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Pituitary-adrenal function in patients with acute subarachnoid haemorrhage: a prospective cohort study

Stepani Bendel1*, Timo Koivisto2, Esko Ruokonen1, Jaakko Rinne2, Jarkko Romppanen3, Ilkka Vauhkonen4, Vesa Kiviniemi5 and Ari Uusaro1

Author Affiliations

1 Department of Intensive Care, Kuopio University Hospital and Kuopio University, Puijonlaaksontie 2, 70211 Kuopio, Finland

2 Department of Neurosurgery, Kuopio University Hospital, Puijonlaaksontie 2, 70211 Kuopio, Finland

3 Eastern Finland Laboratory Centre, Kuopio University Hospital, Puijonlaaksontie 2, 70211 Kuopio, Finland

4 Department of Medicine, Kuopio University Hospital and Kuopio University, Puijonlaaksontie 2, 70211 Kuopio, Finland

5 IT Centre, Kuopio University PO Box 1627, 70211, Finland

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Critical Care 2008, 12:R126 doi:10.1186/cc7084


See related commentary by Groeneveld et al., http://ccforum.com/content/13/1/103

Published: 13 October 2008

Abstract

Introduction

Subarachnoid haemorrhage (SAH) may damage the hypothalamo-pituitary-adrenal gland (HPA) axis and disturb cortisol metabolism. There are no available data that relates to the response of the HPA axis in the acute phase of SAH. We aimed to characterise the behavior of serum adrenocorticotropic hormone (ACTH), total cortisol, stimulated total cortisol and free cortisol concentrations in acute aneurysmal SAH.

Methods

A prospective cohort study was conducted of patients with acute aneurysmal SAH (n = 30) admitted to a tertiary university hospital. Patients admitted for elective aneurysmal surgery (n = 16) served as the control group. An ACTH stimulation test was performed twice during the first week and at three months. The main outcome measure was description of the ACTH-cortisol response by calculating serum free cortisol and measuring total cortisol and ACTH concentrations. A mixed models method was used for testing between the groups, allowing heterogeneity between the groups.

Results

Patients with SAH had higher initial serum total cortisol (mean +/- SD; 793 +/- 312 nmol/L) and free cortisol concentrations (83 +/- 55 nmol/L) than control patients (535 +/- 193 nmol/L, p = 0.001 and 33 +/- 18 nmol/L, p < 0.001, respectively). Thereafter, there were no differences in this respect. Serum free and total cortisol concentrations correlated but were unaffected by the severity of SAH. ACTH concentrations were comparable between SAH and control groups. Patients with Hunt-Hess grades IV to V had higher ACTH concentrations at day one (10.7 +/- 7.1 pmol/l/L) and day five (8.2 +/- 7.7 pmol/L) than patients with grade I-III (day one: 3.8 +/- 2.0 pmol/L, p = 0.002; day five: 4.7 +/- 1.8 pmol/L, p = 0.04).

Conclusions

Calculation of serum free cortisol concentration was not helpful in identifying patients with potential hypocortisolism. SAH severity did not affect cortisol concentrations, possibly indicating relative pituitary-adrenal insufficiency in patients with more severe bleeding.

Trial registration

ClinicalTrials.gov Identifier NCT00614887.