Hypopituitarism After Brain Injury

Question: 

I keep hearing more and more about the need for people with TBI to see an endocrinologist to rule out hypopituitarism. Some studies I’ve read about have found improvements in cognitive outcome following the administration of growth hormone. It is hypothesized that it may be at least partially responsible for the fatigue so common after TBI. Can you shed some light on this topic?

Answer: 

Head injury can damage the pituitary gland and reduce production of two important hormones. The part of the pituitary gland that regulates growth hormone (GH) release is particularly vulnerable to the effects of head injury. Reduced production of GH causes symptoms of fatigue, reduced interest in sex, reduced stamina, anxiety, and depression. This happens in about 18 percent of people with brain injuries, most of whom had moderate to severe TBI. In most patients (90 percent), this condition resolves within a year.

The part of the pituitary gland that makes antiduretic hormone (ADH) is also vulnerable to injury. Reduced production of ADH can cause diabetes insipidus, which causes excessive urination and extreme thirst. (Unlike diabetes mellitus, diabetes insipidus does NOT raise blood sugar levels and is NOT treated with insulin.) Sometimes the resulting dehydration causes a sensation of fatigue. Diabetes insipidus occurs in about 25 percent of the people with brain injury, most of whom have had severe TBI. And again, in most patients, this condition resolves in less than a year.

Bazarian JJ, Cernak I, Noble-Haeusslein L, Potolicchio S, Temkin N. Long-Term Neurologic Outcomes After Traumatic Brain Injury. Journal of Head Trauma Rehabilitation. 2009; 24(6):439-451.

Posted on BrainLine July 11, 2011. Reviewed July 27, 2018.

Comments (22)

I went through a brain surgery in 2016 and now i am feeling very thirsty and always urge to pee. What's the solution? Please help.

From an E.D. point of view, some symptoms do resolve in "simplistic brain injuries..." but a significant number of people have overlying issues: multiple brain injuries over time; specific injuries that are non-detectible via standard methods and/or many that develop symptoms after the individual has left the emergency department setting. The list goes on.'

After brain injury(s) close monitoring by physicians specializing in Neurorehabilitation medicine, family-self-friend, cognitive and behavioral conditions needs to occur to achieve good outcomes.

Dr. Bazarian is wrong to downplay hypopituitarism following TBI. Even mild TBI, and especially a series of mild TBI's, can cause panhypopituitarism. The condition is underrecognized and underdiagnosed by the medical community. The prevalence of hypopituitarism following TBI varies greatly across studies.

Hypopituitarism can occur immediately following a TBI, or it can occur months or years later. The correlation of TBI to deficiency of GH and ADH only is a medical myth. The array of endocrine dyfunction can be vast and affect LH, FSH, TSH, and ACTH.

"Typical brain imaging for concussion (computed tomography, magnetic resonance imaging) is not sensitive enough to detect the diffuse neuronal damage or pituitary abnormalities that occur at the microscopic structural level." - Hypopituitarism After Multiple Concussions: A Retrospective Case Study in an Adolescent Male (Jeffrey C Ives, PhD, Mark Alderman, MS, ATC, and Susan E Stred, MD)

Also, ADH is made in the hypothalumus. It is only stored in the posterior pituitary for release.

https://academic.oup.com/jcem/article/85/4/1353/2851000

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978466/

I have had multiple traumatic brains injuries most with little to no medical help. I am 52 and the multitudes of symptoms have all but taken my life away. I can barely work anymore my days down can be 6- 10 a month severe fatigue, mood changes, depression, migraines that feel like my brain is swelling and the pain radiates down my spine (these can come in clusters and last for days), ocular migraines where I cannot see, sleep disturbances, PTSD which is related to multiple attacks over many years. rapid heart rate Always. Severe anxiety. An old MRI showed my pituitary was pushed to the left and I have asked for years if this is causing my problems no one will answer me. I have been finally diagnosed with Multiple traumatic brain injury sequelae long term. They put me on antidepressants and mood stabilizer anti-anxiety medications and I suffer still.

I am a middle aged female i had a bad mva was on life support x 1 week in a coma with a hematoma in frontal lobe, car accident was 20 years ago, Also was in a abusive relationship 20 plus years ago I was completely knocked out by a blow to my temple that happened at night and didn’t wake up til the next morning, and when I was around 7 years old I was hanging on a bathtub towel.rack and it broke off the wall and I fell back into a hard tub (not plastic tub) landing on my back and head and remember having a severe headache and crying, myself to sleep then in 2008 I was trying to move a plant, I pulled on the pot and it broke and it was a accelerated fall on the concrete sidewalk. After that fall is when I started to have problems, I went to the Emergency Room and was told I had a concussion and cervical sprain,I went back the next day because I started stuttering my words my face scalp and neck were swollen with pain, the ER doctor didn’t want to do any imaging cause he said it was a lot of radiation but I told him I didn’t care, but he released me, the nurses that were taking care of me were apologizing saying they couldn’t believe he was releasing me because they could see there was something definitely wrong, oh and the ER doctor prescribed me muscle relaxant Soma. Which I didn’t take especially with a head injury, I called the neurosurgeon that was on my ER release follow up directions and he said that I didn’t need surgery but I definitely needed to see a neurologist. And now I have extreme anxiety, sleep paralysis, ptsd, memory issues which is not normal for me, mood swings and I was having seizures for 3 years but they have now stopped but I think I maybe having them while falling asleep or right before waking up, I dream (rem) every night as soon as I fall asleep 3-6 times a night for hours until I actually fall into a deep sleep only getting 3-4 hours top of quality refreshing sleep, I’m worried about getting CTE but the doctor acts like only athletes get it, Also my TSH is high

Therapy can greatly help the PTSD but with a lifetime of mild to not so mild TBI/concussions & little medical help until after 60, I can't tell you it's going to get better. But you have to be productive to find whatever you can. Lucky are those with a loving family. But if you determine to find help, you can. But you are the only one that knows how it feels to you.

The best things I have found in my rural area were a few therapies and a primary care doctor who cared enough to learn. He knows more about the realities of TBI than any neurologist I have had the sorrow to see.

I research & follow research. My doctor always follows up & tries to find help for what he can't do. MOST IMPORTANT, HE LISTENS & BELIEVES because he cares & researches & learns.

He has helped me create a support system for those times when things slide backwards. But ultimately, it's up to me to reach out for help, to be determined & not give up.

I'm 70, alive against all odds, & still fighting for a quality of life that is bearable. Domestic violence is very much akin to war when the results of TBI are considered. Unfortunately, it isn't considered in the same light or treated with as much respect. So it's up to us, the victims to find help & solutions. Start now. Be persistent! You matter! And there really is hope. New research comes out every day. Check out neuroscience news.

And don't ignore the physical issues. Immune problems are like ADHD. They are part of the package. Treat each one as important. Research again. Teach your doctor the basics &, if he/she is good, they will help you climb up from the bottom of the hole. Sometimes over & over.

And when you can, HAVE SOME FUN. It's therapeutic. It's as important as cognitive or physical therapy. But the most important person is you! WILL YOU FIGHT FOR YOU? It doesn't matter much why you, as what you are going to do to get better. I know because I have but it will always be a work in progress. I have learned to be proud of what I have done, how far I have come & respect myself for doing it. Yes, I do get tired of the constance of the battle. I don't see an end to it but I do believe in miracles. Maybe it'll be YOU!

Excellent reply to which I fully agree with, I had a relatively mild TBI in 2015 which has left me with considerable difficulties; cognitive decline, memory loss fatigue etc, MRI provided evidence of damaged pituitary gland, blood test showed little or no Testosterone, FSH or LH. I had to medically retire from my career as an RN because of the TBI and associated pituitary damage.

I was t-boned by a car; on my motorized scooter in Feb 2018; I sustained bruises and contusions; and suffered a severe concussion as a result of the accident. Though my bruises and contusions have healed, I continue to have suffer from dizziness, fatigue, lack of concentration, lack of libido and vertigo. I had an MRI done in July, the results showed possible Pituitary malfunction; so my doc has ordered a Pituitary MRI. My question is could this be related to the accident and head trauma I sustained. My Neurologist doesn't think there is a correlation between the two; though I have been reading it implies my Pituitary might have very well been damaged in the accident...could this be?

In 2014 my ex beat me almost to death. I was punched repeatedly in the left temple. Soon afterwards, I noticed both of my breasts were secreting. I saw a dr...and they did blood tests to see if I had raised prolactin levels, and concluded that I didn't. She eliminated all possibilities, except for a pituitary tumor. She gave me medications for depression and anxiety, and a referral for a MRI (which I can't afford to get). Since then my vision has steadily gotten worse, along with fatigue, depression, anxiety, and memory loss . I'm having to retrain my brain and learn to function. I don't know what to do about it.

My mother fell on a tile floor in 2010, she was ambulatory after rehab, but showed extreme anger over everything. Now she has blood collection in the frontal lobe with strong onset dementia. My father is her main caregiver. We have noticed a much stronger odor from her urine and bowel movements. Dad took her to her primary for blood work for testing. Do you have any information on this with TBI patients? Sincerely, T.

I've had six brain injuries in a 10 1/2 year time period due to various accidents. I had pituitary issues within a day of my first head injury in 2005. My menstrual period stopped for six months as my LH and FSH ratio was 1:4 instead of 1:1. My son at age 13 fell on his head out of his loft bed and had GHD after that. He stopped growing and maturing. He has been in the taller range just before for his age. He was put on GH med injections from age 16-18. I wish they would have started sooner. He grew six inches. But his levels are still low for GH and testosterone for his age at 21. They won't give him more GH as he can produce his own under stimulation. I have been treated with HBOT by Dr Paul Harch and have had some objectively verified healing of my brain. See HBOT.com for more information. It's worth it. HBOT is currently approved insurance wise for 15 health issues. We need to fight now for it to be approved as on label for brain injuries and other health issues. HBOT under 2.0 ATA helps heal the brain. I've had some nerve healing too on my head and face after HBOT from trigeminal neuralgia after brain surgeries. HBOT kicks off over 8100 genetic markers for healing and repair. It also stimulates the stem cells to repair and replace/regenerate dead or lost tissues.

Doctors in London state that its unlikely that hypopot from tbi can show signs immediately without there being something else there before as it takes years they say for symptoms to show immediately following tbi or within six months. My son was so injured and showed signs at 4 months when investigated and the denial means he will be unable to secure compensation for this potential negative life changer

to the comment on April 2016- I am in the almost SAME EXACT BOAT. Head was turned also sitting in traffic. Im suffering for 1.5 yrs. Please tell me your near CT.. I can't find anyone to help me but I know this is the case

Two years ago I was struck from behind while at a traffic light.  I was on the way to work, eating a biscuit, while I was struck.  My head was in a turned position eating the biscuit, and this position along with a sudden jerk resulted in a whiplash injury that resulted in a concussion.  I was not aware of it at the time that I sustained a concussion because after five minutes of being hit I felt normal.  However, I believe that the accident resulted in nerve and brain damage that began a cycle of neurons being damaged in the brain.  

At the time, I thought that I had only bone, ligament, and nerve damage, thinking that the light-headedness, dizziness, faintness, rapid heart beats, etc. was all due to damaged nerves.  This is because a false reading of the MRI failed to read the damage to the pituitary gland that had ensued.

Having a concussion that never fully healed (because doctors misdiagnosed me and failed to read my scans accurately), along with a damaged pituitary resulted in hypopituitarism relating to growth hormone and testosterone.  Without these hormones in normal supply, especially growth hormone, my concussion was unable to heal completely.

The past two years has been trying.  Really hard.  A normal day ranges from 1.5 x harder to 5 x harder.  It depends on how tired my brain is.  I've put on a lot of weight due to almost no growth hormone.  The skin on my forehead has gotten very thin and a lot of fine lines now show (I'm almost 39).  I'm talking a lot of them showing up over the past year.  Injuries heal much slower.  I was bit by mosquitos last year, and it took about four months for them to heal.  Before my injury, a mosquito bite would be healed within two weeks tops.  My bones have broken-down, as I can now run my hand along my shin (Tibia or Fibula?) bone and I feel rivets.  Before the injury, I had a solid, straight bone with no rivets.  I find myself very tired or fatigued to some degree much of the time.  Soft tissue damage in the neck from the accident has up until recently still displayed the sound of crunching, the result of not having enough growth hormone to heal the tissues in a timely manner.

Every day is a battle to make it through the day.  People who have not had a brain injury and a damaged pituitary gland at the same time have no idea how hard life is for people in such a predicament.  It is hard, and it makes you a bit irritable at times,  Unfortunately, most people don't really seem to get it, and they act like you should either function as you always did, or they don't want to hear you talk about your problems,  After living with such hardship, you learn that we should appreciate all that we're given, including health.  So many people worry about frivolous things.  They don't realize how blessed they really are.

Thank God I finally was able to have a doctor that noticed my damaged pituitary, and now I am on track to start growth hormone injections which should restore my brain and return me to full health after suffering for two years. 

Completely understand, TBI Oct 2015 with pituitary gland damaged, massive life changer and 22 chest infections in three years, fatigue beyond comparison memory loss and cognitive decline. You're not alone.

I had a closed head injury in 1998, care flight to a Dallas Hospital, X-rayed everything but my head. sustained several injuries but sent home and the nightmare began. A year later an MRI revealed a past closed head injury. From that day on my life changed. Family put off my extremely strange behavior as crazy. Dr's. Depression anything but finding the true cause, so I self medicated, alcohol, drugs both legal and nothing worked but no one really helped and still today 2016 I have to deal with the symptoms and all these years worked in dangerous construction had several concussions but now stay e

My niece of 21 yrs of age has had a  tumor since she was 6 down in the centre of her brain behind her eyes glacoma she has a shunt there for drainage of fluid retained there which worked and she had a productive life up until last yr she had surgery and they had to remove 40% of it to relieve pressure it was life or death situation it effected the puturitary gland  its not working, her thirst is not there, her sodium levels are high due to her fluid intake, she has had multiple seisures and not they have heavily sedated her to stop seisures and to keep low stimulation she fall on the right side where the the new shunt was put in because of enlarged cists formed around the tumor to allow drainage and now there is a small bleed there. shes been sedated for two days now and tried to wake her but she wont they have a air tube in her and now a feeding tube all of this is happening now as I write you she also has short memory loss all of the multiple seisures she had and she had a grandmall seisure that triggered when she fell that put in this terrifying situation. neurologist doctors dont know what to do. she was doing well until all of this happened. There is so more much more to say of this complex situation. The other question if she wakes up will she be in a vegetated state for the rest of her life if she doesnt will she die?

I'm surprised at the figures you give, Dr Bazarian. Most research puts the incidence of longterm hypopituitarism at much higher than that, around 30% after brain injury. http://bit.ly/1aaznvZ and http://bit.ly/1cvWe6w and some papers even higher still. bit.ly/18g66Sd . Diabetes insipidus has also been found to persist in around 6% of TBI patients http://www.ncbi.nlm.nih.gov/pubmed/15579748

Have you explored the possibility that the posterior part of your pituitary gland has been damaged causing diabetes insipidus? This is treatable with anti-diuretic hormone replacement (ADH) and I don't think you need to bother with electrical implants in your bladder.
Hello, I have a son who got a concussion playing D1 basketball. This was 2010. He was treated in Pittsburgh and went through vestibular therapy. He is still dealing with depression, fatigue, has problems doing a full schedule. He was releaseed to return to basketball in 2012 but has yet to be able to resume a full schedule. He attended college as a high school student and is now struggling to stay in school. Could this be hypopituitarism and who do I find to treat it? I have only been able to find anti againg doctors to even aknowledge this exist.
Agood subject. I have a severe TBIs 3 at one time. Front, temporal, cerebellum. Resulted in mild cognitive impairment, short term memory loss, and urine incontency, urge and polyuria. Hx DM type II aodm prior to injury. One contact had acquired diabetes insipidus 2nd TBI blast. Usual TBI sxs for me, extreme faTIGUE since frontal lobe affected believed issue was inhibition and loss of control by frontal lobe to inhibit voiding urgency and urgency which usually results in pre micturation flow and unable to forced avoidance of urine flow initiation. Seen by Urologist who recommend stimulator eletrical implant, and diagnosed neurogenic bladder. Neuro psyche rx'd Provigil to combat fatigue and day time sleepiness which only raised b/p not co-effective for HTN control. Thought polyuria due to elevated blood sugars but wnl 100-110 pre meals w/lantus. Endocrinologist not utilized for eval will try to get a referal to endocrinologist. May have 2ndary injury to pituitary and not realize. Got to GO, GOT TO GO!!!!,,,,,,,,,,,,,,,,,,,,,