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