Hormones and TBI: What We Know, What We Think We Know and What We Should Know

Presenters:

  • Nathan Zasler
  • Tamara Wexler
  • Min Jeong Graf

Objectives:

  • Examine the prevalence of neuroendcrine dysfunction following TBI
  • Review the pathophysiology of post-traumatic neuroendocrine dysfunction
  • Explore the clinical features of hypopituitarism following TBI and its natural history

Description:

Traumatic brain injury (TBI) is a chronic disease process and may be associated with neuroendocrine dysfunction. The prevalence of neuroendocrine dysfunction varies across studies from 15-50%. The Institute of Medicine report on long-term consequences of TBI noted an association between moderate or severe TBI and endocrine dysfunction, particularly hypopituitarism and growth hormone insufficiency. Pituitary dysfunction has also been reported in patients after complicated mild TBI and in patients with sports-related, repetitive concussions/head trauma. Post-traumatic hypopituitarism has been associated with poor quality of life, abnormal body composition, and adverse metabolic profiles which may impact the recovery process after TBI.

There remain significant clinical challenges for health care professionals in the context of assessment and management of this class of post-traumatic disorders. Issues of when to assess, how to assess, when to treat and when not to treeat remain somewhat controversial. Complicating matters further, symptoms from pituitary hormone deficiencies often overlap with symptoms secondary to TBI. Also, some hormonal changes are transient and resolve spontaneously after the acute phase; whereas, some hormonal dysfunctions may develop later after injury. There remain significant debates regarding the reliability of screening and specialized confirmatory methods used to assess pituitary function. Testing all patients with TBI is neither clinically indicated nor cost-effective and it is important to use current evidence based approaches when determining who should be assessed for such impairments. Patients with TBI may have multiple other factors that need to be considered in the clinical context of hormonal assessment including pre-injury medical conditions, as well as post-injury acuity level, stress mediating factors and medication related influences on hormone physiology. The risk benefit analysis with regards to hormone replacement therapy must be considered carefully and holistically.

This symposium will provide attendees with a review of salient controversies and current evidence-based recommendations for post-traumatic neuroendocrine impairments. The presenters, two brain injury medicine certified physiatrists and one neuroendocrinologist, will review the current literature on prevalence and pathophysiology of neuroendocrine dysfunction after mild to severe TBI. A distillation of current guidelines and evidence on screening including who should be screened, when and how long patients should be screened and reassessed and what testing should be used will be presented. The medical literature on the efficacy of hormone replacement therapy for isolated or multiple hormone deficiencies after TBI will also be reviewed.

It is important that providers who treat patients with traumatic brain injury be aware of and understand this area of neuroendocrinology to be able to make evidence-based decisions when evaluating pituitary function in those with traumatic brain injury with the goal of improving function and quality of life.

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