Neural Regeneration Research ›› 2020, Vol. 15 ›› Issue (7): 1259-1265.doi: 10.4103/1673-5374.272611

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Risk factors for corticosteroid insufficiency during the sub-acute phase of acute traumatic brain injury 

Xin Chen1, *, Yan Chai2, Shao-Bo Wang3, Jia-Chong Wang4, Shu-Yuan Yue1, Rong-Cai Jiang1, Jian-Ning Zhang2, *   

  1. 1 Department of Neurosurgery, General Hospital of Tianjin Medical University, Tianjin, China 
    2 Tianjin Neurological Institute; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education; 
    Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China 
    3 Department of Neurosurgery, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region, China 
    4 Department of Neurosurgery, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Changsha, Hunan Province, 
    China
  • Online:2020-07-15 Published:2020-09-12
  • Contact: Jian-Ning Zhang, MD, PhD, jianningzhang@hotmail.com; Xin Chen, MD, PhD, xinchentianjin@me.com.
  • Supported by:
    This work was supported by the National Natural Science Foundation of China, No. 81671902 (to XC); 81501704 (to YC); the Project of
    Tianjin Applied Basic and Cutting-edge Technological Research of China, No. 17JCYBJC25200 (to XC); 15JCQNJC44900 (to YC); Tianjin Health
    Care Elite Prominent Young Doctor Development Program (to XC); the Young and Middle-aged Backbone Innovative Talent Program (to XC).

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Abstract:

Hypothalamic-pituitary-adrenal axis dysfunction may lead to the occurrence of critical illness-related corticosteroid insufficiency. Critical
illness-related corticosteroid insufficiency can easily occur after traumatic brain injury, but few studies have examined this occurrence.
A multicenter, prospective, cohort study was performed to evaluate the function of the hypothalamic-pituitary-adrenal axis and the inci
dence of critical illness-related corticosteroid insufficiency during the sub-acute phase of traumatic brain injury. One hundred and forty
patients with acute traumatic brain injury were enrolled from the neurosurgical departments of three tertiary-level hospitals in China,
and the critical illness-related corticosteroid insufficiency incidence, critical-illness-related corticosteroid insufficiency-related risk factors,
complications, and 28-day mortality among these patients was recorded. Critical illness-related corticosteroid insufficiency was diagnosed
in patients with plasma total cortisol levels less than 10 μg/dL (275.9 nM) on post-injury day 4 or when serum cortisol was insufficiently
suppressed (less than 50%) during a dexamethasone suppression test on post-injury day 5. The results demonstrated that critical illness-re
lated corticosteroid insufficiency occurred during the sub-acute phase of traumatic brain injury in 5.6% of patients with mild injury, 22.5%
of patients with moderate injury, and 52.2% of patients with severe injury. Traumatic brain injury-induced critical illness-related cortico
steroid insufficiency was strongly correlated to injury severity during the sub-acute stage of traumatic brain injury. Traumatic brain injury
patients with critical illness-related corticosteroid insufficiency frequently presented with hemorrhagic cerebral contusions, diffuse axonal
injury, brain herniation, and hypotension. Differences in the incidence of hospital-acquired pneumonia, gastrointestinal bleeding, and
28-day mortality were observed between patients with and without critical illness-related corticosteroid insufficiency during the sub-acute
phase of traumatic brain injury. Hypotension, brain-injury severity, and the types of traumatic brain injury were independent risk factors
for traumatic brain injury-induced critical illness-related corticosteroid insufficiency. These findings indicate that critical illness-related
corticosteroid insufficiency is common during the sub-acute phase of traumatic brain injury and is strongly associated with poor progno
sis. The dexamethasone suppression test is a practical assay for the evaluation of hypothalamic-pituitary-adrenal axis function and for the
diagnosis of critical illness-related corticosteroid insufficiency in patients with traumatic brain injury, especially those with hypotension,
hemorrhagic cerebral contusions, diffuse axonal injury, and brain herniation. Sub-acute infection of acute traumatic brain injury may be an
important factor associated with the occurrence and development of critical illness-related corticosteroid insufficiency. This study protocol
was approved by the Ethics Committee of General Hospital of Tianjin Medical University, China in December 2011 (approval No. 201189).

Key words: brain herniation, corticosteroid, critical illness-related corticosteroid, dexamethasone suppression test, diffuse axonal injury, astrointestinal bleeding, hemorrhagic cerebral contusions, hospital-acquired pneumonia, insufficiency, prognosis, traumatic brain injury