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Roe T, Welbourne J, Nikitas N. Endocrine dysregulation in aneurysmal subarachnoid haemorrhage. Br J Neurosurg 2022; 36:358-367. [PMID: 35170377 DOI: 10.1080/02688697.2022.2039378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Aneurysmal Subarachnoid haemorrhage (aSAH) is one of the most common causes of neurocritical care admission. Consistent evidence has been suggestive of endocrine dysregulation in aSAH. This review aims to provide an up-to-date presentation of the available evidence regarding endocrine dysregulation in aneurysmal subarachnoid haemorrhage. METHODS A comprehensive literature search was performed using PubMed database. All available evidence related to endocrine dysregulation in hypothalamic-pituitary hormones, adrenal hormones and natriuretic peptides after aSAH, published since 2010, were reviewed. RESULTS There have been reports of varying prevalence of dysregulation in hypothalamic-pituitary and adrenal hormones in aSAH. The cause of this dysregulation and its pattern remain unclear. Hypothalamic-pituitary and adrenal dysregulation have been associated with higher incidence of poor neurological outcome and increased mortality. Whilst there is evidence that long-term dysregulation of these axes may also develop, it appears to be less frequent than the acute-phase dysregulation and transient in pattern. Increased levels of catecholamines have been reported in the hyper-acute phase of aSAH with reported inconsistent correlation with the outcomes and the complications of the disease. There is growing evidence that of a causal link between the endocrine dysregulation and the development of hyponatraemia and delayed cerebral ischaemia, in the acute phase of aSAH. However, the pathophysiological mechanism and pattern of endocrine dysregulation which could be causally associated with these complications still remain debatable. CONCLUSION The evidence, mainly from small observational and heterogeneous in methodology studies, is suggestive of adverse effects of the endocrine dysregulation on the outcome and the incidence of complications of the disease. However, the cause of this dysregulation and a pathophysiological mechanism that could link its presence with the development of acute complications and the outcome of the aSAH remain unclear. Further research is warranted to elucidate the clinical significance of endocrine dysregulation in subarachnoid haemorrhage.
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Affiliation(s)
- Thomas Roe
- Department of Intensive Care Medicine, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jessie Welbourne
- Department of Intensive Care Medicine, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Nikitas Nikitas
- Department of Intensive Care Medicine, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
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Sörbo A, Eiving I, Theodorsson E, Rydenhag B, Jonsdottir IH. Pre-traumatic conditions can influence cortisol levels before and after a brain injury. Acta Neurol Scand 2020; 141:342-350. [PMID: 31879940 DOI: 10.1111/ane.13212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/01/2019] [Accepted: 12/21/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Satisfactory anabolic reactions, including the activation of the hypothalamic-pituitary-adrenal (HPA) axis, are essential following severe traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (SAH). Many factors may influence this activation. This study aimed to investigate whether individuals who reported chronic diseases, psychosocial afflictions, or stressful events before a severe brain injury display a different pattern regarding cortisol levels retrospectively and up to three months compared with those who did not report stressful experiences. MATERIALS AND METHODS Fifty-five patients aged 16-68 years who were admitted to the neurointensive care unit (NICU) were included. Hair cortisol measurements offer a unique opportunity to monitor cortisol levels retrospectively and after the trauma. Hair strands were collected as soon as possible after admission to the NICU and every month until three months after the injury/insult. The participants/relatives were asked about stressful events, psychosocial afflictions and recent and chronic diseases. RESULTS The group who reported chronic diseases and/or stressful events before the brain injury had more than twice as high median hair cortisol levels before the brain injury compared with those who did not report stress, but the difference was not statistically significant (P = .12). Those who reported stress before the brain injury had statistically significantly lower hair cortisol values after the brain injury and they remained until three months after the injury. CONCLUSIONS Stressful events and/or chronic disease before brain injury might affect mobilization of adequate stress reactions following the trauma. However, the large variability in cortisol levels in these patients does not allow firm conclusions and more studies are needed.
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Affiliation(s)
- Ann Sörbo
- Department of Neurology and Rehabilitation Södra Älvsborg Hospital Borås Sweden
- Department of Neurology and Rehabilitation Uddevalla Hospital Uddevalla Sweden
- Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Ingrid Eiving
- Neurointensive Care Unit Department of Anesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden
| | - Elvar Theodorsson
- Department of Clinical Chemistry and Department of Clinical and Experimental Medicine Linköping University Linköping Sweden
| | - Bertil Rydenhag
- Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Neurosurgery Sahlgrenska University Hospital Gothenburg Sweden
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Peeters B, Langouche L, Van den Berghe G. Adrenocortical Stress Response during the Course of Critical Illness. Compr Physiol 2017; 8:283-298. [DOI: 10.1002/cphy.c170022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Catecholamines and Paroxysmal Sympathetic Hyperactivity after Traumatic Brain Injury. J Neurotrauma 2017; 34:109-114. [DOI: 10.1089/neu.2015.4364] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Peeters B, Güiza F, Boonen E, Meersseman P, Langouche L, Van den Berghe G. Drug-induced HPA axis alterations during acute critical illness: a multivariable association study. Clin Endocrinol (Oxf) 2017; 86:26-36. [PMID: 27422812 DOI: 10.1111/cen.13155] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/30/2016] [Accepted: 07/12/2016] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Critical illness is hallmarked by low plasma ACTH in the face of high plasma cortisol. We hypothesized that frequently used drugs could play a role by affecting the hypothalamic-pituitary-adrenal axis. DESIGN Observational association study. PATIENTS A total of 156 medical-surgical critically ill patients. MEASUREMENTS Plasma concentrations of ACTH and total/free cortisol were quantified upon ICU admission and throughout the first 3 ICU days. The independent associations between drugs administered 24 h prior to ICU admission and plasma ACTH and cortisol concentrations upon ICU admission were quantified with use of multivariable linear regression analyses. RESULTS Upon ICU admission, compared with healthy subjects, patients had low mean±SEM plasma ACTH concentrations (2·7 ± 0·6 pmol/l vs 9·0 ± 1·6 pmol/l, P < 0·0001) in the face of unaltered total plasma cortisol (336·7 ± 30·4 nmol/l vs 300·8 ± 16·6 nmol/l, P = 0·3) and elevated free plasma cortisol concentrations (41·4 ± 5·5 nmol/l vs 5·5 ± 0·8 nmol/l, P = 0·04). Plasma ACTH concentrations remained low (P < 0·001) until day 3, whereas plasma (free) cortisol concentrations steeply increased and remained high (P < 0·001). No independent correlations with plasma ACTH were found. In contrast, the total admission plasma cortisol concentration was independently and negatively associated with the cumulative opioid (P = 0·001) and propofol (P = 0·02) dose, the use of etomidate (P = 0·03), and positively with the cumulative dobutamine dose (P = 0·0007). CONCLUSIONS Besides the known suppressive effect of etomidate, opioids and propofol may also suppress and dobutamine increases plasma cortisol in a dose-dependent manner. The observed independent associations suggest drug effects not mediated centrally via ACTH, but rather peripherally by a direct or indirect action on the adrenal cortex.
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Affiliation(s)
- Bram Peeters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Fabian Güiza
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Eva Boonen
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Philippe Meersseman
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Medical Intensive Care Unit, Department of General Internal Medicine, UZ Leuven, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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Nyberg C, Karlsson T, Hillered L, Stridsberg M, Ronne Engström E. The Early Endocrine Stress Response in Experimental Subarachnoid Hemorrhage. PLoS One 2016; 11:e0151457. [PMID: 27007694 PMCID: PMC4805209 DOI: 10.1371/journal.pone.0151457] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 02/28/2016] [Indexed: 12/12/2022] Open
Abstract
Introduction In patients with severe illness, such as aneurysmal subarachnoid hemorrhage (SAH), a physiologic stress response is triggered. This includes activation of the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system. The aim of this study was to investigate the very early responses of these systems. Methods A porcine animal model of aneurysmal SAH was used. In this model, blood is injected slowly to the basal cisterns above the anterior skull base until the cerebral perfusion pressure is 0 mm Hg. Sampling was done from blood and urine at -10, +15, +75 and +135 minutes from time of induction of SAH. Analyses of adrenocorticotropic hormone (ACTH), cortisol, aldosterone, catecholamines and chromogranin-A were performed. Results Plasma ACTH, serum cortisol and plasma aldosterone increased in the samples following induction of SAH, and started to decline after 75 minutes. Urine cortisol also increased after SAH. Urine catecholamines and their metabolites were found to increase after SAH. Many samples were however below detection level, not allowing for statistical analysis. Plasma chromogranin-A peaked at 15 minutes after SAH, and thereafter decreased. Conclusions The endocrine stress response after aneurysmal SAH was found to start within 15 minutes in the HPA axis with early peak values of ACTH, cortisol and aldosterone. The fact that the concentrations of the HPA axis hormones decreased 135 minutes after SAH may suggest that a similar pattern exists in SAH patients, thus making it difficult to catch these early peak values. There were also indications of early activation of the sympathetic nervous system, but the small number of valid samples made interpretation difficult.
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Affiliation(s)
- Christoffer Nyberg
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Torbjörn Karlsson
- Department of Surgical Sciences, Section of Anesthesiology and Intensive care, Uppsala University, Uppsala, Sweden
| | - Lars Hillered
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Mats Stridsberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Brorsson C, Dahlqvist P, Nilsson L, Naredi S. Saliva stimulation with glycerine and citric acid does not affect salivary cortisol levels. Clin Endocrinol (Oxf) 2014; 81:244-8. [PMID: 24521305 DOI: 10.1111/cen.12423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 12/03/2013] [Accepted: 02/04/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In critically ill patients with hypotension, who respond poorly to fluids and vasoactive drugs, cortisol insufficiency may be suspected. In serum over 90% of cortisol is protein-bound, thus routine measures of total serum cortisol may yield 'false lows' due to hypoproteinaemia. Thus, the occurrence of cortisol insufficiency could be overestimated in critically ill patients. Salivary cortisol can be used as a surrogate for free serum cortisol, but in critically ill patients saliva production is decreased, and insufficient volume of saliva for analysis is a common problem. The aim of this study was to investigate if a cotton-tipped applicator with glycerine and citric acid could be used for saliva stimulation without affecting salivary cortisol levels. DESIGN Prospective, observational study. PARTICIPANTS Thirty-six volunteers (six males, 30 females), age 49 ± 9 years, without known oral mucus membrane rupture in the mouth. MEASUREMENTS Forty-two pairs of saliva samples (22 paired morning samples, 20 paired evening samples) were obtained before and after saliva stimulation with glycerine and citric acid. Salivary cortisol was analysed using Spectria Cortisol RIA (Orion Diagnostica, Finland). RESULTS The paired samples correlated significantly (P < 0.0001) and there was no significant difference between un-stimulated and stimulated salivary cortisol levels. CONCLUSIONS Saliva stimulation with a cotton-tipped applicator containing glycerine and citric acid did not significantly influence salivary cortisol levels in healthy volunteers. This indicates that salivary cortisol measurement after saliva stimulation may be a useful complement when evaluating cortisol status in critically ill patients.
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Affiliation(s)
- Camilla Brorsson
- Department of Anaesthesia and Intensive Care, Institution of Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden
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Brorsson C, Dahlqvist P, Nilsson L, Thunberg J, Sylvan A, Naredi S. Adrenal response after trauma is affected by time after trauma and sedative/analgesic drugs. Injury 2014; 45:1149-55. [PMID: 24975481 DOI: 10.1016/j.injury.2014.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 01/21/2014] [Accepted: 02/06/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND The adrenal response in critically ill patients, including trauma victims, has been debated over the last decade. The aim of this study was to assess the early adrenal response after trauma. METHODS Prospective, observational study of 50 trauma patients admitted to a level-1-trauma centre. Serum and saliva cortisol were followed from the accident site up to five days after trauma. Corticosteroid binding globulin (CBG), dehydroepiandrosterone (DHEA) and sulphated dehydroepiandrosterone (DHEAS) were obtained twice during the first five days after trauma. The effect of time and associations between cortisol levels and; severity of trauma, infusion of sedative/analgesic drugs, cardiovascular dysfunction and other adrenocorticotropic hormone (ACTH) dependent hormones (DHEA/DHEAS) were studied. RESULTS There was a significant decrease over time in serum cortisol both during the initial 24 h, and from the 2nd to the 5th morning after trauma. A significant decrease over time was also observed in calculated free cortisol, DHEA, and DHEAS. No significant association was found between an injury severity score ≥ 16 (severe injury) and a low (< 200 nmol/L) serum cortisol at any time during the study period. The odds for a serum cortisol < 200 nmol/L was eight times higher in patients with continuous infusion of sedative/analgesic drugs compared to patients with no continuous infusion of sedative/analgesic drugs. CONCLUSION Total serum cortisol, calculated free cortisol, DHEA and DHEAS decreased significantly over time after trauma. Continuous infusion of sedative/analgesic drugs was independently associated with serum cortisol < 200 nmol/L.
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Affiliation(s)
- Camilla Brorsson
- Department of Anaesthesia and Intensive Care, Institution of Surgery and Perioperative Sciences, Umeå University, 901 87 Umeå, Sweden.
| | - Per Dahlqvist
- Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Leif Nilsson
- Department of Mathematics and Mathematical Statistics, Umeå University, 901 87 Umeå, Sweden
| | - Johan Thunberg
- Department of Anaesthesia and Intensive Care, Institution of Surgery and Perioperative Sciences, Umeå University, 901 87 Umeå, Sweden
| | - Anders Sylvan
- Department of Surgery, Institution of Surgery and Perioperative Sciences, Umeå University, 901 87 Umeå, Sweden
| | - Silvana Naredi
- Department of Anaesthesia and Intensive Care, Institution of Surgery and Perioperative Sciences, Umeå University, 901 87 Umeå, Sweden
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