Pituitary insufficiency after penetrating injury to the sella turcica

The role of the stress system in recovery after traumatic brain injury: A tribute to Bruce S. McEwen

Traumatic brain injury (TBI) represents a major public health concern. Although the majority of individuals that suffer mild-moderate TBI recover relatively quickly, a substantial subset of individuals experiences prolonged and debilitating symptoms. An exacerbated response to physiological and psychological stressors after TBI may mediate poor functional recovery. Individuals with TBI can suffer from poor stress tolerance, impairments in the ability to evaluate stressors, and poor initiation (and cessation) of neuroendocrine stress responses, all of which can exacerbate TBI-mediated dysfunction. Here, we pay tribute to the pioneering neuroendocrinologist Dr. Bruce McEwen by discussing the ways in which his work on stress physiology and allostatic loading impacts the TBI patient population both before and after their injuries. Specifically, we will discuss the modulatory role of hypothalamic-pituitary-adrenal axis responses immediately after TBI and later in recovery. We will also consider the impact of stressors and stress responses in promoting post-concussive syndrome and post-traumatic stress disorders, two common sequelae of TBI. Finally, we will explore the role of early life stressors, prior to brain injuries, as modulators of injury outcomes.

Neuroendocrine Dysfunction in the Acute Setting of Penetrating Brain Injury: A Systematic Review

BACKGROUND

Data on neuroendocrine dysfunction (NED) in the acute setting of penetrating brain injury (PBI) are scarce, and the clinical approach to diagnosis and treatment remains extrapolated from the literature on blunt head trauma.

METHODS

Three databases were searched (PubMed, Scopus, and Cochrane). Risk of bias was computed using the Newcastle-Ottawa Scale, or the methodological quality of case series and case reports, as indicated. This systematic review was registered in PROSPERO (42020172163).

RESULTS

Six relevant studies involving 58 patients with PBI were included. Two studies were prospective cohort analyses, whereas 4 were case reports. The onset of NED was acute in all studies, by the first postinjury day. Risk factors for NED included worse injury severity and the presence of cerebral edema on imaging. Dysfunction of the anterior hypophysis involved the hypothalamic-pituitary-thyroid axis, treated with hormonal replacement, and hypocortisolism, treated with hydrocortisone. The prevalence of central diabetes insipidus was up to 41%. Most patients showed persistent NED months after injury. In separate reports, diabetes insipidus and hypocortisolism showed an association with higher mortality. The available literature for this review is poor, and the studies included had overall low quality with high risk of bias.

CONCLUSIONS

NED seems to be prevalent in the acute phase of PBI, equally involving both anterior and posterior hypophysis. Despite a potential association between NED and mortality, data on the optimal management of NED are limited. This situation defines the need for prospective studies to better characterize the clinical features and optimal therapeutic interventions for NED in PBI.

Nonmissile Penetrating Head Injuries: Surgical Management and Review of the Literature

BACKGROUND

Nonmissile penetrating head injuries (NPHIs) in the civilian population are rare but potentially fatal. Although numerous cases have been reported in the literature, the surgical management of such injuries is still ambiguous, especially with development of surgical techniques. Here, we report 5 cases of NPHIs managed with different surgical techniques and review the literature on surgical treatment of these injuries to outline the appropriate management for these patients from a neurosurgical perspective.

METHODS

We retrospectively reviewed 5 cases of NPHIs managed surgically in our department. The clinical data were collected, including cause, type of objects, way of penetration, initial clinical evaluation, imaging, surgical intervention, postoperative care, complication, follow-up, and outcome. In addition, a systematic review of the literature was performed in the PubMed database to search for articles on surgical treatment of these injuries.

RESULTS

These 5 cases were caused by twisted steel bar, electric welding rod, and sewing needle, respectively. Preoperative imaging, including computed tomography, magnetic resonance imaging, and digital subtraction angiography, was selectively performed to assist the operative plan. Foreign objects were removed surgically in all cases. Postoperative prophylactic administration of antibiotics and anticonvulsants was used to prevent infectious and epileptic complications. Most of the patients achieved a better outcome except for one.

CONCLUSIONS

NPHIs can be fatal but they can be managed with satisfactory results by proper preoperative imaging evaluation, rapid appropriate surgical management, and accurate postoperative care. Personalized surgical intervention should be undertaken depending on the mechanism and extent of the NPHI.

Negative effect of hypopituitarism following brain trauma in patients with diffuse axonal injury

Object

The aim of this prospective observational study was to assess the incidence and pattern of hypopituitarism after diffuse axonal injury (DAI) and to identify its effect on these patients in terms of functional outcome.

Methods

Of 1307 patients with traumatic brain injury treated at the authors' institution between March 2005 and June 2008, 65 patients with DAI were enrolled in the present study. The authors determined basal hormone levels, initial Glasgow Coma Scale scores, the Marshall CT grades, the presence of abnormal signal intensity indicating lesions on MR images, and duration of unconsciousness. At the 6-month follow-up visits, functional outcomes were estimated using the Modified Barthel Index. Univariate and multivariate analyses were performed to identify factors that influenced functional outcomes.

Results

Twenty-one patients with hypopituitarism (Group A) had more lesions in the body of the corpus callosum, basal ganglia, thalamus, and the gray–white matter junction than those without hypopituitarism (Group B). In Group A, growth hormone deficiency (17 patients, 80.9%) was the most common, and multiple pituitary hormone deficiencies were found in 12 patients (57.1%). The mean Modified Barthel Index score at the 6-month follow-up was 64.7 in Group A and 88.5 in Group B (p = 0.027). Duration of unconsciousness (p = 0.035), the Marshall CT grade (p = 0.021), hypopituitarism (p = 0.044), and abnormal signal intensities on MR imaging in midline or deep structures of the brain (p = 0.001) were found to be associated with functional outcome.

Conclusions

The findings in this prospective observational study suggest that hypopituitarism in patients with DAI has a relationship not only with injuries in the midline or deep structures of the brain, but also with a poor outcome.

Penetrating head injury from nailguns: a case series from New Zealand

Penetrating head injury from nailguns has become increasingly recognised due to their frequent use in the construction industry and home. We report a New Zealand case series of 12 penetrating nailgun head injuries, the largest of its type, detailing presentation, management, risk factors and outcomes. Recommendations based on these factors are provided, suggesting a minimal surgical approach and an individually case-assessed need for antibiotic prophylaxis and anti-epileptic drugs. Prognostic factors on initial imaging are discussed. The majority of injuries, despite being visually impressive, are associated with minimal neurological impairment.

Managing patients with hypopituitarism after traumatic brain injury

PURPOSE OF REVIEW

To highlight how traumatic brain injury as well as subarachnoid hemorrhage and primary brain tumors of the central nervous system can induce hypopituitarism - an underdiagnosed clinical problem. Then, further information of the problem is likely to stimulate appropriate screening programs for patients with brain injuries, at high risk of developing an unrecognized hypopituitarism.

RECENT FINDINGS

Recent papers have alerted endocrinologists about brain injury-induced hypopituitarism. Both retrospective and prospective studies recommended that patients with more severe forms of head injury and, in particular, those with fractures of the base of the skull or early diabetes insipidus be closely monitored for signs and symptoms of endocrine dysfunction, and appropriate dynamic pituitary function tests performed.

SUMMARY

We hope this review will stimulate further interest in the endocrine community about the pathophysiology and management (diagnosis and treatment) of different kinds and degrees of pituitary insufficiency due to traumatic brain injury. Further studies will be crucial to raise awareness and remind physicians of the prevalence of hypopituitarism in patients with traumatic brain injury, and elucidate any incremental benefits these patients may receive from hormone replacement.