Traumatic panhypopituitarism resulting in acute adrenal crisis

Acute neuroendocrine changes after traumatic brain injury

Introduction

Post-traumatic hypopituitarism (PTHP) is a significant, but often neglected consequence of traumatic brain injury (TBI).

Research question

We aimed to provide a comprehensive overview of epidemiology, pathophysiology, clinical features and diagnostic approaches of PTHP.

Materials and methods

MEDLINE, EMBASE, Cochrane Library and Web of Science were searched. 45 articles of human studies evaluating acute endocrine changes following mild, moderate and severe TBI were selected.

Results

Severity of TBI seems to be the most important risk factor of PTHP. Adrenal insufficiency (AI) was present in 10% of TBI patients (prevalence can be as high as 50% after severe TBI), and hypocortisolemia is a predictor of mortality and long-term hypopituitarism. Suppression of the thyroid axis in 2-33% of TBI patients may be an independent predictor of adverse neurological outcome, as well. 9-36% of patients with severe TBI exhibit decreased function of the somatotrophic axis with a divergent effect on the central nervous system. Arginine-Vasopressin (AVP) deficiency is present in 15-51% of patients, associated with increased mortality and unfavorable outcome. Due to shear and injury of the stalk hyperprolactinemia is relatively common (2-50%), but it bears little clinical significance. Sex hormone levels remain within normal values.

Discussion and conclusion

PTHP occurs frequently after TBI, affecting various axis and determining patients' outcome. However, evidence is scarce regarding exact epidemiology, diagnosis, and effective clinical application of hormone substitution. Future studies are needed to identify patients at-risk, determine the optimal timing for endocrine testing, and refine diagnostic and treatment approaches to improve outcome.

Motorcycle-Associated Ocular Injuries: A Narrative Review

Purpose

Motorcycle-related injuries involving the eye and orbit are not well characterized, with a paucity of prospective studies focusing specifically on motorcycle-associated eye injuries nor literature reviews having been conducted on the subject. To better understand the injury types and descriptive characteristics of patients experiencing motorcycle-associated eye injuries, we sought to conduct a narrative review.

Methods

The research team utilized the following databases: PubMed, EMBASE, and Web of Science to query for English articles from peer-reviewed journals that provided some patient data regarding eye injury due to motorcycle or moped accidents or usage.

Results

A total of 65 studies were included in our qualitative synthesis. Of these studies, 40 (61.5%) were case reports, 20 retrospective case series (30.8%), and five (7.69%) were observational prospective studies. Among the 25 retrospective and prospective studies, 12 (48.0%) of these studies primarily focused on motorcycle-associated injuries. These 65 studies described a wide variety of motorcycle-associated eye injuries, including but not limited to orbital fractures and associated sequelae, foreign bodies, vitreoretinal trauma, neuro-ophthalmic trauma, corneal injuries, open globe injuries, lacerations, and globe avulsions.

Conclusion

The current state of the literature indicates that knowledge regarding the ocular manifestations of motorcycle accidents is limited to mostly case reports and few retrospective cohort studies focused specifically on motorcycle-associated eye injuries. However, it is evident that the types of motorcycle-associated eye injuries are legion and predominantly seen in adult males, potentially leading to severe injuries and loss of vision and blindness.

Adrenal crisis: prevention and management in adult patients

Adrenal crisis is an acute life-threatening emergency contributing to the excess mortality that is reported in patients with adrenal insufficiency. The incidence of adrenal crisis is estimated to be 8 per 100 patient years in patients with adrenal insufficiency. Patients with adrenal crisis present systemically unwell with nonspecific signs and symptoms often leading to misdiagnosis and delayed treatment. An adrenal crisis may be the first presentation of adrenal insufficiency or can occur in patients who have been established on glucocorticoid replacement therapy. Infections are the major precipitating factor, but other causes include physical stress such as a surgical procedure or trauma, forgetting or discontinuing glucocorticoid therapy, pronounced physical activity, and psychological stress. The emergency treatment involves prompt recognition and administration of parenteral hydrocortisone, rehydration and management of electrolyte abnormalities. Prevention is centred around patient education. All patients should be educated on stress dosing and parenteral glucocorticoid administration. They should carry a steroid dependency alert card and wear a medical alert bracelet or similar identification. Despite many improvements in the management of patients with adrenal insufficiency, adrenal crisis continues to occur and represents a major source of morbidity, mortality and distress for patients. Improved patient and clinician education and measures to facilitate parenteral hydrocortisone self-administration in impending crisis are central to the management of this life-threatening event.