Road traffic accidents resulting in traumatic brain injuries are increasingly common. Patients are often males in their third decade. Many of these patients persist to have various symptoms even after recovery from the acute phase, which tend to be diagnosed as post concussion syndromes. Interest has increased of late in Post traumatic hypopituitarism. We report two patients with head injuries with endocrine insufficiencies.
A 21 year male was hit by a car at 50 mph resulting in multiple fractures and dislocations including left zygomatic, orbital canal, base of skull and pituitary fossa fractures and bifrontal haemorrhages. From the first week in the ITU, he became polyuric with a urine output persistently between 200400 ml/hr, serum sodium concentration of 167 mmol/L, plasma osmolality of 332 mosm/kg, urinary osmolality of 215 mosm/kg and a specific gravity <1005. He was treated with DDAVP 0.5 mcg bd,s.c. and underwent basal pituitary assessments which showed LH&FSH: <1.0 IU/L,Testosterone 0.8 nmol/l, prolactin: 98 mU/L,IGF-1: 11.5 nmol/L, TSH: 0.42 mU/L, fT4:9 pmol/L and serum cortisol: 21 nmol/L. Hydrocortisone 50 mg tds IV and subsequently 10,5 and 5 mg along withThyroxine 100 mcg od, when a PEG was sited and Sustanon 250 mg IM/4 weeks were also commenced. Four weeks later he was successfully weaned off DDAVP but has persistent anterior hypopituitarism.
Our second patient, a 34 year male, sustained multiple skull fractures after a fall from a 20 feet high bridge. He underwent right frontal craniotomy, frontal lobectomy and repair of anterior fossa floor. Post operatively polyuria >200 ml/hr, serum osmolalities of 305 mosmo/kg and urinary osmolality 180 mosmo/kg with serum sodium 135 mmol/l were noted. Polyuria responded to DDAVP. His baseline pituitary functions revealed LH and FSH <1.0 U/L, testosterone of 2.3 nmol/L, TSH of 3 mU/L and fT4: 8 pmol/L. These two patients illustrate the potential of headinjuries to cause Pituitary insufficiencies. Increased awareness and a high index of suspicion will help in identifying problems early enough.