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Exp Clin Endocrinol Diabetes 2006; 114(6): 316-321
DOI: 10.1055/s-2006-924254
Article

J. A. Barth Verlag in Georg Thieme Verlag KG Stuttgart · New York

Hypopituitarism following Severe Traumatic Brain Injury

B. L. Herrmann1 , 2 , J. Rehder2 , S. Kahlke2 , H. Wiedemayer3 , A. Doerfler4 , W. Ischebeck5 , R. Laumer6 , M. Forsting4 , D. Stolke3 , K. Mann2
  • 1Institute of Cardio-Diabetes, Technology-Center Bochum, Bochum, Germany
  • 2Department of Endocrinology, University Hospital of Essen, Essen, Germany
  • 3Department of Neurosurgery, University Hospital of Essen, Essen, Germany
  • 4Department of Neuroradiology, University Hospital of Essen, Essen, Germany
  • 5Clinic of Neurosurgical Rehabilitation, University Witten/Herdecke, Witten, Germany
  • 6Department of Neurosurgery, Alfried-Krupp-Clinic, University of Essen, Essen, Germany
Further Information

Publication History

Received: July 9, 2005 First decision: October 21, 2005

Accepted: February 3, 2006

Publication Date:
26 July 2006 (online)

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Abstract

Although hypopituitarism is a known complication of traumatic head injury, it may be under-recognized due to its subtle clinical manifestations. To address this issue, we determine the prevalence of neuroendocrine abnormalities in patients rehabilitating from severe traumatic brain injury (Glasgow Coma Scale ≤ 8). 76 patients (mean age 39 ± 14 yr; range 18 - 65; 53 males and 23 females; BMI 25.8 ± 4.2 kg/m²; mean ± SD) with a severe traumatic brain injury, an average of 22 ± 10 months before this study (median, 20 months), underwent a series of standard endocrine tests, including TSH, free T4, T4, T3, prolactin, testosterone (males), estradiol (females), cortisol, ACTH, GH, and IGF‐I. All subjects also underwent GH response to GHRH + arginine. Growth hormone deficiency (GHD) was defined as a GH response < 9 µg/L to GHRH + arginine and was confirmed by ITT (< 3 µg/L). Pituitary deficiency was shown in 24 % of the patients (18/76). 8 % (n = 6) had GHD (GH-peak range [GHRH + arginine]: 2.8 - 6.3 µg/L; GH-peak range [ITT]: 1.5 - 2.2 µg/L; IGF‐I range: 62 - 174 µg/L). 17 % (n = 13) had hypogonadism (total testosterone < 9.5 nmol/L and low gonadotropins in 12 males; low estradiol, and low gonadotropins in 1 female). Total testosterone levels did not correlate with BMI or age. 2 males with hypogonadism also showed a mild hyperprolactinemia (33 and 41 ng/ml). 3 % (n = 2) patients had partial ACTH-deficiency (cortisol-peak [ITT] 392 and 417 nmol/L) and 3 % (n = 2) had TSH-deficiency. In summary, we have found hypopituitarism in one-fourth of patients with predominantly secondary hypogonadism and GHD. These findings strongly suggest that patients who suffer head trauma must routinely include neuroendocrine evaluations.

Key words

Severe traumatic brain injury - hypopituitarism

References

  • 1 Abs R. Update on the diagnosis of GH deficiency in adults.  Eur J Endocrinol. 2003;  148 (Suppl 2) S3-S8
    CrossrefPubMedSearch in Google Scholar
  • 2 Agha A, Rogers B, Mylotte D, Taleb F, Tormey W, Phillips J, Thompson C J. Neuroendocrine dysfunction in the acute phase of traumatic brain injury.  Clin Endocrinol (Oxf). 2004 c;  60 584-591
    CrossrefPubMedSearch in Google Scholar
  • 3 Agha A, Rogers B, Sherlock M, O'Kelly P, Tormey W, Phillips J, Thompson C J. Anterior pituitary dysfunction in survivors of traumatic brain injury.  J Clin Endocrinol Metab. 2004 a;  89 4929-4936
    CrossrefPubMedSearch in Google Scholar
  • 4 Agha A, Sherlock M, Phillips J, Tormey W, Thompson C J. The natural history of post-traumatic neurohypophysial dysfunction.  Eur J Endocrinol. 2005;  152 371-377
    CrossrefPubMedSearch in Google Scholar
  • 5 Agha A, Thornton E, O'Kelly P, Tormey W, Phillips J, Thompson C J. Posterior pituitary dysfunction after traumatic brain injury.  J Clin Endocrinol Metab. 2004 b;  89 5987-5992
    CrossrefPubMedSearch in Google Scholar
  • 6 Aimaretti G, Ambrosio M R, Benvenga S, Borretta G, De Marinis L, De Menis E, Di Somma C, Faustini-Fustini M, Grottoli S, Gasco V, Gasperi M, Logoluso F, Scaroni C, Giordano G, Ghigo E. Hypopituitarism and growth hormone deficiency (GHD) after traumatic brain injury (TBI).  Growth Horm IGF Res. 2004;  14 (Suppl A) S114-S117
    PubMedSearch in Google Scholar
  • 7 Bengtsson B A, Brummer R J, Bosaeus I. Growth hormone and body composition.  Horm Res. 1990;  33 19-24
    PubMedSearch in Google Scholar
  • 8 Benvenga S, Campenni A, Ruggeri R M, Trimarchi F. Clinical review 113: hypopituitarism secondary to head trauma.  J Clin Endocrinol Metab. 2000;  85 1353-1361
    CrossrefPubMedSearch in Google Scholar
  • 9 Benvenga S, Lo Giudice F, Campenni A, Longo M, Trimarchi F. Post-traumatic selective hypogonadotropic hypogonadism.  J Endocrinol Invest. 1997;  20 675-680
    PubMedSearch in Google Scholar
  • 10 Bondanelli M, De Marinis L, Ambrosio M R, Monesi M, Valle D, Zatelli M C, Fusco A, Bianchi A, Farneti M, degli Uberti E C. Occurrence of pituitary dysfunction following traumatic brain injury.  J Neurotrauma. 2004;  21 685-696
    CrossrefPubMedSearch in Google Scholar
  • 11 Breed S T, Flanagan S R, Watson K R. The relationship between age and the self-report of health symptoms in persons with traumatic brain injury.  Arch Phys Med Rehabil. 2004;  85 S61-S67
    CrossrefPubMedSearch in Google Scholar
  • 12 Clifton G L, Grossman R G, Makela M E, Miner M E, Handel S, Sadhu V. Neurological course and correlated computerized tomography findings after severe closed head injury.  J Neurosurg. 1980;  52 611-624
    CrossrefPubMedSearch in Google Scholar
  • 13 Coiro V, Volpi R, Cataldo S, Capretti L, Caffarri G, Pilla S, Chiodera P. Dopaminergic and cholinergic involvement in the inhibitory effect of dexamethasone on the TSH response to TRH.  J Investig Med. 2000;  48 133-136
    PubMedSearch in Google Scholar
  • 14 Edwards O M, Clark J D. Post-traumatic hypopituitarism. Six cases and a review of the literature.  Medicine (Baltimore). 1986;  65 281-290
    PubMedSearch in Google Scholar
  • 15 Goni M J, Monreal M, Goni F, Sopena M, Gil M J, Moncada E, Salvador J. Effects of cholinergic blockade on nocturnal thyrotropin and growth hormone (GH) secretion in type I diabetes mellitus: further evidence supporting somatostatin's involvement in GH suppression.  Metabolism. 1997;  46 1305-1311
    CrossrefPubMedSearch in Google Scholar
  • 16 Growth Hormone Research Society . Consensus guidelines for the diagnosis and treatment of adults with growth hormone deficiency: summary statement of the Growth Hormone Research Society Workshop on Adult Growth Hormone Deficiency.  J Clin Endocrinol Metab. 1998;  83 379-381
    CrossrefPubMedSearch in Google Scholar
  • 17 Herrmann B L, Berg C, Vogel E, Nowak T, Renzing-Koehler K, Mann K, Saller B. Effects of a combination of recombinant human growth hormone with metformin on glucose metabolism and body composition in patients with metabolic syndrome.  Horm Metab Res. 2004;  36 54-61
    Thieme ConnectPubMedSearch in Google Scholar
  • 18 Jean-Bay E. The biobehavioral correlates of post-traumatic brain injury depression.  J Neurosci Nurs. 2000;  32 169-176
    PubMedSearch in Google Scholar
  • 19 Johannsson G, Marin P, Lonn L, Ottosson M, Stenlof K, Bjorntorp P, Sjostrom L, Bengtsson B A. Growth hormone treatment of abdominally obese men reduces abdominal fat mass, improves glucose and lipoprotein metabolism, and reduces diastolic blood pressure.  J Clin Endocrinol Metab. 1997;  82 727-734
    CrossrefPubMedSearch in Google Scholar
  • 20 Kelly D F, Gonzalo I T, Cohan P, Berman N, Swerdloff R, Wang C. Hypopituitarism following traumatic brain injury and aneurysmal subarachnoid hemorrhage: a preliminary report.  J Neurosurg. 2000;  93 743-752
    CrossrefPubMedSearch in Google Scholar
  • 21 Lieberman S A, Oberoi A L, Gilkison C R, Masel B E, Urban R J. Prevalence of neuroendocrine dysfunction in patients recovering from traumatic brain injury.  J Clin Endocrinol Metab. 2001;  86 2752-2756
    CrossrefPubMedSearch in Google Scholar
  • 22 Marshall L F, Marshall S B, Klauber M R, Van Berkum Clark M, Eisenberg H, Jane J A, Luerssen T G, Marmarou A, Foulkes M A. The diagnosis of head injury requires a classification based on computed axial tomography.  J Neurotrauma. 1992;  9 (Suppl 1) S287-S292
    PubMedSearch in Google Scholar
  • 23 Masel B E. Rehabilitation and hypopituitarism after traumatic brain injury.  Growth Horm IGF Res. 2004;  14 (Suppl A) S108-S113
    PubMedSearch in Google Scholar
  • 24 Mazaux J M, Richer E. Rehabilitation after traumatic brain injury in adults.  Disabil Rehabil. 1998;  20 435-447
    PubMedSearch in Google Scholar
  • 25 Muller E E. Neural control of somatotropic function.  Physiol Rev. 1987;  67 962-1053
    PubMedSearch in Google Scholar
  • 26 Radetti G, Bernasconi S, Bozzola M, Volta C, Tonini G, Gentili L, Rigon F. Pyridostigmine and metoclopramide do not restore the TSH response to TRH inhibited by L-thyroxine treatment in children with goiter.  J Endocrinol Invest. 2000;  23 744-747
    PubMedSearch in Google Scholar
  • 27 Rees P. Hypopituitarism after head injury.  Lancet. 2001;  358 1812
    PubMedSearch in Google Scholar
  • 28 Richard I, Rome J, Lemene B, Louis F, Perrouin-Verbe B, Mathe J F. Post-traumatic endocrine deficits: analysis of a series of 93 severe traumatic brain injuries.  Ann Readapt Med Phys. 2001;  44 19-25
    PubMedSearch in Google Scholar
  • 29 Seidell J C, Visscher T L. Body weight and weight change and their health implications for the elderly.  Eur J Clin Nutr. 2000;  54 (Suppl 3) S33-S39
    PubMedSearch in Google Scholar
  • 30 Valenta L J, De Feo D R. Post-traumatic hypopituitarism due to a hypothalamic lesion.  Am J Med. 1980;  68 614-617
    CrossrefPubMedSearch in Google Scholar
  • 31 Webster J B, Bell K R. Primary adrenal insufficiency following traumatic brain injury: a case report and review of the literature.  Arch Phys Med Rehabil. 1997;  78 314-318
    CrossrefPubMedSearch in Google Scholar

M.D. Burkhard L. Herrmann

Institute of Cardio-Diabetes
Technology-Center of Bochum

Universitätsstraße 142

44799 Bochum

Germany

Phone: + 49-234-7099057

Fax: + 49-234-7099058

Email: herrmann@kardio-diabetes.biz

Email: burkhard.herrmann@uni-essen.de