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Testing and Treatment for Traumatic Brain Injury (TBI) (Part 1)

In the United States, there are more than 3.5 million emergency department visits for TBI, which may be categorized as mild, moderate or severe. There are also many more individuals who may never seek medical attention. The majority of TBI cases are classified as mild TBI (mTBI). Approximately half of patients with TBI in the United States experience some form of short-term disability. However, brain injury after significant trauma has been associated with an increased risk of Alzheimer disease and seizures and repetitive TBIs is a risk factor for chronic traumatic encephalopathy(CTE) and Parkinson’s disease.

Very often, TBI after a concussive injury is not managed beyond an ER visit where a CT scan may or may not be performed. Acute hospitalization or Neurological follow up are usually only recommended if there is loss of consciousness or evidence of serious injury. Brain imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) are often used but unfortunately can be interpreted as being “negative” or normal despite the fact that brain injury is present.

The good news is that there are now better options, including using biomarkers, newer brain imaging modalities and laboratory diagnostics, that can help make a diagnosis of TBI.  And these advances also make it possible to help identify the degree of brain injury after TBI and direct better treatment. Here we will focus on biomarkers and laboratory testing, and in my next blog we will focus on brain imaging.

Hormone Imbalances in TBI

Depending on the degree of brain injury, approximately 10-20% of patients with TBI can develop hormonal imbalances, including pituitary insufficiency. The pituitary gland is the factory for hormone production involving growth, reproduction, thyroid, etc.

  • Growth hormone deficiency (GHD) is one of the most frequent pituitary disturbances after TBI, followed by gonadotropin (sex hormones such as the precursors for testosterone), cortisol and thyroid-stimulating hormone insufficiency. Common symptoms after TBI, such as memory and concentration difficulties, anxiety, depression, social isolation, weight gain, bone loss, and exercise intolerance can be symptoms directly related to TBI or hormone imbalances.
  • We can measure subnormal Growth Hormone levels by measuring the levels of insulin-like growth factor-1 (IGF-1) which is used as a surrogate biomarker for Growth hormone. But results of IGF1 are often normal, and therefore reliance on IGF-1 as an assessment of GH function after TBI may be misleading.

Specific Hormone Assays to Evaluate TBI

Here are the tests you should ask your doctor to do, for a better evaluation of the severity of your TBI or head injury.  

  • After an overnight fast, serum levels of thyroid stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), follicle stimulating hormone (FSH), luteinizing hormone (LH), total and free testosterone (males only), estradiol, cortisol (a.m.) and IGF-1 are measured at  baseline.  
  • Serum and urine sodium and osmolality and urine specific gravity are also collected to assess posterior pituitary function.
  • For Growth hormone (GH) deficiency, Glucagon, 1mg is administered intramuscularly, and blood (serum) is drawn at baseline, 90, 120, 150, and 180min to measure GH.

Integrative Treatment (non-pharmaceutical)

Here are some suggestions for repairing the hormone imbalance caused by TBI:

 

  • Vitamin D3/week has been shown to significantly raise IGF1 levels.
  • Angelica sinesis is a natural herbal treatment that contains polysaccharides such as  arabinose, rhamnose, and mannose which act to  stimulate IGF1/IGF1R gene expression.
  • Andrographolide is another herbal treatment has been shown to decrease levels of NSE, S-100β, and IL-6, inflammatory factors that are frequently elevated in TBI patients. . Andrographolides may help to  turns off the over-reactive inflammatory response related to alterations in blood brain barrier permeability, a frequent occurrence in TBI patients that may account for inflammation.
  • Resolvins are bioactive novel endogenous products which are metabolites of the polyunsaturated ω-3 fatty acids. They have potent anti-inflammatory and pro-resolution effects in the brain. I will discuss these in more detail in my upcoming blog on the use of biomarkers in TBI related to inflammation and neurodegeneration.
  • Nucelotides such as Inosine and Cytidine have been shown to activate repair mechanisms after brain injury and potentially promote remyelination.

Medical Options to Treat Hormone Imbalance from TBI

  • Growth hormone replacement if clinically indicated (GH of <3ng/mL is considered as being deficient and in need of GH treatment). GH replacement therapy 0.3 mg/day to 1 mg/day, showed significant improvement in cognitive functions. Ideally, these treatments are best given under the supervision of an Endocrinologist.
  • Cortisol replacement, such as low doses of hydrocortisone can be used if clinically warranted and if there are no contraindications.
  • In human studies, intranasal insulin has been shown to enhance memory. Clinical studies using 10 IU of insulin twice a day nasal drug delivery device designed to deliver drugs to the olfactory region are currently ongoing.
  • Cerebrolysin, a neuropeptide preparation of porcine origin, consists of neuropeptides and free amino acids and has been shown to enhance nerve growth and capable of stimulating the restorative capacity of the brain after injury. It is approved in Europe for recovery after brain injury but can only be administered in IV fashion.

In my next blog, I will review advances in brain imaging for TBI patients including SPECT, MRI, DTI and PET studies, as well as novel blood tests that assess tau protein, enolase and S100B. These can be utilized to help develop a unique treatment program for patients with TBI.

Meet Dr. Lombard: Dr. Jay Lombard is an Integrative Neurologist and co-founder of Genomind. He maintains a private practice at the Blum Center in Rye Brook, NY where he is known as the brain detective because of his ongoing research in patients with complex neuropsychiatric disorders.

Make an appointment:  If you live in our area, Dr. Lombard is available for in-person appointments at Blum Center for Health.  If you don’t live nearby and would like to work with Dr. Lombard, he is available for remote consultations via video or phone.  Please use this link to make an appointment.