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Assessment, investigation, and early management of head injury: summary of NICE guidance

Re: Assessment, investigation, and management of head injury: summary of NICE guidance

6 December 2012

LETTER TO THE EDITOR OF THE BRITISH MEDICAL JOURNAL

5 December 2012

We write as members of a group of fifty consultants and representatives of charities who recently signed a letter to the Scottish Intercollegiate Guidelines Group about post-traumatic hypopituitarism (PTHP). We asked that the guideline on brain injury rehabilitation currently in development and due out next March should include two sentences on PTHP. These sentences were:

“Post-traumatic hypopituitarism is not uncommon after traumatic brain injury and pituitary function tests should be considered in anyone presenting with symptoms which might be indicative of deficits in one or more pituitary hormones. There should be close and expert follow-up after moderate or severe traumatic brain injury as some symptoms can go unrecognized for years.” (References were added.)

We were disappointed at SIGN’s refusal. By omitting any mention of PTHP, SIGN is helping to perpetuate a situation where around a third of survivors of brain injury, whether severe or mild, remain undiagnosed with a condition that can destroy their libido and fertility and give rise to obesity, fatigue and depression, with the ensuing consequences of emotional stress, relationship breakdown and suicides. SIGN’s decision to ignore this sequel of head injury is puzzling in view of the stated scope of the guideline 'providing recommendations, where possible, about assessment for adults and children with brain injuries in primary care and interventions for cognitive, communicative, emotional, behavioural and physical rehabilitation,' http://www.sign.ac.uk/pdf/head-injury-rehab-prog.pdf

It is an unsatisfactory situation that the NICE head injury guideline also fails to mention this serious and significant sequel of head injury, when its scope specifically includes “secondary care with the aim of early detection of intracranial complications” [Appendix A4] which are described as giving rise to “persistent disability or even death . . . which can potentially be minimised or avoided with early detection and appropriate treatment.” Their omission is in contrast to head injury guidelines elsewhere, for example, in Germany, Canada, and the US Military. We hope that NICE's update, due to appear in 2014, will rectify the omission. In the meantime we would exhort clinicians to warn the patients and their carers of the risk of PTHP after head injury, and that they should be aware that this condition may not appear immediately but with a delay of up to decades after injury.

References

Schneider HJ et al, Hypothalamopituitary Dysfunction following Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage: a Systematic Review, 2007 JAMA http://jama.jamanetwork.com/article.aspx?articleid=208915
Traumatic Brain Injury-Related Hypopituitarism: A Review and Recommendations for Screening Combat Veterans, Guerrero AF, Alfonso A Military Medicine 175, 8:574, 2010
www.ncbi.nlm.nih.gov/pubmed/20731261
Prevalence of Anterior Pituitary Dysfunction in Patients following Traumatic Brain Injury in a German Multi-centre Screening Program, Berg C et al, Exp Clin Endocrinol Diabetes 2010.
www.ncbi.nlm.nih.gov/pubmed/19691014

joannalane@blueyonder.co.uk

Competing interests: None declared

Joanna Lane, parent, retired teacher

Professor Michael Barnes, Chair of UK Acquired Brain Injury Forum, Professor Julian F Bion, Professor of Intensive Care Medicine, University of Birmingham, Dr Peter Brambleby, FFPH, FRCP(Edin), Independent Public Health Consultant, Miss Jennifer Brown, Consultant Neurosurgeon, Institute of Neurological Sciences, and Royal Hospital for Sick Children, Glasgow, Dr Andrew Coe, Consultant Paediatrician, University Hospitals Coventry and Warwickshire, Dr Andrew Curran, Paediatric Neurologist, Alder Hey Children’s Hospital, Dr Nikolaos Daskas, Paediatrician and Paediatric Endocrinology Research Fellow, Royal Hospital for Children, Bristol, Dr Richard Fitzgerald, Consultant Radiologist, Royal Wolverhampton Hospitals NHS Trust, Professor Peter Fleming, Consultant Paediatrician, Royal Hospital for Children, Bristol, Professor Clare Fowler, Consultant Uro-neurologist, National Hospital for Neurology and Neurosurgery, Dr Tom Goodfellow, Consultant Radiologist, University Hospitals Coventry and Warwickshire NHS Trust, Mr Richard Grunewald, Consultant Neurologist, Sheffield Teaching Hospitals NHS Foundation, Professor Julian P Hamilton-Shield, Consultant Paediatrician, Royal Hospital for Children, Bristol, Headway – the Brain Injury Association, Chief Executive Officer Peter McCabe, Professor Peter Hindmarsh, Paediatric Endocrinologist, Great Ormond Street Hospital, London, Dr Tim Kenny, Consultant Editor and Lead Author, Patient UK, Professor Jai Kulkarni, Rehabilitation Consultant, University Hospitals of South Manchester, Dr Raman Lakshman, Consultant Paediatrician, West Suffolk Hospital, Mr Peter McCabe, Chief Executive Officer of Headway – the Brain Injury Association, Professor John Monson, Consultant Physician and Emeritus Professor Clinical Endocrinology, St Bartholomew’s and the Royal London Hospitals, Miss Anne Moore, Consultant Neurosurgeon, Derriford Hospital, Plymouth, Immediate Past President of the Society of British Neurological Surgeons, Miss Lynn Myles, Consultant Neurosurgeon, Western General Hospital, Edinburgh, Dr Paul Newrick, Consultant Physician and Endocrinologist, Worcestershire Acute Hospitals NHS Trust, Professor David Nutt, DM FRCP FRCPsych FSB FMedSci, the Edmond J Safra Chair in Neuropsychopharmacology, Imperial College, London, The Pituitary Foundation, Chief Executive Officer, Ms Menai Owen-Jones*, Dr Harpal Randeva, Consultant Endocrinologist, University Hospitals Coventry and Warwickshire NHS Trust, Society of British Neurological Surgeons, Dr David Shakespeare, Consultant in Neurological Rehabilitation Medicine, Lancashire Teaching Hospitals Foundation Trust, Mr Patrick Statham, Consultant Neurosurgeon, Western General Hospital, Edinburgh, Mr James Steers, Past President of the Society of British Neurological Surgeons, UK Acquired Brain Injury Forum, Dr Jane Young, Consultant Radiologist, Whittington NHS Trust, Mr and Mrs J B Lane, parents

headinjuryhypo.org.uk, Coulsdon, Surrey

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