Neuroendocrine Dysfunction Following Traumatic Brain Injury

Anne Louise Houle-Gregory RN, BSNClinical Educator Trauma and Emergency Services

Regional One Health

Objectives

Relate where the hypothalamus is located and the role it play in controlling visceral, autonomic, endocrine and emotional functions.

Describe pituitary gland as “Master Gland”. Discuss mechanisms of injury to the hypothalamus and pituitary. Recognize clinical features and endocrine disturbances. Define ACTH (HPA Axis). Define TSH (Pituitary Thyroid Axis). Differentiate between disease entities. Restate clinical precursors. List and explain the components of admission endocrine panel. Discuss the Glucagon Stimulation Test (GST) Protocol

introduced in 2013. Examine suggested protocol Evaluation

HypothalamusLocation and Function

Location Function Responsible for

Brain Made Simple, n.d.

Pituitary Gland

“Master Gland” Hypothalamus link Anatomy Hormones

› Anterior Lobe› Posterior Lobe

The Washington Endocrine Clnic, 2014

Mechanisms of Injury to the Hypothalamus and Pituitary Hypoxic insult Hemorrhage

(compression) Edema Increased intracranial

pressure Vascular injury Direct mechanical

injury › Hypothalamus› Pituitary stalk› Pituitary gland Life Extensions (2012)

Clinical Features and Endocrine Disturbances Endocrine Disorders

› Diabetes insipidus› Anterior

hypopituitarism› Syndrome of

inappropriate antidiuretic hormone

› Cerebral salt washing

› Primary adrenal insufficiency

Polyuria

Polydipsia

Nocturia

Headache

↓ AppetiteFatigue

Low Blood PressureHyponatremia

Cognitive Slowing

Ataxia

Anorexai

↓Serum OsmolarityCerebral

EdemaSeizures

Coma

Weakness

Skin pigmentation

Abdominal pain

ACTH (HPA Axis)

CRF↓

CRF and CRF Receptors↓

ACTH Released↓

Receptors of Adrenal Cortex↓

Cortisol Release

University of Virginia (2014)

TSH (Pituitary Thyroid Access

Thyroid stimulating hormone

Pituitary thyroid access.

(University of Virginia 2014)

FSH-LH (Pituitary Gondal Axis)

FSH› Males› Females

LH› Males› Females

Pituitary Gonadal Axis

Geeky Medics (2011)

Disease Processes

Growth Hormone› Deficiency› Excess

Diabetes Insipidus (ID)

Syndrome of Inappropriate Antidiruetic Hormone (SIADH)

Cerebral Salt Wasting (Significance, 2013)

Clinical Precursors

Elevated ICP Prolonged

Hypotension Subarachnoid

Hemorrhage Ischemia Hypoxia

(Significance, 2013)

Admission Endocrine Panel

Primary› Growth Hormone› Lutenizing

Hormone› Thyroid Stimulating

Hormone (TSH)› Adrenocorticotropic

Hormone (ACTH)› Follicle-Stimulating

Hormone, acts at ovaries and testes (FSH)

Secondary› IGF-1

(Insulin-like growth factor-1)

› Testosterone/Estrogens› T3 and T4

(Thyroid Hormones)› Cortisol

Glucagon Stimulation Test (GST) Protocol

Assessment of pituitary-adrenal axis (GH and ACTH/cortisol).

Contraindications to testing

Principle of test Side Effects Preparation Supplies Interpretation Sensitivity and Specificity

Blood Draws

0 Minutes take 2 mL blood into plain tube for cortisol & GHimmediately give Glucagon intra-muscularly.

150 Minutes take 2 mL blood into plain tube for cortisol & GH

180 Minutes take 2 mL blood into plain tube for cortisol & GH

Questions?

ReferencesAcerni, C., & Tasker, R. (2008). Neuroedocrine consequences of traumatic brain injury. Journal of Pediatric Endocrinology Metabolism, 21(7), 611-619.

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Behan, L., Phillips, J., & Thompson, C. (2008). Neuroendocrine disorders after traumatic brain injury. Journal of Neurology/Neurosurgery/Psychiatry, 79(7), 753-759.

Berkely University. (n.d.). FSH and LH. Retrieved from https://mcb.berkeley.edu/courses/mcb135e/fsh-lh.htmlBrain Made Simple. (n.d.). Hypothalamus. Retrieved from http://brainmadesimple.com/hypothalamus.html

Biochemical Investigations in Laboratory Medicine. (2013). Glucagon test of the hypothalamo-pituitary axis. Retrieved from http://www.pathology.leedsth.nhs.uk/dnn_bilm/Investigationprotocols/Pituitaryprotocols/GlucagonTestforPituitaryFunction.aspx

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References

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Kaulfers, A., Backejauw, P., Reifschneider, K., Blum, S., Machaud, L., & Weiss, M. (2010). Endocrine dysfunction following traumatic brain injury in children. Journal of Pediatric Endocrinol Metabolism, 157(6), 891-899.

Klauer, K., & Khardori, R. (2014). Adrenal crisis in emergency medicine clinical presentation. Retrieved from http://emedicine.medscape.com/article/765753-clinical

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