What is the treatment for postconcussive pituitary dysfunction?

Treatment of Postconcussive Pituitary Dysfunction

The treatment of postconcussive pituitary dysfunction requires hormone replacement therapy specific to the deficient hormones, with corticosteroid replacement being the most urgent priority for adrenal insufficiency, followed by appropriate management of other hormonal deficiencies. 1

Diagnosis and Assessment

Before initiating treatment, proper assessment of pituitary function is essential:

• Comprehensive pituitary hormone panel including:

  • Morning cortisol and ACTH
  • TSH and free T4
  • Growth hormone and IGF-1
  • Prolactin
  • Gonadotropins (FSH, LH) and sex hormones (testosterone/estradiol)

• Prevalence of pituitary dysfunction after traumatic brain injury is significant:

  • 12.2% in female athletes with mild TBI 2
  • 28.4% in moderate to severe TBI survivors 3
  • Growth hormone deficiency is most common in athletes 4

Treatment Algorithm

1. Immediate Management of Adrenal Insufficiency

For severe hypoadrenalism with symptoms such as hypotension or severe electrolyte disturbances:

• Initiate IV (methyl)prednisolone 1 mg/kg immediately 1
• Convert to oral prednisolone when stable
• Aim to wean to maintenance dose of 5 mg daily as symptoms allow over 4 weeks

2. Thyroid Hormone Replacement

For central hypothyroidism (low/normal TSH with low free T4):

• Begin levothyroxine replacement
• Important: Always replace cortisol for 1 week prior to initiating thyroid hormone replacement to prevent precipitating adrenal crisis 1
• Monitor thyroid function tests every 1-2 weeks initially

3. Growth Hormone Replacement

For documented GH deficiency:

• Consider GH replacement therapy, especially for patients with:
  • Increased body mass index
  • Low IGF-1 levels
  • Persistent fatigue and decreased quality of life 3
• Note: Athletes may require therapeutic use exemption if competing 4

4. Sex Hormone Replacement

For hypogonadism:

• Males: Testosterone replacement
• Females: Estrogen with or without progesterone based on menopausal status
• Monitor for improvement in sexual function, energy levels, and bone health

5. Management of Hyperprolactinemia

• If prolactinoma is diagnosed, consider dopamine agonist therapy 2
• For mild hyperprolactinemia without tumor, monitor and treat symptomatically

Multidisciplinary Approach

In addition to hormone replacement, consider these complementary interventions:

1. Early information and education about postconcussion symptoms and management 1

2. Graded physical exercise with gradual increase in intensity over time, at least once weekly for 4 weeks 1

3. Vestibular rehabilitation for patients with persistent vestibular dysfunction 1

4. Manual therapy for the neck and spine if indicated 1

5. Psychological treatment for emotional symptoms and cognitive difficulties 1

Monitoring and Follow-up

• Regular monitoring of hormone levels to adjust replacement doses
• Patient education on "sick day rules" for stress dosing of corticosteroids
• Consider alert card or bracelet for patients on corticosteroid replacement 1
• Long-term follow-up with an endocrinologist is essential

Important Considerations and Pitfalls

• Avoid stopping corticosteroid replacement in patients with central adrenal insufficiency 1
• Failure to recognize pituitary dysfunction may lead to persistent postconcussive symptoms that could be improved with appropriate hormone replacement 5
• Symptoms of pituitary dysfunction overlap considerably with PTSD and other postconcussive symptoms 5
• Pituitary dysfunction can develop or resolve over time, necessitating ongoing monitoring 4
• Female athletes may be an underdiagnosed population, with recent studies showing significant prevalence of pituitary dysfunction after mild TBI 2

By systematically addressing each hormonal deficiency while incorporating complementary rehabilitative approaches, treatment of postconcussive pituitary dysfunction can significantly improve morbidity, mortality, and quality of life outcomes.