Research

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

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

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

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

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

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

author email corresponding author email

Critical Care 2008, 12:R126doi:10.1186/cc7084

Published:	13 October 2008

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

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.