[Post-traumatic hypopituitarism after skull injury: apropos of 3 cases]

Trauma and thyroid-stimulating hormone abnormalities in pediatric patients

Background

There is limited literature on trauma and endocrine abnormalities in the pediatric trauma setting.

Aim

We studied demographic, medical history, injury experience, and mortality factors to determine their association with abnormal thyroid-stimulating hormone in pediatric trauma patients.

Methods

The 414 pediatric trauma patients were from those seen at an emergency department. The primary outcome variable was abnormal thyroid-stimulating hormone. Secondary outcome variables were abnormal high and abnormal low thyroid-stimulating hormone. Predictor variables were demographics (age, sex, race/ethnicity, body mass index), medical history (thyroid disease, diabetes mellitus, autoimmune disease, psychiatric disease), injury experience (injury cause, injury severity score ≥ 15, moderate/severe traumatic brain injury, length of stay), and mortality (mortality, survival probability). Multivariate logistic regression analyses were conducted.

Results

There were 8.0% ( n = 33) with any abnormal thyroid-stimulating hormone value. In the analysis for abnormal thyroid-stimulating hormone, females (odds ratio:4.95, 95% confidence interval: 2.01, 12.21, p < 0.01) and traumatic brain injury (odds ratio: 8.11, 95% confidence interval: 2.51, 26.16, p < 0.001) were each significantly associated with increased odds. In the analysis for abnormal high thyroid-stimulating hormone (odds ratio: 3.75, 95% confidence interval: 1.37, 10.24, p < 0.05), traumatic brain injury (odds ratio: 11.59, 95% confidence interval: 3.45, 38.97, p < 0.001), and mortality (odds ratio: 35.59, 95% confidence interval: 1.40, 906.57, p < 0.05) were each significantly associated with increased odds. In the analysis for abnormal low thyroid-stimulating hormone, only females (odds ratio: 11.10, 95% confidence interval: 1.26, 97.60, p < 0.05) were significantly associated with increased odds.

Conclusion

In conclusion, females and traumatic brain injury have increased odds for abnormal thyroid-stimulating hormone. Mortality has increased odds for abnormal high thyroid-stimulating hormone. We suggest that clinicians in the pediatric trauma setting carefully monitor females and traumatic brain injury patients with abnormal thyroid-stimulating hormone.

Evaluation of pituitary function in cases with the diagnosis of pediatric mild traumatic brain injury: Cross-sectional study

BACKGROUND

This study was to determine whether pituitary dysfunction occurs after head trauma in children or not and which axis is affected more; to define the association of pituitary dysfunction with the severity of head trauma and duration time after the diagnosis of head trauma.

MATERIALS AND METHODS

In this study, 24 children who were diagnosed with head trauma were evaluated regarding pituitary dysfunction. In all cases, after 12 h fasting, serum cortisol, fT3, fT4, thyroid-stimulating hormone, prolactin, insulin-like growth factor-1, serum sodium, urine density, follicle-stimulating hormone, luteinizing hormone, in female cases E₂, in male cases, TT levels were determined.

RESULTS

Mean age of children was 9.5 ± 3.1 years, 14 children (58.3%) had mild, 9 children (37.5%) had moderate, and 1 children (4.2%) had severe head trauma according to the Glasgow coma scale. Mean duration time after head trauma was 29.4 ± 9.8 months. In all cases, no pathologic condition was determined in the pituitary hormonal axis. In one children (4.2%), low basal cortisol level was found. There were no children with hormonal deficiency in this study.

CONCLUSION

Although pituitary dysfunction after head trauma may develop in the early period, some may present in the late period; therefore, all cases should be followed up at outpatient clinics for a longer period.

Endocrine dysfunction following traumatic brain injury in children

OBJECTIVE

To identify the incidence of endocrine dysfunction in children following traumatic brain injury (TBI).

STUDY DESIGN

This was a prospective evaluation of 31 children after TBI. Inclusion criteria included Glasgow Coma Scale score ≤ 12 and age 1.5-18 years. We evaluated thyroid function, insulin-like growth factor I, insulin-like growth factor-binding protein 3, and cortisol at 1, 3, 6, and 12 months after injury, and assessed prolactin at 3 and 6 months. At 6 months, we also assessed overnight spontaneous growth hormone secretion, nocturnal thyrotropin surge, adrenal reserve, and serum and urine osmolarity.

RESULTS

The average patient age was 11.6 years, and mean Glascow Coma Scale score was 6. The incidence of endocrine dysfunction was 15% at 1 month, 75% at 6 months, and 29% at 12 months. At 12 months after injury, 14% had precocious puberty, 9% had hypothyroidism, and 5% had growth hormone deficiency. Endocrine dysfunction at 1 year did not correlate with the severity of injury.

CONCLUSIONS

Endocrine dysfunction after TBI is common in children, but most cases resolve by 1 year. We recommend endocrine surveillance at both 6 and 12 months following moderate or severe TBI to ensure early intervention for persistent or late-occurring endocrine sequelae.

The effects of head trauma on hypothalamic-pituitary function in children and adolescents

PURPOSE OF REVIEW

Endocrine dysfunctions have been increasingly recognized following traumatic brain injury. Ever more numerous studies on acute head-injured adults have also raised concern about this risk in children and adolescents who have experienced head injury. The current review of the pediatric literature summarizes recent findings on acute-phase dysfunction and traumatic brain injury-associated hypopituitarism.

RECENT FINDINGS

The pathophysiologic mechanisms underlying acute-phase hyponatremic and hypernatremic disorders have been elucidated. Prospective studies on traumatic brain injury-associated hypopituitarism in pediatric patients are ongoing and preliminary data are available.

SUMMARY

Traumatic brain injury, a 'silent epidemic' that carries a considerable burden of disabilities, leads to a variety of endocrine dysfunctions in 28-69% of adult acute head-injured patients. In the acute posttraumatic phase, adrenal insufficiency and electrolyte disorders are critical conditions. Neurosurgical patients, particularly those prone to neurological damage, require prompt diagnosis. Hypopituitarism may be diagnosed months or years after a traumatic brain injury event. Since growth hormone and gonadotropin secretion are most frequently compromised, careful follow-up of growth and pubertal development is mandatory in children hospitalized for traumatic brain injury.

Traumatic brain injury induced hypothalamic-pituitary dysfunction: a paediatric perspective

In survivors of traumatic brain injury (TBI), impairment in anterior pituitary hormone function may be an important cause of long-term morbidity. Histopathological evidence from post-mortem studies suggests that the hypothalamic-pituitary structures are vulnerable to damage following head injury. Pituitary dysfunction, present months or years after injury, is now well recognised in adults, however, little evidence is known about this potential complication in children and adolescents. This article reviews the available paediatric data, which shows that hypopituitarism may occur after both mild and severe TBI, with growth hormone and gonadotrophin deficiencies appearing to be most common abnormalities. Central precocious puberty has also been documented. There are, however, few published data within a population of children with TBI on the incidence or prevalence of hypopituitarism, nor on its natural history or response to hormone replacement, and prospective studies are needed. Given the critical role of anterior pituitary hormones in the regulation of growth, pubertal and neurocognitive development in childhood, early detection of hormone abnormalities following TBI is important. We propose that a multidisciplinary approach to follow-up and endocrine assessment is required for the long-term management and rehabilitation of children and adolescents who survive moderate to severe head injury.

[Pituitary stalk transection syndrome]

BACKGROUND

Pituitary stalk transection is a non-negligible cause of growth hormone (GH) deficiency.

POPULATION AND METHODS

We studied 22 children (13 boys, nine girls) aged at the first clinical manifestations from 2 days to 10 years (average = 5.33 +/- 2 years). Pituitary stalk transection was assessed by the means of magnetic resonance imaging (MRI). The children's past history showed fetal distress in 12 cases (54.5%), cranial trauma in three (13%) and a midline anomaly in three (13%). The first clinical manifestations were neonatal hypoglycemia (two cases), decreased growth velocity (18 cases) and diabetes insipidus (two cases).

RESULTS

GH deficiency was complete, present from the onset in 19 of 22 cases and isolated in four. Fifteen of 22 cases had adreno-corticotrophic hormone (ACTH) and thyroid stimulating hormone (TSH) deficiency. Diabetes insipidus was present in six cases and revealed the syndrome in two. All children older than normal age of puberty (n = 10) had gonadotropin deficiency. In our study, these hormonal anomalies progressed from isolated GH deficiency to multiple hormonal deficiencies.

CONCLUSION

The recently described stalk transection syndrome is relatively frequent and should be suspected after cranial trauma or fetal distress syndrome. The outcome is progressive evolution towards panhypopituitarism and these patients require regular clinical survey and hormonal controls.