Pituitary Dysfunction After Aneurysmal Subarachnoid Hemorrhage (TIRASH)

Recently, the occurrence and potential impact of pituitary dysfunction after aSAH has gained increasing interest. Several studies have demonstrated pituitary dysfunction after SAH suggesting that pituitary dysfunction may be a contributing factor for residual symptoms after SAH. This is an observational multicentric study aimed to test the prevalence of thyroid abnormalities, other neuroendocrinological dysfunction and their influence on outcome of patients affected by aSAH.

Study Overview

• Status: Unknown
• Conditions: Thyroid Disfunction; Subarachnoid Haemorrhage From Cerebral Aneurism Rupture; Pituitary Disfunction
• Intervention / Treatment: Biological: Evaluation of pituitary endocrine function; Behavioral: Evaluation of clinical outcome; Behavioral: Evaluation of neuropsychological function

Detailed Description

The incidence of aneurysmal subarachnoid hemorrhage (aSAH) varies between 6 to 10/100,000 subjects per year and it is a major cause of death and disability. The mortality rate ranges from 40 to 50%, and those who do survive SAH have high rates of functional limitations that could lead to impaired quality of life, including fatigue, depression, and loss of motivation.

Because aSAH affects patients in their most productive years of life, the disease has important social, and economic implications, and early prediction of long-term outcome is based on multiple factors including the primary injury secondary insults as well as neurorehabilitation interventions.

Recently, the occurrence and potential impact of pituitary dysfunction after aSAH has gained increasing interest. Several studies have demonstrated pituitary dysfunction after SAH suggesting that pituitary dysfunction may be a contributing factor for residual symptoms after SAH. However, questions remain about the real prevalence and impact of such dysfunction on patients' outcome both in the acute and chronic phase after these events.

In two recent metanalysis, the prevalence of total pituitary dysfunction was found with pooled frequencies of 0.31 (95% confidence interval CI: 0.22-0.43) [Can et a.] and 49.3.0% (95% CI 41.6%-56.9%) [Robba et al] during the acute phase (< 6 months from aSAH) and decreasing in the chronic phase to 0.25 (95% CI: 0.16-0.36) [Can et al.] and 25.6% (95% CI 18.0%-35.1%) [Robba et al]. However, the authors found high heterogenicity and different results between the available literature; many differences were found in the in the choice of time of pituitary function assessment and SAH, of diagnostic criteria and units of measurement used to establish the diagnosis of hypopituitarism after SAH.

Finally, it is not clear which is the hormone axis more likely to be affected after aSAH.

It is believed that, among the other, the incidence of thyroid dysfunction is the most relevant, as it is associated with severe clinical impairment and symptoms. In literature, the prevalence of thyroid dysfunction after aSAH is reported from 0 to 35%.[Karaka, Tanrivedi].

Hypothyroidism includes a wide variety of symptoms including weakness, fatigue, depression, irritability, memory loss and decreased libido. Should these abnormalities complicate more than one third of the patients, hormone testing and eventually replacement should become "standard of care" to test.

In order to define the actual incidence of these abnormalities, an observational multicentric study to test thyroid abnormalities, including TSH, fT4 (free thyroxine) and fT3 (free triiodothyronine) changes, is warranted.

Secondary endpoints of such study include the prevalence of other neuroendocrinological dysfunction and their influence on the patients' outcome.

• Study Type: Observational
• Enrollment (Anticipated): 50

Contacts and Locations

• Study Contact: Name: Chiara Robba, MD; Email: kiarobba@gmail.com
• Study Contact Backup: Name: Rita Bertuetti, MD; Email: rita_zoso@yahoo.it

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 70 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Patients admitted for aneurysmal subarachnoid haemorrhage

Description

Inclusion Criteria:

• patients with acute aneurysmal SAH aged between 18 and 70 years of age who could be subjected to endocrine evaluation within 10 days of ictus and at follow-up.

Exclusion Criteria:

• be major depression, psychiatric premorbidity, pituitary adenoma or perisellar lesion,preexisting hypopituitarism of any degree, previous hormonal substitution, patients in moribund state, pregnancy, glucocorticoid medication on admission to hospital or during treatment, prior pituitary insufficiency, and unsalvageable aSAH.

Study Plan

How is the study designed?

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of thyroid disfunction	Thyroid-stimulating hormone (TSH), free thyroxin (fT4), free triiodothyronine (fT3).	At 2 weeks after aSAH
Incidence of thyroid disfunction	Thyroid-stimulating hormone (TSH), free thyroxin (fT4), free triiodothyronine (fT3).	3 months after aSAH
Incidence of thyroid disfunction	Thyroid-stimulating hormone (TSH), free thyroxin (fT4), free triiodothyronine (fT3).	6 months after aSAH
Incidence of thyroid disfunction	Thyroid-stimulating hormone (TSH), free thyroxin (fT4), free triiodothyronine (fT3).	12 months after aSAH

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of pituitary- sexual hormones disfunction	serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (in women), testosterone (in men), sex hormone-binding globulin (SHBG).	At 2 weeks, and at follow up at 3, 6 and 12 months.
Survival	Modified Ranking Scale	At 2 weeks, and at follow up at 3, 6 and 12 months
Incidence of pituitary-adrenal axis disfunction	Serum levels of adrenocortico-tropic hormone (ACTH), cortisol, Na, K; serum and urine osmolality. Adrenal function will be evaluated through ACTH-stimulation testing with injection of 250 mcg of ACTH, and a peak of cortisol <500 nmol/l will be considered pathologic. Adrenal or GH insufficiency will be evaluated by insulin tolerance testing (ITT), and peak response of more than 3ng/ml for GH and and 500 nmol/l for cortisol will be considered as normal.	At 2 weeks, and at follow up at 3, 6 and 12 months.
Incidence of growth hormone insufficiency	serum levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1). Adrenal or GH insufficiency will be evaluated by insulin tolerance testing (ITT), and peak response of more than 3ng/ml for GH and and 500 nmol/l for cortisol will be considered as normal.	At 2 weeks, and at follow up at 3, 6 and 12 months
Incidence of language disorders	Neuropsychological examination focused on verbal comprehension will be evaluated through the application of Token Test . Incidence of impaired scoring will be correlated to incidence of altered hormone levels detected in the blood.	At 2 weeks, and at follow up at 3, 6 and 12 months
Incidence of memory disorders	Verbal and visual short term and working memory visuospatial construction and figural memory will be performed through Rey Osterrieth Complex figure test. Incidence of impaired scoring will be correlated to incidence of altered hormone levels detected in the blood.	At 2 weeks, and at follow up at 3, 6 and 12 months
Incidence of attention disorders	Psychomotor speed attention and concentration will be assessed through Trail Making Test. Incidence of impaired scoring will be correlated to incidence of altered hormone levels detected in the blood.	At 2 weeks, and at follow up at 3, 6 and 12 months

Collaborators and Investigators

• Sponsor: Dr. Rita Bertuetti
• Collaborators: Cambridge University Hospitals NHS Foundation Trust
• Investigators: Study Director: Chiara Robba, MD, Addenbrookes Hospital

Study record dates

Study Major Dates

• Study Start: January 1, 2017
• Primary Completion (Anticipated): January 1, 2018
• Study Completion (Anticipated): January 1, 2018

Study Registration Dates

• First Submitted: September 6, 2016
• First Submitted That Met QC Criteria: September 23, 2016
• First Posted (Estimate): September 27, 2016

Study Record Updates

• Last Update Posted (Estimate): September 27, 2016
• Last Update Submitted That Met QC Criteria: September 23, 2016
• Last Verified: September 1, 2016

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Pathologic Processes; Cardiovascular Diseases; Vascular Diseases; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Wounds and Injuries; Endocrine System Diseases; Hypothalamic Diseases; Intracranial Arterial Diseases; Intracranial Hemorrhages; Hemorrhage; Pituitary Diseases; Rupture; Aneurysm; Subarachnoid Hemorrhage; Intracranial Aneurysm
• Other Study ID Numbers: TIRASH-1.0

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED