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  Acute and long-term pituitary insufficiency in traumatic brain injury: a prospective single-centre study

Authors: Klose, M.¹; Juul, A.²; Struck, J.³; Morgenthaler, N. G.³; Kosteljanetz, M.⁴; Feldt-Rasmussen, U.¹

Source: Clinical Endocrinology, Volume 67, Number 4, October 2007 , pp. 598-606(9)

Publisher: Blackwell Publishing

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Summary Objective  To assess the prevalence of hypopituitarism following traumatic brain injury (TBI), describe the time-course and assess the association with trauma-related parameters and early post-traumatic hormone alterations. Design  A 12-month prospective study. Patients  Forty-six consecutive patients with TBI (mild: N = 22; moderate: N = 9; severe: N = 15). Measurements  Baseline and stimulated hormone concentrations were assessed in the early phase (0-12 days post-traumatically), and at 3, 6 and 12 months postinjury. Pituitary tests included the Synacthen-test (acute +6 months) and the insulin tolerance test (ITT) or the GHRH + arginine test if the ITT was contraindicated (3 + 12 months). Insufficiencies were confirmed by retesting. Results  Early post-traumatic hormone alterations mimicking central hypogonadism or hypothyroidism were present in 35 of the 46 (76%) patients. Three months post-traumatically, 6 of the 46 patients failed anterior pituitary testing. At 12 months, one patient had recovered, whereas none developed new insufficiencies. All insufficient patients had GH deficiency (5 out of 46), followed by ACTH- (3 out of 46), TSH- (1 out of 46), LH/FSH- (1 out of 46) and ADH deficiency (1 out of 46). Hypopituitary patients had more frequently been exposed to severe TBI (4 out of 15) than to mild or moderate TBI (1 out of 31) (P = 0·02). Early endocrine alterations including lowered thyroid and gonadal hormones, and increased total cortisol, free cortisol and copeptin were positively associated to TBI severity (P < 0·05), but not to long-term development of hypopituitarism (P > 0·1), although it was indicative in some. Conclusion  Long-term hypopituitarism was frequent only in severe TBI. During the 3-12 months follow-up, recovery but no new insufficiencies were recorded, indicating manifest hypothalamic or pituitary damage already a few months postinjury. Very early hormone alterations were not associated to long-term post-traumatic hypopituitarism. Clinicians should, nonetheless, be aware of potential ACTH deficiency in the early post-traumatic period.Document Type: Research article

DOI: 10.1111/j.1365-2265.2007.02931.x

Affiliations: 1: Department of Medical Endocrinology, 2: Department of Growth and Reproduction, 3: Department of Research, BRAHMS Aktiengesellschaft, Hennigsdorf, Germany 4: Department of Neurosurgery, the University Hospital of Copenhagen, Denmark,

Acute and long-term pituitary insufficiency in traumatic brain injury: a prospective single-centre studyAuthors: Klose, M.¹; Juul, A.²; Struck, J.³; Morgenthaler, N. G.³; Kosteljanetz, M.⁴; Feldt-Rasmussen, U.¹

Source: Clinical Endocrinology, Volume 67, Number 4, October 2007 , pp. 598-606(9)

Publisher: Blackwell Publishing

• < previous article
• |
• next article >
• |
• View Table of Contents

Key: - Free content - New Content - Subscribed Content - Free Trial Content CM8ShowAd(”Skyscraper”);Abstract:

Summary Objective  To assess the prevalence of hypopituitarism following traumatic brain injury (TBI), describe the time-course and assess the association with trauma-related parameters and early post-traumatic hormone alterations. Design  A 12-month prospective study. Patients  Forty-six consecutive patients with TBI (mild: N = 22; moderate: N = 9; severe: N = 15). Measurements  Baseline and stimulated hormone concentrations were assessed in the early phase (0-12 days post-traumatically), and at 3, 6 and 12 months postinjury. Pituitary tests included the Synacthen-test (acute +6 months) and the insulin tolerance test (ITT) or the GHRH + arginine test if the ITT was contraindicated (3 + 12 months). Insufficiencies were confirmed by retesting. Results  Early post-traumatic hormone alterations mimicking central hypogonadism or hypothyroidism were present in 35 of the 46 (76%) patients. Three months post-traumatically, 6 of the 46 patients failed anterior pituitary testing. At 12 months, one patient had recovered, whereas none developed new insufficiencies. All insufficient patients had GH deficiency (5 out of 46), followed by ACTH- (3 out of 46), TSH- (1 out of 46), LH/FSH- (1 out of 46) and ADH deficiency (1 out of 46). Hypopituitary patients had more frequently been exposed to severe TBI (4 out of 15) than to mild or moderate TBI (1 out of 31) (P = 0·02). Early endocrine alterations including lowered thyroid and gonadal hormones, and increased total cortisol, free cortisol and copeptin were positively associated to TBI severity (P < 0·05), but not to long-term development of hypopituitarism (P > 0·1), although it was indicative in some. Conclusion  Long-term hypopituitarism was frequent only in severe TBI. During the 3-12 months follow-up, recovery but no new insufficiencies were recorded, indicating manifest hypothalamic or pituitary damage already a few months postinjury. Very early hormone alterations were not associated to long-term post-traumatic hypopituitarism. Clinicians should, nonetheless, be aware of potential ACTH deficiency in the early post-traumatic period.Document Type: Research article

DOI: 10.1111/j.1365-2265.2007.02931.x

Affiliations: 1: Department of Medical Endocrinology, 2: Department of Growth and Reproduction, 3: Department of Research, BRAHMS Aktiengesellschaft, Hennigsdorf, Germany 4: Department of Neurosurgery, the University Hospital of Copenhagen, Denmark,

PORT CANAVERAL, Fla. — An early morning boating accident off the coast of Port Canaveral claimed the life of an Oviedo man and injured his son Sunday morning.Fish and wildlife agents said the pair were returning from an overnight fishing trip, when they were hit by a second boat around 6:40am, 6 to 8 miles off the coast of Port Canaveral. That boat was driven by Eric Copp, 39, of Merritt Island. Two passengers, Joey and Antonio Giambianco, also of Merritt Island, were on board as well. No one in this group was hurt.

But Christopher Diaz, 46, was knocked unconscious while his son Christian Jensen, 22, suffered injuries on his lower legs.

A mayday call was sent out and two people in another boat arrived at the scene and pulled Jensen aboard.

Two Coast Guard rescue boats from the Port Canaveral station arrived and pulled Diaz on board.

Rescue crews applied CPR to the victim and continued until they pulled into the Sunrise Marina in Port Canaveral where EMS crews determined Diaz could not be revived.

Jensen was transferred to EMS and taken to Holmes Regional Medical Center where he was treated for the injury and shock.

The investigation of the incident has been turned over to the Florida Fish and Wildlife Conservation Commission.PORT CANAVERAL, Fla. — An early morning boating accident off the coast of Port Canaveral claimed the life of an Oviedo man and injured his son Sunday morning.

Fish and wildlife agents said the pair were returning from an overnight fishing trip, when they were hit by a second boat around 6:40am, 6 to 8 miles off the coast of Port Canaveral. That boat was driven by Eric Copp, 39, of Merritt Island. Two passengers, Joey and Antonio Giambianco, also of Merritt Island, were on board as well. No one in this group was hurt.

But Christopher Diaz, 46, was knocked unconscious while his son Christian Jensen, 22, suffered injuries on his lower legs.

A mayday call was sent out and two people in another boat arrived at the scene and pulled Jensen aboard.

Two Coast Guard rescue boats from the Port Canaveral station arrived and pulled Diaz on board.

Rescue crews applied CPR to the victim and continued until they pulled into the Sunrise Marina in Port Canaveral where EMS crews determined Diaz could not be revived.

Jensen was transferred to EMS and taken to Holmes Regional Medical Center where he was treated for the injury and shock.

The investigation of the incident has been turned over to the Florida Fish and Wildlife Conservation Commission.

The following is an interesting article that describes symptoms in some of our TBI cases here  at Hickey Law Firm.    If you or a loved one have experienced an accident or medical malpractice (on land or on a cruise ship) which has resulted in Traumatic brain injury, call us:  1.800.215.7117.     

  

Brain injury and addiction are often linked

Traumatic brain injury is a trauma to the brain caused by an outside force, which may result in a reduced or altered state of mind. Those who have experienced a brain injury may be dealing with cognitive, behavioral and functional deficits.

Often, victims of a brain injury may experience problems thinking, changes in behavior and changes in personality. Survivors are at risk of memory, attention and concentration impairments. Neuropsychologists have found that individuals with TBI may have decreased problem-solving skills, decreased reasoning, faulty decision-making and impaired judgment.

Other neurobehavioral problems include increased irritability, lowered frustration tolerance, difficulty controlling impulses, increased angry aggression, increased apathetic indifference and problems relating well with others.

Because of the complexity of the brain, the specific effects of an injury depend on the cause, location and severity of the trauma.

Many people with TBI, who did not use alcohol or drugs before their injury, are more susceptible to alcohol and drug use. Vulnerability to substance misuse and abuse can be a result of chronic pain, cognitive problems, adjustment and grief issues, and reduced ability to cope with life’s new challenges.

In some cases, substance abuse may be related to the occurrence of the brain injury. Sometimes people’s insight is impaired, increasing one’s risk of misusing substances. A lack of insight and self-awareness can make it difficult for them to understand their behaviors or to predict the negative consequences of those behaviors.

Individuals with a brain injury and substance-related addictions are at risk for seizures and additional brain injuries. Slower-paced substance abuse treatment programs are helpful in accommodating the cognitive and behavioral deficits inherent with a brain injury.

Alcoholics or Narcotics Anonymous-type groups can be helpful for individuals with a brain injury and substance abuse issues; however, the informational material used in these 12-Step programs may need to be modified to become more comprehensible for brain-injured persons. Stress management techniques such as meditation can also be helpful for recovery. Preventative alcohol and drug abuse education for suffers of TBI who are not currently using substances is critically important.

Local head injury foundations or mental health centers can help identify appropriate programs that cater to brain injury survivors and their families. Involving a survivor’s family in the addiction recovery process is often crucial and necessary for the brain-injured patient to recover from addiction.

It’s important to understand that TBI and addictions frequently exist together and that early prognosis and intervention can help a suffering individual recover successfully.

Geeta Arora is pursuing a doctorate in clinical psychology at Argosy University in Tampa and currently works with substance-abusing adults at Manatee Glens. Tobi Gilbert is a clinical neuropsychologist and certified addictions professional currently working at the Florida Institute for Neurologic Rehabilitation Inc. in Wauchula. Manatee Glens, a nonprofit health care provider that delivers services from seven Manatee County locations, produces this biweekly column and welcomes your questions about mental health and substance abuse matters. For further information, call 782-4299 or send an e-mail to nancy.mccarty@manateeglens.org.

MENTAL HEALTH MINUTE

Brain injury and addiction are often linked

Traumatic brain injury is a trauma to the brain caused by an outside force, which may result in a reduced or altered state of mind. Those who have experienced a brain injury may be dealing with cognitive, behavioral and functional deficits.

Often, victims of a brain injury may experience problems thinking, changes in behavior and changes in personality. Survivors are at risk of memory, attention and concentration impairments. Neuropsychologists have found that individuals with TBI may have decreased problem-solving skills, decreased reasoning, faulty decision-making and impaired judgment.

Other neurobehavioral problems include increased irritability, lowered frustration tolerance, difficulty controlling impulses, increased angry aggression, increased apathetic indifference and problems relating well with others.

Because of the complexity of the brain, the specific effects of an injury depend on the cause, location and severity of the trauma.

Many people with TBI, who did not use alcohol or drugs before their injury, are more susceptible to alcohol and drug use. Vulnerability to substance misuse and abuse can be a result of chronic pain, cognitive problems, adjustment and grief issues, and reduced ability to cope with life’s new challenges.

In some cases, substance abuse may be related to the occurrence of the brain injury. Sometimes people’s insight is impaired, increasing one’s risk of misusing substances. A lack of insight and self-awareness can make it difficult for them to understand their behaviors or to predict the negative consequences of those behaviors.

Individuals with a brain injury and substance-related addictions are at risk for seizures and additional brain injuries. Slower-paced substance abuse treatment programs are helpful in accommodating the cognitive and behavioral deficits inherent with a brain injury.

Alcoholics or Narcotics Anonymous-type groups can be helpful for individuals with a brain injury and substance abuse issues; however, the informational material used in these 12-Step programs may need to be modified to become more comprehensible for brain-injured persons. Stress management techniques such as meditation can also be helpful for recovery. Preventative alcohol and drug abuse education for suffers of TBI who are not currently using substances is critically important.

Local head injury foundations or mental health centers can help identify appropriate programs that cater to brain injury survivors and their families. Involving a survivor’s family in the addiction recovery process is often crucial and necessary for the brain-injured patient to recover from addiction.

It’s important to understand that TBI and addictions frequently exist together and that early prognosis and intervention can help a suffering individual recover successfully.

Geeta Arora is pursuing a doctorate in clinical psychology at Argosy University in Tampa and currently works with substance-abusing adults at Manatee Glens. Tobi Gilbert is a clinical neuropsychologist and certified addictions professional currently working at the Florida Institute for Neurologic Rehabilitation Inc. in Wauchula. Manatee Glens, a nonprofit health care provider that delivers services from seven Manatee County locations, produces this biweekly column and welcomes your questions about mental health and substance abuse matters. For further information, call 782-4299 or send an e-mail to nancy.mccarty@manateeglens.org.

MENTAL HEALTH MINUTE

REAUTHORIZATION OF THE TRAUMATIC BRAIN INJURY

ACT

AUGUST 1, 2007.-Ordered to be printed

Mr. KENNEDY, from the Committee on Health, Education, Labor,

and Pensions, submitted the following

REPORT

[To accompany S. 793]

The Committee on Health, Education, Labor, and Pensions, to

which was referred the bill (S. 793) to provide for the expansion

and improvement of traumatic brain injury programs, having considered

the same, reports favorably thereon with an amendment in

the nature of a substitute and recommends that the bill do pass.

CONTENTS

Page

I. Purpose and Need for Legislation ………………………………………………………. 1

II. Summary ………………………………………………………………………………………….. 2

III. History of Legislation and Votes in Committee …………………………………… 3

IV. Explanation of Bill and Committee Views …………………………………………… 4

V. Cost Estimate ……………………………………………………………………………………. 5

VI. Regulatory Impact Statement …………………………………………………………….. 6

VII. Application of Law to the Legislative Branch ……………………………………… 6

VIII. Section-by-Section Analysis ……………………………………………………………….. 6

IX. Changes in Existing Law …………………………………………………………………… 8

I. PURPOSE AND NEED FOR LEGISLATION

The purpose of the ‘‘Reauthorization of the Traumatic Brain Injury

Act” is to direct the Secretary of Health and Human Services

(HHS) to expand and intensify programs with respect to research

and related activities concerning traumatic brain injury (TBI).

Every year, of the 1.5 million people in the United States who sustain

a TBI, 50,000 die and 235,000 are hospitalized. Estimates

show that at a minimum, brain injuries cost the United States $60

billion per year.

VerDate Aug 31 2005 05:59 Aug 06, 2007 Jkt 059010 PO 00000 Frm 00001 Fmt 6659 Sfmt 6602 E:\HR\OC\SR140.XXX SR140 hmoore on PRODPC68 with HMRPT

2

TBI is defined as brain damage from externally inflicted trauma

to the head resulting in significant impairment to an individual’s

physical, psychosocial, and/or cognitive functional abilities. According

to CDC, brain injuries are among the most likely types of injury

to cause death or permanent disability. People ages 15 to 24

years and those over age 75 are the two age groups at highest risk

for TBI. Motor vehicle accidents, sports accidents, falls, and violence

are the major causes of TBI. Whereas motor vehicle accidents

and violence, such as firearm assaults and child abuse, account for

70 percent of TBI in the overall U.S. population, falling is the

major cause in people aged 75 years or older.

TBI is also caused by explosives, and medical experts have described

it as the signature wound of the Iraq war. Up to two-thirds

of injuries in the Iraq war may be brain injuries.

Long known as the silent epidemic, TBI can strike anyone-infant,

youth, or elderly person-without warning and with devastating

results. It is particularly common among young males and

people of both sexes who are 75 years and older. TBI affects the

whole family and often results in huge medical and rehabilitation

expenses over a lifetime.

TBI is different from other disabilities due to the severity of cognitive

loss. Most rehabilitation programs are designed for people

with physical disabilities, not cognitive disabilities that require

special accommodations. Finding needed services is typically a

logistical, financial, and psychological challenge for family members

and other caregivers, because few coordinated systems of care exist

for individuals with TBI. The passage of the Traumatic Brain Injury

Act of 1996 has improved TBI service systems at the statelevel

and also increased the overall visibility of TBI. However, more

work needs to be done at both the national and State level to build

an effective, durable service system for meeting the needs of individuals

with TBI and their families.

REAUTHORIZATION OF THE TRAUMATIC BRAIN INJURY

ACT

AUGUST 1, 2007.-Ordered to be printed

Mr. KENNEDY, from the Committee on Health, Education, Labor,

and Pensions, submitted the following

REPORT

[To accompany S. 793]

The Committee on Health, Education, Labor, and Pensions, to

which was referred the bill (S. 793) to provide for the expansion

and improvement of traumatic brain injury programs, having considered

the same, reports favorably thereon with an amendment in

the nature of a substitute and recommends that the bill do pass.

CONTENTS

Page

I. Purpose and Need for Legislation ………………………………………………………. 1

II. Summary ………………………………………………………………………………………….. 2

III. History of Legislation and Votes in Committee …………………………………… 3

IV. Explanation of Bill and Committee Views …………………………………………… 4

V. Cost Estimate ……………………………………………………………………………………. 5

VI. Regulatory Impact Statement …………………………………………………………….. 6

VII. Application of Law to the Legislative Branch ……………………………………… 6

VIII. Section-by-Section Analysis ……………………………………………………………….. 6

IX. Changes in Existing Law …………………………………………………………………… 8

I. PURPOSE AND NEED FOR LEGISLATION

The purpose of the ‘‘Reauthorization of the Traumatic Brain Injury

Act” is to direct the Secretary of Health and Human Services

(HHS) to expand and intensify programs with respect to research

and related activities concerning traumatic brain injury (TBI).

Every year, of the 1.5 million people in the United States who sustain

a TBI, 50,000 die and 235,000 are hospitalized. Estimates

show that at a minimum, brain injuries cost the United States $60

billion per year.

VerDate Aug 31 2005 05:59 Aug 06, 2007 Jkt 059010 PO 00000 Frm 00001 Fmt 6659 Sfmt 6602 E:\HR\OC\SR140.XXX SR140 hmoore on PRODPC68 with HMRPT

2

TBI is defined as brain damage from externally inflicted trauma

to the head resulting in significant impairment to an individual’s

physical, psychosocial, and/or cognitive functional abilities. According

to CDC, brain injuries are among the most likely types of injury

to cause death or permanent disability. People ages 15 to 24

years and those over age 75 are the two age groups at highest risk

for TBI. Motor vehicle accidents, sports accidents, falls, and violence

are the major causes of TBI. Whereas motor vehicle accidents

and violence, such as firearm assaults and child abuse, account for

70 percent of TBI in the overall U.S. population, falling is the

major cause in people aged 75 years or older.

TBI is also caused by explosives, and medical experts have described

it as the signature wound of the Iraq war. Up to two-thirds

of injuries in the Iraq war may be brain injuries.

Long known as the silent epidemic, TBI can strike anyone-infant,

youth, or elderly person-without warning and with devastating

results. It is particularly common among young males and

people of both sexes who are 75 years and older. TBI affects the

whole family and often results in huge medical and rehabilitation

expenses over a lifetime.

TBI is different from other disabilities due to the severity of cognitive

loss. Most rehabilitation programs are designed for people

with physical disabilities, not cognitive disabilities that require

special accommodations. Finding needed services is typically a

logistical, financial, and psychological challenge for family members

and other caregivers, because few coordinated systems of care exist

for individuals with TBI. The passage of the Traumatic Brain Injury

Act of 1996 has improved TBI service systems at the statelevel

and also increased the overall visibility of TBI. However, more

work needs to be done at both the national and State level to build

an effective, durable service system for meeting the needs of individuals

with TBI and their families.

Traumatic Brain Injury (TBI) is an extrememly hard to detect injury.  We are just now developing ways to detect it.  Below is a fascinating article on research into TBI detection through the damage to the axons in the brain.  

If you have a personal injury case whether it involves a cruise ship or on land, call Hickey Law Firm, P.A. toll free at 1.800.215.7117.  We have experience in TBI cases and can look at your case and talk to you.  Call today:  1.800.215.7117.   See us at www.hickeylawfirm.com.        

Brain

• 10.1093/brain /awm216

Brain Advance Access published online on September 14, 2007
Brain, doi:10.1093/brain/awm216

This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My Personal Archive Download to citation manager Request Permissions Disclaimer Google Scholar Articles by Kraus, M. F. Articles by Little, D. M. PubMed Articles by Kraus, M. F. Articles by Little, D. M.

http://brain.oxfordjournals.org/misc/terms.shtml

White matter integrity and cognition in chronic traumatic brain injury: a diffusion tensor imaging study

Marilyn F. Kraus^1,2,7, Teresa Susmaras^2,8, Benjamin P. Caughlin^2,8,9, Corey J. Walker^2,8, John A. Sweeney^1,2,3,4,7 and Deborah M. Little^2,3,5,6,7,81Department of Psychiatry, ²Department of Neurology, ³Department of Psychology, ⁴Department of Bioengineering, ⁵Department of Anatomy, ⁶Department of Ophthalmology, ⁷Center for Cognitive Medicine, ⁸Center for Stroke Research, University of Illinois at Chicago Medical Center, Chicago, IL and ⁹Wayne State University School of Medicine, Detroit, MI, USA

Correspondence to: Dr Marilyn F. Kraus, MD, Center for Cognitive Medicine and Department of Psychiatry, University of Illinois College of Medicine, 912 South Wood Street, MC 913, USA E-mail: mkraus@psych.uic.edu  Skip Navigation

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• Brain Advance Access
• 10.1093/brain/awm216

Brain Advance Access published online on September 14, 2007
Brain, doi:10.1093/brain/awm216

This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My Personal Archive Download to citation manager Request Permissions Disclaimer Google Scholar Articles by Kraus, M. F. Articles by Little, D. M. PubMed Articles by Kraus, M. F. Articles by Little, D. M.

http://brain.oxfordjournals.org/misc/terms.shtml

White matter integrity and cognition in chronic traumatic brain injury: a diffusion tensor imaging study

Marilyn F. Kraus^1,2,7, Teresa Susmaras^2,8, Benjamin P. Caughlin^2,8,9, Corey J. Walker^2,8, John A. Sweeney^1,2,3,4,7 and Deborah M. Little^2,3,5,6,7,81Department of Psychiatry, ²Department of Neurology, ³Department of Psychology, ⁴Department of Bioengineering, ⁵Department of Anatomy, ⁶Department of Ophthalmology, ⁷Center for Cognitive Medicine, ⁸Center for Stroke Research, University of Illinois at Chicago Medical Center, Chicago, IL and ⁹Wayne State University School of Medicine, Detroit, MI, USA

Correspondence to: Dr Marilyn F. Kraus, MD, Center for Cognitive Medicine and Department of Psychiatry, University of Illinois College of Medicine, 912 South Wood Street, MC 913, USA E-mail: mkraus@psych.uic.edu