04/19/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hypopituitarism is a recognized sequela of traumatic brain injury (TBI) and may worsen the quality of life (QoL) in survivors. AIMS To assess the prevalence of post-traumatic hypopituitarism (PTHP) and growth hormone deficiency (GHD), and determine their correlation with QoL. METHODS Survivors of moderate to severe TBI were recruited from two Algerian centres. At 3 and 12 months, pituitary function was evaluated using insulin tolerance test (ITT), QoL by growth hormone deficiency in adults' questionnaire (QoL-AGHDA), and 36-item short-form (SF-36) health survey. RESULTS Of 133 (M: 128; F: 5) patients aged 18-65 years, PTHP and GHD were present at 3 and 12 months in 59 (44.4%) and 23 (17.29%), 41/116 (35.3%) and 18 (15.5%). Thirteen patients with GHD at 3 months tested normally at 12 months, while 9 had become GHD at 12 months. At 3 and 12 months, peak cortisol was < 500 nmol/L) in 39 (29.3%) and 29 (25%) patients, but <300 nmol/L in only five and seven. Prevalence for gonadotrophin deficiency was 6.8/8.6%, hypo- and hyperprolactinaemia 6.8/3.8% and 5.2/8.6%, and thyrotrophin deficiency 1.5/0.9%. Mean scores for QoL-AGHDA were higher in patients with PTHP at 3 and 12 months: 7.07 vs 3.62 (P = .001) and in patients with GHD at 12 months: 8.72 vs 4.09 (P = .015). Mean SF-36 scores were significantly lower for PTHP at 3 months. CONCLUSION Prevalence of PTHP and GHD changes with time. AGHDA measures QoL in GHD more specifically than SF-36. Full pituitary evaluation and QoL-AGHDA 12 months after TBI are recommended.
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Affiliation(s)
| | | | - Malek Labassen
- Endocrinology UnitCentral Hospital of ArmyAlgiersAlgeria
| | - Lyes Cherfi
- Critical Care UnitCentral Hospital of ArmyAlgiersAlgeria
| | | | | | | | - Kamel Guenane
- Critical care UnitSalim Zemirli HospitalAlgiersAlgeria
| | - Zahra Kemali
- Endocrinology UnitCentral Hospital of ArmyAlgiersAlgeria
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Yang WH, Chen PC, Wang TC, Kuo TY, Cheng CY, Yang YH. Endocrine dysfunction following traumatic brain injury: a 5-year follow-up nationwide-based study. Sci Rep 2016; 6:32987. [PMID: 27608606 PMCID: PMC5017132 DOI: 10.1038/srep32987] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 08/16/2016] [Indexed: 11/23/2022] Open
Abstract
Post-traumatic endocrine dysfunction is a complication of traumatic brain injury (TBI). However, there is lack of long-term follow-up and large sample size studies. This study included patients suffering from TBI registered in the Health Insurance Database. Endocrine disorders were identified using the ICD codes: 244 (acquired hypothyroidism), 253 (pituitary dysfunction), 255 (disorders of the adrenal glands), 258 (polyglandular dysfunction), and 259 (other endocrine disorders) with at least three outpatient visits within 1 year or one admission diagnosis. Overall, 156,945 insured subjects were included in the final analysis. The 1- and 5-year incidence rates of post-traumatic endocrinopathies were 0.4% and 2%, respectively. The risks of developing a common endocrinopathy (p < 0.001) or pituitary dysfunction (P < 0.001) were significantly higher in patients with a TBI history. Patients with a skull bone fracture had a higher risk of developing pituitary dysfunction at the 1-year follow up (p value < 0.001). At the 5-year follow up, the association between intracranial hemorrhage and pituitary dysfunction (p value: 0.002) was significant. The risk of developing endocrine dysfunction after TBI increased during the entire 5-year follow-up period. Skull bone fracture and intracranial hemorrhage may be associated with short and long-term post-traumatic pituitary dysfunction, respectively.
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Affiliation(s)
- Wei-Hsun Yang
- Division of Neurosurgery, Department of Surgery, Chang Gung Memorial Hospital, Chia-Yi Center, Taiwan
| | - Pau-Chung Chen
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan.,Department of Environmental and Occupational Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ting-Chung Wang
- Division of Neurosurgery, Department of Surgery, Chang Gung Memorial Hospital, Chia-Yi Center, Taiwan
| | - Ting-Yu Kuo
- Center of Excellence for Chang Gung Research Datalink, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chun-Yu Cheng
- Division of Neurosurgery, Department of Surgery, Chang Gung Memorial Hospital, Chia-Yi Center, Taiwan
| | - Yao-Hsu Yang
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan.,Center of Excellence for Chang Gung Research Datalink, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chia-Yi, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Tritos NA, Yuen KCJ, Kelly DF. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY DISEASE STATE CLINICAL REVIEW: A NEUROENDOCRINE APPROACH TO PATIENTS WITH TRAUMATIC BRAIN INJURY. Endocr Pract 2016; 21:823-31. [PMID: 26172127 DOI: 10.4158/ep14567.dscr] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is now recognized as a major public health concern in the United States and is associated with substantial morbidity and mortality in both children and adults. Several lines of evidence indicate that TBI-induced hypopituitarism is not infrequent in TBI survivors and may contribute to the burden of illness in this population. The goal of this article is to review the published data and propose an approach for the neuroendocrine evaluation and management of these patients. METHODS To identify pertinent articles, electronic literature searches were conducted using the following keywords: "traumatic brain injury," "pituitary," "hypopituitarism," "growth hormone deficiency," "hypogonadism," "hypoadrenalism," and "hypothyroidism." Relevant articles were identified and considered for inclusion in the present article. RESULTS TBI-induced hypopituitarism appears to be more common in patients with severe TBI. However, patients with mild TBI or those with repeated, sports-, or blast-related TBI are also at risk for hypopituitarism. Deficiencies of growth hormone and gonadotropins appear to be most common and have been associated with increased morbidity in this population. A systematic approach is advised in order to establish the presence of pituitary hormone deficiencies and implement appropriate replacement therapies. CONCLUSION The presence of traumatic hypopituitarism should be considered during the acute phase as well as during the rehabilitation phase of patients with TBI. All patients with moderate to severe TBI require evaluation of pituitary function. In addition, symptomatic patients with mild TBI and impaired quality of life are at risk for hypopituitarism and should be offered neuroendocrine testing.
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Karamouzis I, Pagano L, Prodam F, Mele C, Zavattaro M, Busti A, Marzullo P, Aimaretti G. Clinical and diagnostic approach to patients with hypopituitarism due to traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), and ischemic stroke (IS). Endocrine 2016; 52:441-50. [PMID: 26573924 DOI: 10.1007/s12020-015-0796-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 11/01/2015] [Indexed: 02/06/2023]
Abstract
The hypothalamic-pituitary dysfunction attributable to traumatic brain injury (TBI), aneurysmal subarachnoid hemorrhage (SAH), and ischemic stroke (IS) has been lately highlighted. The diagnosis of TBI-induced-hypopituitarism, defined as a deficient secretion of one or more pituitary hormones, is made similarly to the diagnosis of classical hypopituitarism because of hypothalamic/pituitary diseases. Hypopituitarism is believed to contribute to TBI-associated morbidity and to functional and cognitive final outcome, and quality-of-life impairment. Each pituitary hormone must be tested separately, since there is a variable pattern of hormone deficiency among patients with TBI-induced-hypopituitarism. Similarly, the SAH and IS may lead to pituitary dysfunction although the literature in this field is limited. The drive to diagnose hypopituitarism is the suspect that the secretion of one/more pituitary hormone may be subnormal. This suspicion can be based upon the knowledge that the patient has an appropriate clinical context in which hypopituitarism can be present, or a symptom known as caused by hypopituitarism. Hypopituitarism should be diagnosed as a combination of low peripheral and inappropriately normal/low pituitary hormones although their basal evaluation may be not distinctive due to pulsatile, circadian, or situational secretion of some hormones. Evaluation of the somatotroph and corticotroph axes require dynamic stimulation test (ITT for both axes, GHRH + arginine test for somatotroph axis) in order to clearly separate normal from deficient responses.
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Affiliation(s)
- Ioannis Karamouzis
- Endocrinology, Diabetology and Metabolic Disease, Department of Translational Medicine, University of Piemonte Orientale "A. Avogadro", Via Solaroli 17, 28100, Novara, Italy
| | - Loredana Pagano
- Endocrinology, Diabetology and Metabolic Disease, Department of Translational Medicine, University of Piemonte Orientale "A. Avogadro", Via Solaroli 17, 28100, Novara, Italy
| | - Flavia Prodam
- Endocrinology, Diabetology and Metabolic Disease, Department of Translational Medicine, University of Piemonte Orientale "A. Avogadro", Via Solaroli 17, 28100, Novara, Italy
| | - Chiara Mele
- Endocrinology, Diabetology and Metabolic Disease, Department of Translational Medicine, University of Piemonte Orientale "A. Avogadro", Via Solaroli 17, 28100, Novara, Italy
- Division of General Medicine, Ospedale S. Giuseppe, Istituto Auxologico Italiano, Verbania, Italy
| | - Marco Zavattaro
- Endocrinology, Diabetology and Metabolic Disease, Department of Translational Medicine, University of Piemonte Orientale "A. Avogadro", Via Solaroli 17, 28100, Novara, Italy
| | - Arianna Busti
- Endocrinology, Diabetology and Metabolic Disease, Department of Translational Medicine, University of Piemonte Orientale "A. Avogadro", Via Solaroli 17, 28100, Novara, Italy
| | - Paolo Marzullo
- Endocrinology, Diabetology and Metabolic Disease, Department of Translational Medicine, University of Piemonte Orientale "A. Avogadro", Via Solaroli 17, 28100, Novara, Italy
- Division of General Medicine, Ospedale S. Giuseppe, Istituto Auxologico Italiano, Verbania, Italy
| | - Gianluca Aimaretti
- Endocrinology, Diabetology and Metabolic Disease, Department of Translational Medicine, University of Piemonte Orientale "A. Avogadro", Via Solaroli 17, 28100, Novara, Italy.
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Abstract
It is time to stop using the term concussion as it has no clear definition and no pathological meaning. This confusion is increasingly problematic as the management of ‘concussed’ individuals is a pressing concern. Historically, it has been used to describe patients briefly disabled following a head injury, with the assumption that this was due to a transient disorder of brain function without long-term sequelae. However, the symptoms of concussion are highly variable in duration, and can persist for many years with no reliable early predictors of outcome. Using vague terminology for post-traumatic problems leads to misconceptions and biases in the diagnostic process, producing uninterpretable science, poor clinical guidelines and confused policy. We propose that the term concussion should be avoided. Instead neurologists and other healthcare professionals should classify the severity of traumatic brain injury and then attempt to precisely diagnose the underlying cause of post-traumatic symptoms.
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Affiliation(s)
- David J Sharp
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - Peter O Jenkins
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital Campus, London, UK
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Moreno JA, McKerral M. Differences according to Sex in Sociosexuality and Infidelity after Traumatic Brain Injury. Behav Neurol 2015; 2015:914134. [PMID: 26543323 PMCID: PMC4620288 DOI: 10.1155/2015/914134] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 08/23/2015] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To explore differences according to sex in sociosexuality and infidelity in individuals with TBI and in healthy controls. PARTICIPANTS Forty-two individuals with mild, moderate, and severe TBI having completed a postacute TBI rehabilitation program, at least six months after injury, and 47 healthy controls. MAIN MEASURES Sociosexual Orientation Inventory-Revised (SOI-R) and Attitudes toward Infidelity Scale. RESULTS Overall, men score significantly higher than women in sociosexuality. However, there was a nonsignificant trend towards a reduction of sociosexuality levels in men with TBI. Infidelity levels were comparable in healthy controls and individuals with TBI. In individuals with TBI, less acceptance of infidelity was significantly associated with an unrestricted sociosexual orientation, but not in healthy controls. CONCLUSIONS As documented in previous cross-cultural studies, men have higher levels of sociosexuality than women. However, men with TBI showed a tendency towards the reduction of sociosexuality. The possibility of a latent explanatory variable is suggested (e.g., post-TBI neuroendocrinological changes). TBI does not seem to have an impact on infidelity, but individuals with TBI who express less acceptance of infidelity also report a more promiscuous mating strategy regarding their behavior, attitudes, and desire. Theoretical implications are discussed in terms of evolutionary theories of human sexuality and neuropsychology.
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Affiliation(s)
- Jhon Alexander Moreno
- Center for Interdisciplinary Research in Rehabilitation (CRIR), Centre de Réadaptation Lucie-Bruneau (CRLB), 2275 Laurier Avenue East, Montréal, QC, Canada H2H 2N8
- Centre de Recherche en Neuropsychologie et Cognition (CERNEC), Département de Psychologie, Université de Montréal, Montréal, QC, Canada
| | - Michelle McKerral
- Center for Interdisciplinary Research in Rehabilitation (CRIR), Centre de Réadaptation Lucie-Bruneau (CRLB), 2275 Laurier Avenue East, Montréal, QC, Canada H2H 2N8
- Centre de Recherche en Neuropsychologie et Cognition (CERNEC), Département de Psychologie, Université de Montréal, Montréal, QC, Canada
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Hypopituitarism in Traumatic Brain Injury-A Critical Note. J Clin Med 2015; 4:1480-97. [PMID: 26239687 PMCID: PMC4519801 DOI: 10.3390/jcm4071480] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/25/2015] [Accepted: 06/30/2015] [Indexed: 01/29/2023] Open
Abstract
While hypopituitarism after traumatic brain injury (TBI) was previously considered rare, it is now thought to be a major cause of treatable morbidity among TBI survivors. Consequently, recommendations for assessment of pituitary function and replacement in TBI were recently introduced. Given the high incidence of TBI with more than 100 pr. 100,000 inhabitants, TBI would be by far the most common cause of hypopituitarism if the recently reported prevalence rates hold true. The disproportion between this proposed incidence and the occasional cases of post-TBI hypopituitarism in clinical practice justifies reflection as to whether hypopituitarism has been unrecognized in TBI patients or whether diagnostic testing designed for high risk populations such as patients with obvious pituitary pathology has overestimated the true risk and thereby the disease burden of hypopituitarism in TBI. The findings on mainly isolated deficiencies in TBI patients, and particularly isolated growth hormone (GH) deficiency, raise the question of the potential impact of methodological confounding, determined by variable test-retest reproducibility, appropriateness of cut-off values, importance of BMI stratified cut-offs, assay heterogeneity, pre-test probability of hypopituitarism and lack of proper individual laboratory controls as reference population. In this review, current recommendations are discussed in light of recent available evidence.
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Fernandez-Rodriguez E, Bernabeu I, Castro AI, Casanueva FF. Hypopituitarism after traumatic brain injury. Endocrinol Metab Clin North Am 2015; 44:151-9. [PMID: 25732651 DOI: 10.1016/j.ecl.2014.10.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The prevalence of hypopituitarism after traumatic brain (TBI) injury is widely variable in the literature; a meta-analysis determined a pooled prevalence of anterior hypopituitarism of 27.5%. Growth hormone deficiency is the most prevalent hormone insufficiency after TBI; however, the prevalence of each type of pituitary deficiency is influenced by the assays used for diagnosis, severity of head trauma, and time of evaluation. Recent studies have demonstrated improvement in cognitive function and cognitive quality of life with substitution therapy in GH-deficient patients after TBI.
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Affiliation(s)
- Eva Fernandez-Rodriguez
- Endocrinology Division, Departamento de Medicina, Complejo Hospitalario Universitario de Santiago de Compostela, SERGAS, Universidad de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ignacio Bernabeu
- Endocrinology Division, Departamento de Medicina, Complejo Hospitalario Universitario de Santiago de Compostela, SERGAS, Universidad de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ana I Castro
- Endocrinology Division, Departamento de Medicina, Complejo Hospitalario Universitario de Santiago de Compostela, SERGAS, Universidad de Santiago de Compostela, Santiago de Compostela, Spain; Research Centre in Physiopathology of Obesity and Nutrition, Instituto Salud Carlos III, Santiago de Compostela, Spain
| | - Felipe F Casanueva
- Endocrinology Division, Departamento de Medicina, Complejo Hospitalario Universitario de Santiago de Compostela, SERGAS, Universidad de Santiago de Compostela, Santiago de Compostela, Spain; Research Centre in Physiopathology of Obesity and Nutrition, Instituto Salud Carlos III, Santiago de Compostela, Spain.
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Murtagh K, Arrol L, Goncalves R, Granger N, German AJ, Smith PM. Hypothalamic-anterior pituitary hormone deficiencies following traumatic brain injury in dogs. Vet Rec 2015; 176:20. [PMID: 25200430 DOI: 10.1136/vr.102626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Traumatic brain injury is an important cause of hypopituitarism in human beings, but limited information exists in the veterinary literature regarding this condition. The primary study objective was to investigate whether hypothalamic-anterior pituitary axis dysfunction exists following traumatic brain injury in 17 client owned dogs. In this retrospective, observational, open, cohort study, information about dogs presented to four separate referral centres between April 2008 and October 2013 was reviewed. Cases were included if they had suffered from non-fatal traumatic brain injury, resulting in neurological dysfunction, and follow-up evaluation included measurement of the serum concentration of insulin-like growth factor 1 (IGF-1), endogenous adrenocorticotrophic hormone (ACTH), basal cortisol, thyroid-stimulating hormone, total thyroxine (TT4) and, if appropriate, free thyroxine. Decreased IGF-1 concentration was the most common abnormality detected (7/17, 41 per cent; median 132 ng/ml, range <15-536), followed by a decreased TT4 concentration (4/17, 23 per cent; median 19, range 4-49). Basal cortisol concentration was less than 20 nmol/l in two cases (2/17, 12 per cent; median 65, range <20-1735), with concurrently undetectable ACTH (<5 pg/ml). This study demonstrates that dogs with a history of traumatic brain injury can develop endocrine abnormalities indicative of hypothalamic-anterior pituitary dysfunction.
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Affiliation(s)
- K Murtagh
- Department of Veterinary Internal Medicine, Small Animal Teaching Hospital, University of Liverpool, Chester High Road, Neston CH64 7TE, UK
| | - L Arrol
- Cave Veterinary Specialists, George's Farm, West Buckland, Nr. Wellington TA21 9LE, UK
| | - R Goncalves
- Department of Veterinary Internal Medicine, Small Animal Teaching Hospital, University of Liverpool, Chester High Road, Neston CH64 7TE, UK
| | - N Granger
- School of Veterinary Sciences, University of Bristol, Langford House, Langford, North Somerset BS40 5DU, UK
| | - A J German
- Department of Veterinary Internal Medicine, Small Animal Teaching Hospital, University of Liverpool, Chester High Road, Neston CH64 7TE, UK
| | - P M Smith
- Davies Veterinary Specialists, Hertfordshire SG5 3HR, UK
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Pekic S, Popovic V. Alternative causes of hypopituitarism: traumatic brain injury, cranial irradiation, and infections. HANDBOOK OF CLINICAL NEUROLOGY 2014; 124:271-90. [PMID: 25248593 DOI: 10.1016/b978-0-444-59602-4.00018-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Hypopituitarism often remains unrecognized due to subtle clinical manifestations. Anterior pituitary hormone deficiencies may present as isolated or multiple and may be transient or permanent. Traumatic brain injury (TBI) is recognized as a risk factor for hypopituitarism, most frequently presenting with isolated growth hormone deficiency (GHD). Data analysis shows that about 15% of patients with TBI have some degree of hypopituitarism which if not recognized may be mistakenly ascribed to persistent neurologic injury and cognitive impairment. Identification of predictors for hypopituitarism after TBI is important, one of them being the severity of TBI. The mechanisms involve lesions in the hypothalamic-pituitary axis and inflammatory changes in the central nervous system (CNS). With time, hypopituitarism after TBI may progress or reverse. Cranial irradiation is another important risk factor for hypopituitarism. Deficiencies in anterior pituitary hormone secretion (partial or complete) occur following radiation damage to the hypothalamic-pituitary region, the severity and frequency of which correlate with the total radiation dose delivered to the region and the length of follow-up. These radiation-induced hormone deficiencies are irreversible and progressive. Despite numerous case reports, the incidence of hypothalamic-pituitary dysfunction following infectious diseases of the CNS has been underestimated. Hypopituitarism usually relates to the severity of the disease, type of causative agent (bacterial, TBC, fungal, or viral) and primary localization of the infection. Unrecognized hypopituitarism may be misdiagnosed as postencephalitic syndrome, while the presence of a sellar mass with suprasellar extension may be misdiagnosed as pituitary macroadenoma in a patient with pituitary abscess which is potentially a life-threatening disease.
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Affiliation(s)
- Sandra Pekic
- Faculty of Medicine, University of Belgrade, and Clinic of Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center Belgrade, Belgrade, Serbia
| | - Vera Popovic
- Faculty of Medicine, University of Belgrade, and Clinic of Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center Belgrade, Belgrade, Serbia.
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Zhu H, Zhao Z, Zhou Y, Chen X, Li Y, Liu X, Lu H, Zhang Y, Zhang J. High-dose glucocorticoid aggravates TBI-associated corticosteroid insufficiency by inducing hypothalamic neuronal apoptosis. Brain Res 2013; 1541:69-80. [PMID: 24103812 DOI: 10.1016/j.brainres.2013.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 10/01/2013] [Accepted: 10/02/2013] [Indexed: 01/28/2023]
Abstract
Emerging experimental and clinical data suggest that severe illness, such as traumatic brain injury (TBI), can induce critical illness-related corticosteroid insufficiency (CIRCI). However, underlying mechanisms of this TBI-associated CIRCI remain poorly understood. We hypothesized that dexamethasone (DXM), a synthetic glucocorticoid, which was widely used to treat TBI, induces hypothalamic neuronal apoptosis to aggravate CIRCI. To test this hypothesis, we have evaluated the dose effect of DXM (1 or 10mg/kg) on the development of acute CIRCI in rats with fluid percussion injury-induced TBI and on cultured rat hypothalamic neurons in vitro (DXM, 10(-5)-10(-8)mol/L). Corticosterone Increase Index was recorded as the marker for CIRCI. In addition, MTT and TUNEL assays were used to measure the viability and apoptosis of hypothalamic neurons in primary culture. Moreover, high-resolution hopping probe ion conductance microscopy (HPICM) was used to monitor the DXM-induced morphological changes in neurons. The incidence of acute CIRCI was significantly higher in the high-dose DXM group on post-injury day 7. Cellular viability was significantly decreased from 12h to 24h after the treatment with a high-dose of DXM. A significantly increase in TUNEL positive cells were detected in cultured cells treated with a high-dose of DXM after 18h. Neurites of hypothalamic neuron were dramatically thinner and the numbers of dendritic beadings increased in neurons treated with the high dose of DXM for 12h. In conclusion, high-dose DXM induced hypothalamic neurons to undergo apoptosis in vivo and in vitro, which may aggravate TBI-associated CIRCI.
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Affiliation(s)
- Hui Zhu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, PR China; Tianjin Neurological Institute, 154 Anshan Road, Heping District, Tianjin 300052, China; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin 300052, PR China; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin 300052, PR China.
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Obiols Alfonso G. Impact of head trauma on pituitary function. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2012; 59:505-515. [PMID: 22652114 DOI: 10.1016/j.endonu.2012.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Revised: 03/13/2012] [Accepted: 03/14/2012] [Indexed: 06/01/2023]
Abstract
There have been in the past decade a growing number of studies relating head trauma to hypopituitarism. This condition may affect the rehabilitation process, and identification of such patients is therefore required. However, the widely different methods used so far for this purpose have provided inconsistent results. The incidence rate of hypopituitarism has probably been overestimated. This review focuses on the impact of head trauma on pituitary function, the diagnostic method, risk factors, and treatment options.
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Affiliation(s)
- Gabriel Obiols Alfonso
- Servicio de Endocrinología y Nutrición, Hospital Universitari Vall d'Hebron, Barcelona, España.
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15
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Czirják S, Rácz K, Góth M. Neuroendocrine dysfunctions and their consequences following traumatic brain injury. Orv Hetil 2012; 153:927-33. [DOI: 10.1556/oh.2012.29399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Posttraumatic hypopituitarism is of major public health importance because it is more prevalent than previously thought. The prevalence of hypopituitarism in children with traumatic brain injury is unknown. Most cases of posttraumatic hypopituitarism remain undiagnosed and untreated in the clinical practice, and it may contribute to the severe morbidity seen in patients with traumatic brain injury. In the acute phase of brain injury, the diagnosis of adrenal insufficiency should not be missed. Determination of morning serum cortisol concentration is mandatory, because adrenal insufficiency can be life threatening. Morning serum cortisol lower than 200 nmol/L strongly suggests adrenal insufficiency. A complete hormonal investigation should be performed after one year of the trauma. Isolated growth hormone deficiency is the most common deficiency after traumatic brain injury. Sports-related chronic repetitive head trauma (because of boxing, kickboxing, football and ice hockey) may also result in hypopituitarism. Close co-operation between neurosurgeons, endocrinologists, rehabilitation physicians and representatives of other disciplines is important to provide better care for these patients. Orv. Hetil., 2012, 153, 927–933.
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Affiliation(s)
| | - Károly Rácz
- Semmelweis Egyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika Budapest
| | - Miklós Góth
- MH Honvédkórház II. Belgyógyászati Osztály Budapest Podmaniczky u. 111. 1062
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16
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Heather N, Cutfield W. Traumatic brain injury: is the pituitary out of harm's way? J Pediatr 2011; 159:686-90. [PMID: 21784444 DOI: 10.1016/j.jpeds.2011.05.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Revised: 04/22/2011] [Accepted: 05/31/2011] [Indexed: 10/18/2022]
Affiliation(s)
- Natasha Heather
- Liggins Institute, University of Auckland, Auckland, New Zealand
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17
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Kokshoorn NE, Smit JWA, Nieuwlaat WA, Tiemensma J, Bisschop PH, Groote Veldman R, Roelfsema F, Franken AAM, Wassenaar MJE, Biermasz NR, Romijn JA, Pereira AM. Low prevalence of hypopituitarism after traumatic brain injury: a multicenter study. Eur J Endocrinol 2011; 165:225-31. [PMID: 21646286 DOI: 10.1530/eje-11-0365] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Hypopituitarism after traumatic brain injury (TBI) is considered to be a prevalent condition. However, prevalence rates differ considerably among reported studies, due to differences in definitions, endocrine assessments of hypopituitarism, and confounding factors, such as timing of evaluation and the severity of the trauma. Aim To evaluate the prevalence of hypopituitarism in a large cohort of TBI patients after long-term follow-up using a standardized endocrine evaluation. Study design Cross-sectional study. PATIENTS AND METHODS We included 112 patients with TBI, hospitalized for at least 3 days and duration of follow-up >1 year after TBI from five (neurosurgical) referral centers. Evaluation of pituitary function included fasting morning hormone measurements and insulin tolerance test (n=90) or, when contraindicated, ACTH stimulation and/or CRH stimulation tests and a GH releasing hormone-arginine test (n=22). Clinical evaluation included quality of life questionnaires. RESULTS We studied 112 patients (75 males), with median age 48 years and mean body mass index (BMI) 26.7±4.8 kg/m(2). Mean duration of hospitalization was 11 (3-105), and 33% of the patients had a severe trauma (Glasgow Coma Scale <9) after TBI. The mean duration of follow-up was 4 (1-12) years. Hypopituitarism was diagnosed in 5.4% (6/112) of patients: severe GH deficiency (n=3), hypogonadism (n=1), adrenal insufficiency (n=2). Patients diagnosed with pituitary insufficiency had significantly higher BMI (P=0.002). CONCLUSION In this study, the prevalence of hypopituitarism during long-term follow-up after TBI was low. Prospective studies are urgently needed to find reliable predictive tools for the identification of patients with a significant pre-test likelihood for hypopituitarism after TBI.
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Affiliation(s)
- N E Kokshoorn
- Department of Endocrinology and Metabolic Diseases C4-R, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands.
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Chen X, Zhang B, Chai Y, Dong B, Lei P, Jiang R, Zhang J. Methylprednisolone exacerbates acute critical illness-related corticosteroid insufficiency associated with traumatic brain injury in rats. Brain Res 2011; 1382:298-307. [PMID: 21262204 DOI: 10.1016/j.brainres.2011.01.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 01/12/2011] [Accepted: 01/14/2011] [Indexed: 10/18/2022]
Abstract
Emerging evidence demonstrates that severe illness could induce critical illness-related corticosteroid insufficiency (CIRCI) and cause poor prognosis. The purpose of this study was to test the hypothesis that methylprednisolone (MP), a synthetic glucocorticoid, promotes post-traumatic apoptosis in both the hypothalamus and pituitary, resulting in acute CIRCI and increased mortality in the acute phase of traumatic brain injury (TBI). We tested this hypothesis by measuring acute CIRCI in rats subjected to fluid percussion injury (FPI) and treated with MP (5-30mg/kg). The corticosteroid response to TBI was evaluated using the corticosterone increase index (CII), where values less than 2.5 were considered indicative of acute CIRCI. The CII of MP treated rats was comparable to that of saline treated control rats before injury but was significantly decreased in injured rats receiving high-dose MP on post-injury day 7. Similarly, the incidence of acute CIRCI was significantly higher in the high-dose MP group on post-injury day 7. Furthermore, the CII of rats that did not survive post-injury was significantly lower compared to that of survival and was indicative of acute CIRCI. We also examined apoptosis in the paraventricular nucleus (PVN) of the hypothalamus and the adenohypophysis of the pituitary, using a TUNEL assay and transmission electron microscopy (TEM). The number of TUNEL-positive cells was significantly higher in injured rats treated with high-dose MP. No TUNEL-positive cells were detected in the adenohypophysis across experimental groups at either 7 or 14days after TBI. However, autopsies performed on rats that did not survive post-injury revealed obvious apoptotic cells in the adenohypophysis. Moreover, TEM revealed morphological changes characteristic of apoptosis in both the PVN and adenohypophysis of high-dose MP treated rats. These data suggest that MP therapy for TBI could increase neuronal apoptosis in both the hypothalamus and pituitary and consequently exacerbate acute CIRCI and mortality induced by TBI.
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Affiliation(s)
- Xin Chen
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, PR China
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Fernandez-Rodriguez E, Bernabeu I, Castro AI, Kelestimur F, Casanueva FF. Hypopituitarism following traumatic brain injury: determining factors for diagnosis. Front Endocrinol (Lausanne) 2011; 2:25. [PMID: 22649368 PMCID: PMC3355957 DOI: 10.3389/fendo.2011.00025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 08/09/2011] [Indexed: 11/13/2022] Open
Abstract
Neuroendocrine dysfunction, long recognized as a consequence of traumatic brain injury (TBI), is a major cause of disability that includes physical and psychological involvement with long-term cognitive, behavioral, and social changes. There is no standard procedure regarding at what time after trauma the diagnosis should be made. Also there is uncertainty on defining the best methods for diagnosis and testing and what types of patients should be selected for screening. Common criteria for evaluating these patients are required on account of the high prevalence of TBI worldwide and the potential new cases of hypopituitarism. The aim of this review is to clarify, based on the evidence, when endocrine assessment should be performed after TBI and which patients should be evaluated. Additional studies are still needed to know the impact of post-traumatic hypopituitarism and to assess the impact of hormone replacement in the prognosis.
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Affiliation(s)
- Eva Fernandez-Rodriguez
- Endocrinology Division, Complejo Hospitalario Universitario de Santiago de Compostela, SERGAS, Departamento de Medicina, Universidad de Santiago de CompostelaSantiago de Compostela, Spain
| | - Ignacio Bernabeu
- Endocrinology Division, Complejo Hospitalario Universitario de Santiago de Compostela, SERGAS, Departamento de Medicina, Universidad de Santiago de CompostelaSantiago de Compostela, Spain
| | - Ana Isabel Castro
- Endocrinology Division, Complejo Hospitalario Universitario de Santiago de Compostela, SERGAS, Departamento de Medicina, Universidad de Santiago de CompostelaSantiago de Compostela, Spain
| | | | - Felipe F. Casanueva
- Endocrinology Division, Complejo Hospitalario Universitario de Santiago de Compostela, SERGAS, Departamento de Medicina, Universidad de Santiago de CompostelaSantiago de Compostela, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología Obesidad y Nutrición, Instituto Salud Carlos IIISantiago de Compostela, Spain
- *Correspondence: Felipe F. Casanueva, Endocrinology Division, Hospital Clinico Universitario, Travesía da Choupana, s/n 15706 Santiago de Compostela, La Coruña, Spain. e-mail:
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Kokshoorn NE, Wassenaar MJE, Biermasz NR, Roelfsema F, Smit JWA, Romijn JA, Pereira AM. Hypopituitarism following traumatic brain injury: prevalence is affected by the use of different dynamic tests and different normal values. Eur J Endocrinol 2010; 162:11-8. [PMID: 19783619 DOI: 10.1530/eje-09-0601] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) has emerged as an important cause of hypopituitarism. However, considerable variations in the prevalence of hypopituitarism are reported. These can partly be explained by severity of trauma and timing of hormonal evaluation, but may also be dependent on endocrine tests and criteria used for diagnosis of hypopituitarism. METHODS Systematic review of studies reporting prevalence of hypopituitarism in adults >or=1 year after TBI focusing on used (dynamic) tests and biochemical criteria. RESULTS We included data from 14 studies with a total of 931 patients. There was considerable variation in definition of hypopituitarism. Overall, reported prevalences of severe GH deficiency varied between 2 and 39%. Prevalences were 8-20% using the GHRH-arginine test (cutoff <9 microg/l), 11-39% using the glucagon test (cutoff 1-5 microg/l), 2% using the GHRH test (no cutoff), and 15-18% using the insulin tolerance test (ITT; cutoff <3 microg/l). Overall, the reported prevalence of secondary adrenal insufficiency had a broad range from 0 to 60%. This prevalence was 0-60% with basal cortisol (cutoff <220 or <440 nmol/l), 7-19% using the ACTH test, and 5% with the ITT as first test (cutoff <500 or <550 nmol/l). Secondary hypothyroidism was present in 0-19% (free thyroxine) or 5-15% (thyroid-releasing hormone stimulation). Secondary hypogonadism was present in 0-29%. CONCLUSION The reported variations in the prevalence rates of hypopituitarism after TBI are in part caused by differences in definitions, endocrine assessments of hypopituitarism, and confounding factors. These methodological issues prohibit simple generalizations of results of original studies on TBI-associated hypopituitarism in the perspective of meta-analyses or reviews.
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Affiliation(s)
- Nieke E Kokshoorn
- Department of Endocrinology and Metabolic Diseases C4-R, Leiden University Medical Center, Leiden, The Netherlands.
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