JAMA-2007-Schneider-1429-38

CLINICIAN’S CORNER CLINICAL REVIEW Hypothalamopituitary Dysfunction Following Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage A Systematic Review Harald J o ¨ rn Schne ider, MD Ilonka Kreitschmann-Andermahr, MD Ezio Ghigo, MD Gu ¨ nter Karl Stall a, MD Amar Agha, MD T RAUMATIC BRAIN INJUR Y (TBI) IS a major public health prob- lem with an overall incidence of 23 5 pe r 100 00 0 pe rsons pe r year 1 and some 80 individuals per 100000 pop ulation are hos pit ali zed for TBI in the United States each year. 2 Traumatic brain injury is the leading cause of death and disability in young adults. 3 Aneurys mal subarachnoid hemorrhage (SAH) occurs in 6 to 10 individuals per 100 000 populati on each year. 4 Both TBI and SAH leave many survivors with signif icant advers e physi- cal and psychological sequelae of the trauma. 5,6 Hypopituitaris m caused by TBI was fir st rep ort ed in 191 8, 7 only 4 ye ars af - ter the initi al cli nical desc rip tio n of hypopituitarism. However, in subse- quent dec ade s, TBI hasbeen co nsi der ed a rare cau se of hyp opi tuit arism. In 200 0, a review reported 367 cases of posttraumatic hypopituitarism. 8 Aneurys- mal SAH has been considered to be an even rarer cause of hypopituitarism CME available online at www.jama.com AuthorAffiliations: Clinical Neuroendoc rinologyGroup, Max Planck Institute of Psychia try, Munich, Germany (Drs Schneider and Stalla); Department of Neurosur- gery, RWTHAachenUnive rsity, Aach en,German y (Dr Kreitschmann-Andermahr); Division of Endocrinology andMetabol ism,Departme nt of Inter nalMedicine , Uni- ver sityof Tur in, Tur in, Ital y (Dr Ghig o); and Divi sionof Endo crinolo gy, Beaumont Hospital and the RCSI Medi- cal School, Dublin, Ireland (Dr Agha). Corresponding Author: Harald Jo ¨ rn Schneider, MD, Neuroendocrinology Group, Max Planck Institute of Psychiatry, Kraepelinstrasse 10, 80804 Munich, Ger- many ([email protected]). Clinical Review Section Editor: Michael S. Lauer, MD. We encou rage authors to submit paper s for consideration as a Clinical Review. Please contact Michae l S. Lauer,MD, at michae l.lauer@j ama-archives .org. Context Neuroendocrine dysfunction following traumatic brain injury and aneurysmal subarachnoid hemorrhage may occur with a much higher prevalence than previ- ously suspe cted. Thi s seq uel a is a pot entially ser ious but tre ata ble compli cationofbrain injury. Objective To review research on hypothalamopituitary dysfunction as an underdi- agnos ed conseq uence of traumatic brain injury and subar achnoi d hemor rhage, the natural history of this complication, and the potential clinical and public health impli- cations of posttraumatic hypopituitarism. Evidence Acquisition The MEDLINE database was searched for articles pub- lished between 2000 and 2007 using any combination of the terms traumatic brain injury or subarachnoid hemorrhage with pituitary, hypopituitarism, growth hor- mone deficienc y, hypogonadism, hypocortisolism, hypothyroidism, or diabetes insipidus. The reference lists of articles identified by this search strategy were also search ed. All articl es reporting original data on endocrine outcomes after trauma tic brain injury or aneurysmal subarachnoid hemorrhage in peer-reviewed journals with regard to prevalence, pathogenesis, risk factors, outcomes, and clinical course were selected. We pooled data and calculated prevalence rates and 95% confidence intervals (CIs). Results We identified 19 studies including 1137 patients. The pooled prevalences of hypopitui tarism in the chronic phase after traumatic brain injury and aneury smal subarachnoid hemorrhage were 27.5% (95% confidence interval [CI], 22.8%- 28.9%) and 47% (95% CI, 37.4%- 56.8%) , respec tively . The pooled prevalence of hypopituitarism was greater in patients with severe compared with those with mild or mod erate tra uma tic bra in inj ury . Ear ly neuroe ndocri ne abnormali ties were tra nsi ent in some patients while, less commonly, hypopituitarism evolved over time in others. Pa- tients with posttraumatic hypopituitarism showed an impaired quality of life and an adverse metabolic profile. Conclusion Hypopituitarism is a common complication of both traumatic brain injury and aneurysmal subarachnoid hemorrhage and might contribute to morbidity and poor recovery after brain injury. JAMA. 2007;298(12):1429-1438 www.jama.com ©2007 American Medical Association. All rights reserved. (Reprinted) JAMA, September 26, 2007—Vol 298, No. 12 1429 by guest on February 12, 2012 jama.ama-assn.org Downloaded from

JAMA-2007-Schneider-1429-38

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