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Head Injury and Pituitary Dysfunction - Are we failing to Diagnose it?
Recently a quarterback in the National Football League sustained a serious head injury. He was hospitalized for three days with a diagnosis of a serious concussion. The question needs to be asked, has any of his treating physicians considered the possibility of an injury to the pituitary gland? Did they draw a baseline IGF-1? Did they draw a Prolactin level or a cortisol level with an ACTH? Have they looked at FSH/LH level with testosterone? Does this sound like labs that are routinely done when an athlete presents with a head injury whether it is a major injury or even a minor injury? Unfortunately, these labs are not routinely done either in the emergency department, during the hospitalization or even after dismissal.
How will this failure to diagnose a possible pituitary problem affect this quarterback? For now, his injury will be contributed to the head injury itself and the doctors will anticipate that he will either get better or he won't. If he does not return to his premorbid state, will he get the care that would return him to his previous level of functionality. We think not. Why, because too few doctors are educated about the problems of head injury and subsequent pituitary dysfunction or failure.
Fall is right around the corner and this means football games for all ages, from grade school up to professional players. Unfortunately with the fun comes injuries and some of those injuries can be very serious, even deadly. One of the injuries that may not appear to be obvious to coaches, trainers or even the doctors is an injury to the pituitary. Pituitary failure or dysfunction can occur with even mild trauma to the head.
Unless the medical team treating the injured player is suspicious of pituitary dysfunction, the injury will go undiagnosed only to cause problems for the player in the future. Rarely does the medical team include an endocrinologist. And even if the team did include an endocrinologist, few endocrinologists are educated about the relationship between head injury and pituitary failure or dysfunction. One of the major reasons the International Hormone Society was created, to educate doctors about the problems associated with head injury and pituitary injury and other frequently undiagnosed and untreated hormone related conditions.
Current research suggests that any injury to the pituitary that results in sustained hypoxia (hypovolemia) may result in pituitary damage. One of the first pituitary cells damaged are the somatotrophs (growth hormone secreting cells). The second pituitary cells, it is believed, to be damaged are the gonadotrophs (follicle stimulating and lutenizing hormone producing cells). It is unclear when the thyroid secreting hormone cells are damaged but it is known that the adrenocorticotropin cells (ACTH cells) are likely the last cells to be damaged.
It is known that 40% of the pituitary cells are somatotrophs, or growth hormone secreting cells. Many of these cells can be damaged and life will continue. The problem is that health will not continue. So, one of the first hormones that should be suspected to become deficient in a head injury is growth hormone. The screening test for growth hormone is the growth factor that is produced in the liver, insulin like growth factor one (IGF-1) as this is the form that persists in the body throughout the entire day.
Some studies of head injury suggest that prolactin may initially become elevated in head injury and then decline as the pituitary function declines. Prolactin would be a sensible baseline hormone to test in head injured patients.
It is logical that any insult to the head or the body would result in an elevated cortisol level (the stress response). The problem arises if the cortisol level is very high and is sustained for a prolonged period of time. In post traumatic stress disorder (PTSD), studies are revealing that a flood of cortisol may cause damage to cells in the hypothalamus, thus creating pituitary damage. A baseline cortisol level with and ACTH level would be helpful to predict whether the head injured patient may develop pituitary damage.
Thyroid stimulating hormone (TSH) is believed to be the main hormone that is be followed regarding thyroid disease. The problem with pituitary damage, the TSH may not elevate in the presence of thyroid disease or the TSH may not be produced and thus thyroid hormone is not released. It is imperative that a TSH, FREE T4 and FREE T3 be part of the labs drawn on the patient presenting with head injury.
If pituitary damage goes undiagnosed in a patient, the result will be impairment of quality of life and most likely a shortened life span. Quality of life is a difficult thing to measure but tools have now been developed to establish if a patient is suffering from impaired quality of life. One such tool measures specifically whether a patient has an impaired quality of life due to growth hormone deficiency. This tool is titled "Qualify of Life Assessment of Growth Hormone Deficient Adults". This tool also should become part of the assessment of a patient suffering from a head injury.
A shortened life span can be the result of a pituitary deficient patient.