Over the past 15 years, tremendous progress has been made in the medical/scientific community to better understand the role that head injuries play in causing traumatic pituitary injuries. There has been a lot of great press coverage over the past 20 years about concussions from sports, car crashes, slips and falls, and even military blast related injuries that has raised our awareness about this important public health problem. But what has been very absent from all the talk about concussions, is any real consideration of pituitary injuries. According to a number of very credible scientific studies on TBI and pituitary damage over the last 15 years, between 30-50% of all brain injuries involve damage to the pituitary gland.
The pituitary gland is known as the “master” gland. It regulates the majority of important hormonal functions in the human body. Damage to the pituitary can have devastating consequences, and yet it is routinely missed in mild to moderate brain injury cases. That being the case, why has so little been said about this major public health problem?
The Center for Disease control (CDC) attempts to track the number of reported brain injuries that occur in the US each year. According to the CDC, there is on average 2.8 million emergency room visits each year where a concussion is diagnosed. However, this number is unquestionably low. In a 2005 study out of the University of Washington that looked at how frequently an ER doctor diagnoses a concussion, it found that a concussion is properly diagnosed only 56% of the time. Thus, the actual number of brain injuries each year is closer to 4 million.
YEARLY TRAUMATIC BRAIN INJURY STATISTICS (U.S. CDC)
Hits by/against people or things
SHIPS PASSING IN THE NIGHT
Imagine then that 30-50% of the 4 million folks injured annually in activities like those listed above – that means between 1.3 to 2.0 million people per year potentially have sustained a pituitary injury. Given that so few pituitary injuries in mild to moderate brain injury cases are diagnosed-we don’t know how often they are missed because there are no studies looking at this problem so far-but it can be said with certainty that the number is closer to 95%+ of such injuries are missed in ER rooms. The reason is simple. Pituitary injuries don’t typically start to show symptoms until several weeks to months after the traumatic event causing the brain injury. Additionally, pituitary injuries often mimic those of normal brain injury or post-concussion syndrome. Thus, well meaning and very competent physicians in ER rooms understandably miss pituitary damage that is not even on their radar medical screen while they are seeing patients in an emergent setting. It therefore falls on those physicians providing follow up care to catch the symptoms and onset of a pituitary injury.
So why is the pituitary injury so often overlooked? As noted above, the symptoms of a pituitary injury (hereafter referred to as neuro-endocrine dysfunction, or NED) are often mistaken for those of post-concussive syndrome, or traumatic brain injury.
Given all the attention that brain injuries have received over the past 10-15 years, it is understandable why NED can be missed or overlooked. However, post-concussion syndrome and NED are two very different medical conditions. With post concussive syndrome, most concussions resolve within 6-8 weeks and folks get on with their lives. Those concussions that don’t resolve and result in longer term issues are tougher to treat and resolve because the type of underlying damage to the brain tissue is not readily treatable except through external measures like cognitive therapy.
With NED, the symptoms tend to start within the 1-4 month time frame following the head injury, often times after many of the acute post-concussive symptoms have resolved, creating a confusing scenario for the patient and their physician when trying to determine what is causing the new onset of concussion like symptoms. In fact, some pituitary studies indicate that NED symptoms in mild brain injury cases can start as long as 12 months post head injury, creating even more confusion with physicians and patients as to what is going on. When this occurs, patients are often viewed with some suspicion given the late onset of symptoms, and are frequently labeled as hypochondriacs or having a set of medical conditions that general practitioners cannot always make sense of given the insurance and time constraints they operate under in a busy primary care practice. If missed, the effects of a pituitary injury can have significant long term health consequences.
However, if a pituitary injury is properly diagnosed, the long term health effects of pituitary injury can be largely controlled, and the person can lead a normal life.
For this reason, the Pituitary Injury Foundation is committed to raising the awareness level of both the medical community and the general public regarding the prevalence of pituitary injuries and how they differ from post-concussive syndrome, so that those with pituitary injuries can get the right treatment and lead healthy and productive lives.
HOW ARE PITUITARY INJURIES CAUSED?
First, it is important to understand where the pituitary is located and why it is easily injured during head trauma. The brain is made of soft tissue that is connected to the brain stem and other structures at the bottom of the brain, but otherwise not strongly connected to the inside of the cranium. The pituitary is located at the base of the brain, and like an apple connected by its stem to a branch, the pituitary is connected to the hypothalamus above it by the pituitary stalk:
The pituitary gland is known as the master gland that regulates hormonal functions in much of the body. In order to receive signals from the hypothalamus to produce certain hormones, the body sends a message from the hypothalamus to the pituitary through the rich supply of blood vessels, capillaries and nerves that run from the brain to the pituitary:
Whenever person has head trauma, whether it comes from a car crash, a fall, from playing sports, or even a blast injury from serving in the military, the brain inside the skull is subjected to what is called a coup-contrecoup type injury. That is a fancy French term for the sudden side to side movement of the brain within the skull when the head is impacted.
When the brain is thrown forward and backwards in the cranium, it impacts the front of the skull and then bounces back and hits the rear of the skull. This type of impact exerts tremendous force on the base of the brain where the pituitary is located. Because the pituitary hangs from the hypothalamus by its stalk into a bony cavity called the sella, the stalk is very prone to injury during head trauma as shown in the diagram below:
Based on studies done on cadavers with head and pituitary injuries, it is thought that when the pituitary stalk is injured, the blood supply to the different portions of the front of the pituitary can be compromised, and in time those sections of the pituitary that are deprived of blood flow become “necrotic”, or lose function because no blood is getting to those sections of the pituitary. As a result, the pituitary is no longer able to send the full hormonal signal to other parts of the body to produce certain hormones, resulting in a condition called hypopituitarism or NED, which simply means that the production of hormones like human growth hormone, testosterone and cortisol can slow down dramatically, and in some cases stop completely.
When this happens, particularly with human low growth hormone (HGH) or testosterone, the symptoms can look a lot like those seen in brain injuries and be overlooked as brain injuries, delaying the diagnosis of NED or pituitary problems:
As noted above, often times a concussion can start to clear up in the 6-8 weeks following head trauma, leading the patient and medical providers to believe that the head injury is resolving. However, in the 2-4 month time frame following the head trauma, the symptoms in the middle of these two diagrams will start to crop up if there has been a pituitary injury. When this happens, patients and medical providers often believe these symptoms are leftover purely from the head injury, when in fact it is the onset of pituitary dysfunction. As a result, many patients never get the help they need.
The good news is that once a pituitary injury is properly diagnosed through simple blood testing and what is called an IGF-1 test or an ITT test, treatment for the conditions noted above is available. If a person is low on HGH or testosterone for example, he or she can be started on hormone supplementation and will start to feel much better once the right dosage amount is determined. Most folks feel 75-80% better following hormone replacement, and can get back to their jobs, leisure activities, and generally enjoy life much more than before they were diagnosed. If you still have TBI or post-concussive related complaints, those will likely persist, but should be less intense with hormone replacement. Better yet, many of the long term health consequences of low HGH such as increased cardiac risks, weight gain and loss of muscle mass can be stopped, and you can lead a longer and healthier life.
In cases involving low testosterone or low FSH following a pituitary injury, (both reproductive hormones), some folks have been rendered infertile. Getting care for this can increase the chances that you can still have children. This problem is often times overlooked in a TBI setting and blamed on unknown causes, when in fact the cause is very clear.