Managing patients with hypopituitarism after traumatic brain injury

Activation of pituitary axis according to underlying critical illness and its effect on outcome

PURPOSE

Critical illness is a life threatening condition inducing a severe acute physical stress. The aim of the study was to investigate the activation of pituitary axis early after ICU admission in patients with critical illnesses of different etiology and its association with outcome.

MATERIALS AND METHODS

Patients admitted for acute respiratory distress syndrome (ARDS), severe traumatic brain injury (TBI), subarachnoid hemorrhage (SAH) and neurocritically ill patients at the moment of brain death (BD) diagnosis were included in the present post-hoc analysis. On day 1, 2-3 and 4-5 after admission the following pituitary axes were assessed: hypothalamic-pituitary-adrenal, hypothalamic-pituitary-thyroid, somatotroph, prolactin and copeptin. ICU mortality was used as outcome measure.

RESULTS

One hundred-thirteen critical ill patients were studied. Thyroid axis suppression and activation of copeptin axis were the most frequent pituitary hormone alterations, present in almost 60% of patients. Activation of the hypothalamic pituitary adrenal axis was a predictor of ICU mortality independently from the underlying critical illness [OR 3.952 (C.I.95% 1.129-13.838)].

CONCLUSIONS

Pituitary axis function is frequently altered early after ICU admission, the magnitude of hormonal response being different according to the underlying critical illness. The activation of the hypothalamic pituitary adrenal axis was a strong predictor of ICU mortality.

The role of autoimmunity in pituitary dysfunction due to traumatic brain injury

PURPOSE

Traumatic brain injury (TBI) is one of the most common causes of mortality and long-term disability and it is associated with an increased prevalence of neuroendocrine dysfunctions. Post-traumatic hypopituitarism (PTHP) results in major physical, psychological and social consequences leading to impaired quality of life. PTHP can occur at any time after traumatic event, evolving through various ways and degrees of deficit, requiring appropriate screening for early detection and treatment. Although the PTHP pathophysiology remains to be elucitated, on the basis of proposed hypotheses it seems to be the result of combined pathological processes, with a possible role played by hypothalamic-pituitary autoimmunity (HPA). This review is aimed at focusing on this possible role in the development of PTHP and its potential clinical consequences, on the basis of the data so far appeared in the literature and of some results of personal studies on this issue.

METHODS

Scrutinizing the data so far appeared in literature on this topic, we have found only few studies evaluating the autoimmune pattern in affected patients, searching in particular for antipituitary and antihypothalamus autoantibodies (APA and AHA, respectively) by simple indirect immunofluorescence.

RESULTS

The presence of APA and/or AHA at high titers was associated with an increased risk of onset/persistence of PTHP.

CONCLUSIONS

HPA seems to contribute to TBI-induced pituitary damage and related PTHP. However, further prospective studies in a larger cohort of patients are needed to define etiopathogenic and diagnostic role of APA/AHA in development of post-traumatic hypothalamic/pituitary dysfunctions after a TBI.

Differences according to Sex in Sociosexuality and Infidelity after Traumatic Brain Injury

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.

Pituitary dysfunction after traumatic brain injury: a clinical and pathophysiological approach

Traumatic brain injury (TBI) is a growing public health problem worldwide and is a leading cause of death and disability. The causes of TBI include motor vehicle accidents, which are the most common cause, falls, acts of violence, sports-related head traumas, and war accidents including blast-related brain injuries. Recently, pituitary dysfunction has also been described in boxers and kickboxers. Neuroendocrine dysfunction due to TBI was described for the first time in 1918. Only case reports and small case series were reported until 2000, but since then pituitary function in TBI victims has been investigated in more detail. The frequency of hypopituitarism after TBI varies widely among different studies (15-50% of the patients with TBI in most studies). The estimates of persistent hypopituitarism decrease to 12% if repeated testing is applied. GH is the most common hormone lost after TBI, followed by ACTH, gonadotropins (FSH and LH), and TSH. The underlying mechanisms responsible for pituitary dysfunction after TBI are not entirely clear; however, recent studies have shown that genetic predisposition and autoimmunity may have a role. Hypopituitarism after TBI may have a negative impact on the pace or degree of functional recovery and cognition. What is not clear is whether treatment of hypopituitarism has a beneficial effect on specific function. In this review, the current data related to anterior pituitary dysfunction after TBI in adult patients are updated, and guidelines for the diagnosis, follow-up strategies, and therapeutic approaches are reported.

Pituitary dysfunction following traumatic brain injury: clinical perspectives

Traumatic brain injury (TBI) is a well recognized public health problem worldwide. TBI has previously been considered as a rare cause of hypopituitarism, but an increased prevalence of neuroendocrine dysfunction in patients with TBI has been reported during the last 15 years in most of the retrospective and prospective studies. Based on data in the current literature, approximately 15%-20% of TBI patients develop chronic hypopituitarism, which clearly suggests that TBI-induced hypopituitarism is frequent in contrast with previous assumptions. This review summarizes the current data on TBI-induced hypopituitarism and briefly discusses some clinical perspectives on post-traumatic anterior pituitary hormone deficiency.

Neuroendocrine dysfunctions and their consequences following traumatic brain injury

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.

Manifesto for the current understanding and management of traumatic brain injury-induced hypopituitarism

Traumatic brain injury (TBI)-induced hypopituitarism remains a relevant medical problem, because it may affect a significant proportion of the population. In the last decade important studies have been published investigating pituitary dysfunction after TBI. Recently, a group of experts gathered and revisited the topic of TBI-induced hypopituitarism. During the 2-day meeting, the main issues of this topic were presented and discussed, and current understanding and management of TBI-induced hypopituitarism are summarized here.

A p1 aneurysm and diabetes insipidus caused by traumatic brain injury

We describe a patient with a P1 aneurysm of the posterior cerebral artery (PCA) with diabetes insipidus (DI) caused by traumatic brain injury. A 21-year-old woman presented with epidural hematoma, left temporal contusion and subarachnoid hemorrhage caused by head trauma. DI occurred with normal anterior hypophyseal function on the second day after admission and cerebral angiography demonstrated an aneurysm at the right P1 portion after one month. DI was treated with administration of desmopressin and the aneurysm and P1 portion of the right PCA were occluded completely. After three months, her DI recovered and decompressin was discontinued. The six month follow-up angiogram confirmed cure of the P1 aneurysm. P1 aneurysm and DI can be caused by traumatic brain injury. Cranial DI caused by head injury with perturbations in water balance may be transitory and resolve.