eMedicine Specialties > Physical Medicine and Rehabilitation > Traumatic Brain Injury

Post Head Injury Endocrine Complications: Differential Diagnoses & Workup

Author: Milton J Klein, DO, MBA, Consulting Physiatrist, Sewickley Valley Hospital, Allegheny General Hospital, Harmarville Rehabilitation Center, Ohio Valley General Hospital, and Aliquippa Community Hospital
Contributor Information and Disclosures

Updated: Jan 5, 2009

Differential Diagnoses

Other Problems to Be Considered

Syndrome of inappropriate antidiuretic hormone (SIADH)
 Diabetes insipidus
Cerebral salt wasting
Postneurosurgery
Tumor
SIADH can be induced by medications (eg, carbamazepine, major tranquilizers, antidepressants).
Phenytoin and chlorpromazine inhibit the release of ADH.
Lithium may block the action of ADH peripherally at the kidney.

Diabetes insipidus (DI)
Hypothalamic (post-TBI) versus peripheral (nephrogenic) DI
Familial - X-linked recessive or autosomal dominant DI
Acquired DI - TBI, postneurosurgery, tumors, granulomatous, infections, vascular disorders, circulating antibodies to vasopressin, autoimmunity, and idiopathic

Cerebral salt wasting
Hypothalamic/nephrogenic DI
SIADH
Primary adrenal insufficiency

Anterior hypopituitarism
Postneurosurgery
Tumors
Vascular (postpartum)
Infections
Granulomatous disease
Idiopathic

Primary adrenal insufficiency
Autoimmune (idiopathic adrenalitis)
Tuberculosis
Sarcoidosis
Malignancy
Acute sepsis (including systemic fungal infections)
Acquired immune deficiency syndrome

Workup

Laboratory Studies

  • The hallmark of endocrine disorders is an abnormal serum level of either a particular hormone or the entire spectrum of associated hormones, such as in anterior hypopituitarism (panhypopituitarism).
    • Serial hormone assays may be used to determine the secretory pattern and to assess the hypothalamic regulation of pituitary function. All patients with traumatic brain injury (TBI) should undergo a baseline hormone evaluation at the time of hospital or intensive care unit (ICU) discharge, as well as at 3 months and 12 months post-TBI. The endocrinologist's workup may include provocative testing. Confirmatory testing of growth hormone (GH) deficiency is by assay of IGF-I. A low level of IGF-I in the absence of malnutrition is indicative of severe GH deficiency; however, aging or other factors (eg, liver disease, chronic renal disease, obesity, diabetes mellitus) can also cause a low level of IGF-I.
    • Careful clinical assessment of patients who have sustained TBI and who develop unexplained lethargy, generalized weakness, or anorexia should include an endocrine evaluation. Endocrine problems interfere with the progress of rehabilitation and are detrimental to the rehabilitation outcome if not recognized and treated promptly.
  • Laboratory/clinical screening studies of pituitary function
    • GH - Height, weight, and bone age (<18 y)
    • IIGF-I (0900)
    • Thyrotropin - Free T4 and T3 by radioimmunoassay (0900)
    • Corticotropin - Serum cortisol (0900 h)
    • Gonadotropins - Serum estradiol or testosterone (0900)
    • Prolactin - Serum prolactin
    • ADH - Serum/urine sodium, serum/urine osmolalities, and urine output

Imaging Studies

  • Cranial magnetic resonance imaging (MRI) provides the most specific cross-sectional views of the hypothalamus and pituitary gland.20 The diagnosis and treatment of endocrine complications following traumatic brain injury (TBI) are based on clinical findings and laboratory studies of overall pituitary hormonal regulation and of each endocrine gland.

More on Post Head Injury Endocrine Complications

Overview: Post Head Injury Endocrine Complications
Differential Diagnoses & Workup: Post Head Injury Endocrine Complications
Treatment & Medication: Post Head Injury Endocrine Complications
Follow-up: Post Head Injury Endocrine Complications
Multimedia: Post Head Injury Endocrine Complications
References
[ CLOSE WINDOW ]

References

  1. Acerini CL, Tasker RC. Neuroendocrine consequences of traumatic brain injury. J Pediatr Endocrinol Metab. Jul 2008;21(7):611-9. [Medline].

  2. Hadani M, Findler G, Shaked I, et al. Unusual delayed onset of diabetes insipidus following closed head trauma. Case report. J Neurosurg. Sep 1985;63(3):456-8. [Medline].

  3. Levitt MA, Fleischer AS, Meislin HW. Acute post-traumatic diabetes insipidus: treatment with continuous intravenous vasopressin. J Trauma. Jun 1984;24(6):532-5. [Medline].

  4. Notman DD, Mortek MA, Moses AM. Permanent diabetes insipidus following head trauma: observations on ten patients and an approach to diagnosis. J Trauma. Jul 1980;20(7):599-602. [Medline].

  5. Shucart WA, Jackson I. Management of diabetes insipidus in neurosurgical patients. J Neurosurg. Jan 1976;44(1):65-71. [Medline].

  6. Tatoian JA Jr, LaDow CS Jr, Diamond MC. Permanent posttraumatic diabetes insipidus. J Oral Surg. Jul 1975;33(7):548-51. [Medline].

  7. Ward MK, Fraser TR. DDAVP in treatment of vasopressin-sensitive diabetes insipidus. Br Med J. Jul 13 1974;3(923):86-9. [Medline].

  8. Klingbeil GE, Cline P. Anterior hypopituitarism: a consequence of head injury. Arch Phys Med Rehabil. Jan 1985;66(1):44-6. [Medline].

  9. Mitchell A, Steffenson N, Davenport K. Hypopituitarism due to traumatic brain injury: a case study. Crit Care Nurse. Aug 1997;17(4):34-7, 40-2, 46-51; quiz 53-4. [Medline].

  10. Soules MR, Sheldon GW. Traumatic hypopituitarism: anterior hypophyseal insufficiency from indirect cranial trauma. South Med J. Dec 1979;72(12):1592-6. [Medline].

  11. Valenta LJ, De Feo DR. Post-traumatic hypopituitarism due to a hypothalamic lesion. Am J Med. Apr 1980;68(4):614-7. [Medline].

  12. Winternitz WW, Dzur JA. Pituitary failure secondary to head trauma. Case report. J Neurosurg. Apr 1976;44(4):504-5. [Medline].

  13. Peters J, Welt L, Sims E. A salt wasting syndrome associated with cerebral disease. Trans Assoc Am Physiol. 1950;63:57-64.

  14. Zafonte RD, Mann NR. Cerebral salt wasting syndrome in brain injury patients: a potential cause of hyponatremia. Arch Phys Med Rehabil. May 1997;78(5):540-2. [Medline].

  15. Powner DJ, Boccalandro C. Adrenal insufficiency following traumatic brain injury in adults. Curr Opin Crit Care. Apr 2008;14(2):163-6. [Medline].

  16. Thurman DJ, Alverson C, Dunn KA, et al. Traumatic brain injury in the United States: a public health perspective. J Head Trauma Rehabil. Dec 1999;14(6):602-15. [Medline].

  17. [Best Evidence] Behan LA, Phillips J, Thompson CJ, et al. Neuroendocrine disorders after traumatic brain injury. J Neurol Neurosurg Psychiatry. Jul 2008;79(7):753-9. [Medline].

  18. De Sanctis V, Sprocati M, Govoni M R, et al. Assessment of traumatic brain injury and anterior pituitary dysfunction in adolescents. Georgian Med News. Mar 2008;18-23. [Medline].

  19. Born JD, Hans P, Smitz S, et al. Syndrome of inappropriate secretion of antidiuretic hormone after severe head injury. Surg Neurol. Apr 1985;23(4):383-7. [Medline].

  20. Makulski DD, Taber KH, Chiou-Tan FY. Neuroimaging in posttraumatic hypopituitarism. J Comput Assist Tomogr. Mar-Apr 2008;32(2):324-8. [Medline].

  21. Adrogue HJ, Madias NE. Hyponatremia. N Engl J Med. May 25 2000;342(21):1581-9. [Medline].

  22. Anmuth CJ, Ross BW, Alexander MA, et al. Chronic syndrome of inappropriate secretion of antidiuretic hormone in a pediatric patient after traumatic brain injury. Arch Phys Med Rehabil. Nov 1993;74(11):1219-21. [Medline].

  23. Childers MK, Rupright J, Jones PS, et al. Assessment of neuroendocrine dysfunction following traumatic brain injury. Brain Inj. Jun 1998;12(6):517-23. [Medline].

  24. Hansen JR, Cook JS. Post-traumatic neuroendocrine disorders. In: Physical Medical and Rehabilitation: State of the Art Reviews. vol 7. Philadelphia, Pa: Hanley & Belfus; 1993:569-80.

  25. Hays RM, Levine SD. Vasopressin. Kidney Int. Nov 1974;6(5):307-22. [Medline].

  26. McLaurin RL, King LR. Recognition and treatment of metabolic disorders after head injuries. Clin Neurosurg. 1972;19:281-300. [Medline].

  27. National Institutes of Health. Rehabilitation of Persons with Traumatic Brain Injury. NIH Consensus Statement. 1998;16:1-41.

  28. Physicians' Desk Reference. vol 54. Oradell, NJ: Medical Economics; 2000:515-8; 1513-6; 1529-30; 1765-6; 1968-9; 2553-6.

  29. Trost HA, Gaab MR. Plasma osmolality, osmoregulation and prognosis after head injury. Acta Neurochir (Wien). 1992;116(1):33-7. [Medline].

  30. Vingerhoets F, de Tribolet N. Hyponatremia hypo-osmolarity in neurosurgical patients. "Appropriate secretion of ADH" and "cerebral salt wasting syndrome". Acta Neurochir (Wien). 1988;91(1-2):50-4. [Medline].

  31. Webster JB, Bell KR. Primary adrenal insufficiency following traumatic brain injury: a case report and review of the literature. Arch Phys Med Rehabil. Mar 1997;78(3):314-8. [Medline].

  32. Werbel SS, Ober KP. Acute adrenal insufficiency. Endocrinol Metab Clin North Am. Jun 1993;22(2):303-28. [Medline].

  33. Zafonte R, Muizelaar JP, Peterson PL. The pathophysiology of brain injury: understanding innovative drug therapies. J Head Trauma Rehabil. Feb 1998;13(1):1-10. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

hormone, hormones, adrenal, endocrine, TBI, head injury, adrenal gland, traumatic brain injury, pituitary gland, endocrine system, hypothalamus, adrenal insufficiency, adrenal glands, pituitary glands, hypopituitarism, panhypopituitarism, posttraumatic brain injury endocrine complications, post-traumatic brain injury endocrine complications, endocrine complications following TBI

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Milton J Klein, DO, MBA, Consulting Physiatrist, Sewickley Valley Hospital, Allegheny General Hospital, Harmarville Rehabilitation Center, Ohio Valley General Hospital, and Aliquippa Community Hospital
Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Patrick J Potter, BSc, MD, FRCP(C), Associate Professor, Physical Medicine and Rehabilitation, The University of Western Ontario; Consulting Staff, Department of Physical Medicine and Rehabilitation, St Joseph's Health Care Centre
Patrick J Potter, BSc, MD, FRCP(C) is a member of the following medical societies: American Paraplegia Society, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical Association, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Kat Kolaski, MD, Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine
Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

RELATED EMEDICINE ARTICLES
Patient Education
 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.