SAT-235 Young Male with Persistent Central Diabetes Insipidus After a Car Accident

Abstract BACKGROUND: Central diabetes insipidus (CDI) occurs in 20% of cases of traumatic brain injury (TBI). Most cases of post-TBI CDI resolve within 2–5 days. Only 6% of long-term survivors of TBI have evidence of persistent CDI.1 We report a patient with persistent CDI after TBI. Clinical Case: A 27 year old male was referred for polyuria. Three months prior he was in a rollover motor vehicle accident. At that time, CT head revealed frontal and occipital contusions with scattered subarachnoid, subdural, and intraventricular blood. There was no evidence of skull fracture, mass-effect, or midline shift. On hospital day 4, his urine output increased to > 3L/day, with serum sodium of 146 mEq/L (n 135–145) and urine specific gravity of 1.015 (n 1.005–1.030). Repeat head CT revealed bilateral subdural hematomas causing mild mass effect. During the rest of his 2-month hospitalization, he continued to have polyuria with specific gravity as low as 1.005, and occasional hypernatremia, with a peak serum sodium of 149 mEq/L. Serum sodium on discharge was 144 mEq/L. On presentation to our clinic, his family and caretakers reported polydipsia, polyuria and nocturia. He had no history of diabetes mellitus or lithium use. On exam he was tachycardic but normotensive with no signs of dehydration. Neurologic exam was normal except for distractibility and impaired long- and short-term memory. After 3 hours of water deprivation, laboratory testing revealed serum sodium 150 mEq/L, serum osmolality 307 mOsmol/kg (n 270–295), urine osmolality 119 mOsmol/kg (n 300–900), and ADH 3 pmol/L (n </= 14); consistent with CDI. Oral desmopressin led to resolution of polydipsia and polyuria. Evaluation of anterior pituitary function was normal. Six months post TBI, CT head revealed increased left frontal subdural hematoma with effacement of the right lateral ventricle and 1cm left-to-right midline shift. A burr hole procedure was performed but CDI persisted. Conclusion: Animal studies have shown that neurohypophyseal apoptosis occurs by inducing intracranial hypertension lasting 12 hours or more.2 Persistent DI may herald rising intracranial pressure (ICP), as reflected by our patient’s case.1 Clinicians should be aware of the reciprocal association between increased ICP and persistent CDI following TBI. References: (1) Tudor R. M., Thompson C. J. Posterior pituitary dysfunction following traumatic brain injury: review. Pituitary. 2019 Jun; 22(3):296–304. (2) Tan H., et al. Assessment of the role of intracranial hypertension and stress on hippocampal cell apoptosis and hypothalamic-pituitary dysfunction after TBI. Sci Rep. 2017 Jun; 7(1):3805.

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Outcome Prediction in Patients of Traumatic Brain Injury Based on Midline Shift on CT Scan of Brain

Indian Journal of Neurosurgery ◽

10.1055/s-0040-1716990 ◽

2021 ◽

Author(s):

Shrikant Govindrao Palekar ◽

Manish Jaiswal ◽

Mandar Patil ◽

Vijay Malpathak

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Head Injury ◽

Ct Scan ◽

Treatment Protocol ◽

Emergency Setting ◽

Midline Shift ◽

Ct Head ◽

Clinical Tools ◽

Gcs Score

Abstract Background Clinicians treating patients with head injury often take decisions based on their assessment of prognosis. Assessment of prognosis could help communication with a patient and the family. One of the most widely used clinical tools for such prediction is the Glasgow coma scale (GCS); however, the tool has a limitation with regard to its use in patients who are under sedation, are intubated, or under the influence of alcohol or psychoactive drugs. CT scan findings such as status of basal cistern, midline shift, associated traumatic subarachnoid hemorrhage (SAH), and intraventricular hemorrhage are useful indicators in predicting outcome and also considered as valid options for prognostication of the patients with traumatic brain injury (TBI), especially in emergency setting. Materials and Methods 108 patients of head injury were assessed at admission with clinical examination, history, and CT scan of brain. CT findings were classified according to type of lesion and midline shift correlated to GCS score at admission. All the subjects in this study were managed with an identical treatment protocol. Outcome of these patients were assessed on GCS score at discharge. Result Among patients with severe GCS, 51% had midline shift. The degree of midline shift in CT head was a statistically significant determinant of outcome (p = 0.023). Seventeen out of 48 patients (35.4%) with midline shift had poor outcome as compared with 8 out of 60 patients (13.3%) with no midline shift. Conclusion In patients with TBI, the degree of midline shift on CT scan was significantly related to the severity of head injury and resulted in poor clinical outcome.

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Successful Treatment of Transient Central Diabetes Insipidus following Traumatic Brain Injury in a Dog

Case Reports in Veterinary Medicine ◽

10.1155/2019/3563675 ◽

2019 ◽

Vol 2019 ◽

pp. 1-6

Author(s):

Catriona Croton ◽

Sarah Purcell ◽

Andrea Schoep ◽

Mark Haworth

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Diabetes Insipidus ◽

Successful Treatment ◽

Serum Sodium ◽

Rapid Onset ◽

Central Diabetes Insipidus ◽

The Other ◽

Clinical Progression ◽

First Report

An 11-year-old female spayed Maltese presented comatose, half an hour after vehicular trauma, and was treated for traumatic brain injury and pulmonary contusions. The dog developed severe hypernatremia within six hours of presentation, which responded poorly to the administration of five percent dextrose in water. As central diabetes insipidus was suspected, desmopressin was trialled and resolution of hypernatremia was achieved six days later. Transient trauma-induced central diabetes insipidus has been described previously in two dogs; in the first, serum sodium concentrations were evaluated three days after injury and the other developed hypernatremia seven days after injury. To the authors’ knowledge, this is the first report of rapid onset, transient, and trauma-induced central diabetes insipidus in a dog that encompasses the complete clinical progression of the syndrome from shortly after injury through to resolution.

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Acute and Chronic Posterior Pituitary Insufficiency Among Traumatic Brain Injury Patients at a Tertiary Care Center

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1270 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A623-A623

Author(s):

Imtiyaz Ahmad Bhat ◽

Moomin Hussain Bhat ◽

Shariq Rashid Masoodi ◽

Javid Ahmad Bhat ◽

Zafar A Shah ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Head Injury ◽

Diabetes Insipidus ◽

Hospital Stay ◽

Tertiary Care ◽

Posterior Pituitary ◽

Urinary Osmolality ◽

Pituitary Dysfunction

Abstract Background: Traumatic brain injury (TBI) is the leading cause of death and disability in young adults. Disorders of salt and water balance are the most commonly recognized medical complications in the immediate post-TBI period and contribute to early morbidity and mortality. Objective: We aimed to evaluate the prevalence of acute (during hospital stay) and chronic posterior pituitary dysfunction in patients of head injury admitted at our tertiary care hospital. Study Design: Prospective, Observational study. Participants: 136 patients, attending tertiary care in North India with TBI with radiological evidence of head injury. Methodology: The severity of brain injury was assessed by the Glasgow Coma Scale (GCS), and Modified Rankin Scale (MRS) score at the time of admission. Lab measurements, apart from routine CBC and biochemical tests, included tests of serum and urinary osmolality, serum sodium, cortisol, and thyroid function test during the hospital stay. All patients were monitored closely during the hospital stay. Surviving patients were evaluated at 3, 6, and 12 months of follow-up. Urinary output and water deprivation tests were done to determine chronic posterior pituitary dysfunction. The results were compared against normative data obtained from 25 matched, healthy controls. Serum & urinary osmolality was measure by the freezing point method. Diabetes insipidus (DI) and Syndrome of inappropriate ADH secretion (SIADH) were diagnosed according to standard criteria. Results: Of 136 patients admitted, 61 (44.85%) had a mild head injury (GCS, ≤8), 47 (35.55%) had a moderate injury (GCS, 9-12), and 27 (19.85%) had a severe injury (GCS, 13-15). DI occurred in 10 patients (7.4%), while SIADH was observed in 4 patients in the immediate TBI period. Risk factors for diabetes insipidus were GCS of ≤ 8 at admission, midline shift, and surgical intervention. DI was an independent risk factor for death. There was a negative correlation between the presence of DI and GCS score (r, -0.367). Most of the patients with DI (8 out of 10) died during the hospital stay. One patient persisted to have partial diabetes insipidus and another one SIADH at three months post-TBI; both patients had recovered at six months of follow-up. No new case of DI or SIADH occurred on the follow up to 12 months. Conclusion: The incidence of acute DI in severe head injury (GCS ≤ 8) could be an indicator of the severity of TBI, and associated with increased mortality as most of our patients died during the hospital stay.

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Vasopressin Bolus Protocol Compared to Desmopressin (DDAVP) for Managing Acute, Postoperative Central Diabetes Insipidus and Hypovolemic Shock

Case Reports in Endocrinology ◽

10.1155/2017/3052102 ◽

2017 ◽

Vol 2017 ◽

pp. 1-4

Author(s):

Anukrati Shukla ◽

Syeda Alqadri ◽

Ashley Ausmus ◽

Robert Bell ◽

Premkumar Nattanmai ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Case Report ◽

Specific Gravity ◽

Diabetes Insipidus ◽

Serum Sodium ◽

Urine Output ◽

Hypovolemic Shock ◽

Central Diabetes Insipidus ◽

Intravenous Fluids ◽

Decompressive Craniotomy

Introduction. Management of postoperative central diabetes insipidus (DI) can be challenging from changes in volume status and serum sodium levels. We report a case successfully using a dilute vasopressin bolus protocol in managing hypovolemic shock in acute, postoperative, central DI. Case Report. Patient presented after bifrontal decompressive craniotomy for severe traumatic brain injury. He developed increased urine output resulting in hypovolemia and hypernatremia. He was resuscitated with intravenous fluids including a dilute vasopressin bolus protocol. This protocol consisted of 1 unit of vasopressin in 1 liter of 0.45% normal saline. This protocol was given in boluses based on the formula: urine output minus one hundred. Initial serum sodium was 148 mmol/L, and one-hour urine output was 1 liter. After 48 hours, he transitioned to 1-desamino-8-D-arginine vasopressin (DDAVP). Pre-DDAVP serum sodium was 149 mmol/L and one-hour urine output 320 cc. Comparing the bolus protocol to the DDAVP protocol, the average sodium was 143.8 ± 3.2 and 149.6 ± 3.2 mmol/L (p=0.0001), average urine output was 433.2 ± 354.4 and 422.3 ± 276.0 cc/hr (p=0.90), and average specific gravity was 1.019 ± 0.009 and 1.016 ± 0.01 (p=0.42), respectively. Conclusion. A protocol using dilute vasopressin bolus can be an alternative for managing acute, central DI postoperatively, particularly in setting of hypovolemic shock resulting in a consistent control of serum sodium.

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Evaluating the predictive factors affecting outcome in patients with severe traumatic brain injury: a prospective observational study

International Surgery Journal ◽

10.18203/2349-2902.isj20212268 ◽

2021 ◽

Vol 8 (6) ◽

pp. 1762

Author(s):

Vikram Singh ◽

Amar Nath ◽

Meenu Beniwal ◽

Paritev Singh ◽

Rockey Dahiya

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Observational Study ◽

Severe Traumatic Brain Injury ◽

Prospective Observational Study ◽

Midline Shift ◽

Late Outcome ◽

Severe Tbi ◽

Ct Head ◽

Gcs Score

Background: Severe traumatic brain injury (TBI) is a neurosurgical emergency and timely intervention is critical for favorable outcome. We aimed to evaluate certain demographic, clinical and radiological factors for outcome prediction in TBI patients in terms of morbidity and mortality.Methods: A prospective observational study was conducted in 100 patients of severe TBI admitted to our hospital from September 2016 to June 2018. Those with penetrating head injury, associated severe chest, abdominal or orthopedic trauma and pregnant or lactating women were excluded. Clinical outcome was assessed at the time of discharge and after three months according to Glasgow outcome score (GOS).Results: Majority of patients were adults in the age group 20 to 39 years. Road-side accident (75%) was the commonest mode of injury followed by fall (23%) and assault (2%). Out of 100 patients, 51 had in-hospital mortality. Of 49 patients who survived for GOS assessment at 3 months, three (6.1%) patients had unfavourable GOS I to III. Presence of hypoxemia, pupil non-reactivity, computerised tomography (CT) head findings of hemorrhagic contusion, subarachnoid hemorrhage (SAH), midline shift and effacement of basal cisterne were associated with significantly increased risk of unfavorable early and late outcome after severe TBI (p<0.05). Poor GCS score and fracture skull were associated with adverse early and late outcome respectively (p<0.001).Conclusions: Low GCS score at admission, pupil non reactivity, presence of hypoxemia, abnormal CT head findings (hemorrhagic contusion, SAH, midline shift and effacement of basal cisterne) were strong predictors of adverse outcome after severe TBI.

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Evaluation of Intracranial Hypertension in Traumatic Brain Injury Patient: A Noninvasive Approach Based on Cranial Computed Tomography Features

Journal of Clinical Medicine ◽

10.3390/jcm10112524 ◽

2021 ◽

Vol 10 (11) ◽

pp. 2524

Author(s):

Yingchi Shan ◽

Yihua Li ◽

Xuxu Xu ◽

Junfeng Feng ◽

Xiang Wu ◽

...

Keyword(s):

Computed Tomography ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Hypertension ◽

Hounsfield Unit ◽

Radiological Feature ◽

Cranial Computed Tomography ◽

Clinical Expertise ◽

Midline Shift ◽

Model Features

Background: Our purpose was to establish a noninvasive quantitative method for assessing intracranial pressure (ICP) levels in patients with traumatic brain injury (TBI) through investigating the Hounsfield unit (HU) features of computed tomography (CT) images. Methods: In this retrospective study, 47 patients with a closed TBI were recruited. Hounsfield unit features from the last cranial CT and the initial ICP value were collected. Three models were established to predict intracranial hypertension with Hounsfield unit (HU model), midline shift (MLS model), and clinical expertise (CE model) features. Results: The HU model had the highest ability to predict intracranial hypertension. In 34 patients with unilateral injury, the HU model displayed the highest performance. In three classifications of intracranial hypertension (ICP ≤ 22, 23–29, and ≥30 mmHg), the HU model achieved the highest F1 score. Conclusions: This radiological feature-based noninvasive quantitative approach showed better performance compared with conventional methods, such as the degree of midline shift and clinical expertise. The results show its potential in clinical practice and further research.

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Hypothalamo-Pituitary Dysfunction in Patients With Chronic Subdural Hematoma

Physiological Research ◽

10.33549/physiolres.932290 ◽

2012 ◽

pp. 161-167 ◽

Cited By ~ 7

Author(s):

V. HÁNA ◽

M. KOSÁK ◽

V. MASOPUST ◽

D. NETUKA ◽

Z. LACINOVÁ ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Diabetes Insipidus ◽

Subdural Hematoma ◽

Chronic Subdural Hematoma ◽

Clinical Severity ◽

Hormone Deficiency ◽

Pituitary Hormone ◽

Pituitary Dysfunction ◽

One Year

Relatively frequent pituitary hormone deficiencies are observed after traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) and according to the published studies the neuroendocrine consequenses of traumatic brain injury are underdiagnosed. In a cohort of 59 patients (49 males, mean age 68.3 years, 36-88 years) after evacuation of subdural hematoma (SDH) were evaluated hypothalamo-pituitary functions one week after surgery, after three months and after one year. Hypogonadism was present in 26 % of patients in an acute phase, but in the majority had a transient character. Less than half of patients was GH deficient (GHD) according to the GHRH+arginine test. We did not find any serious case of hypocortisolism, hypothyroidism, diabetes insipidus centralis nor syndrome of inappropriate secretion of ADH (SIADH). Transient partial hypocortisolism was present in two cases, but resolved. We did not find relation between extension of SDH or clinical severity and development of hypopituitarism. In conclusion, in some patients with SDH growth hormone deficiency or hypogonadism was present. No serious hypocortisolism, hypothyroidism, diabetes insipidus nor SIADH was observed. The possibility of neuroendocrine dysfunction should be considered in patients with SDH, although the deficits are less frequent than in patients after TBI or SAH.

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