Hypopituitarism in patients after
subarachnoid hemorrhage:
screening and treatment

Spontaneous subarachnoidal hemorrhage (SAH) occurs with an incidence of six
cases per 100.000 patient years, with a case mortality amounting to 50% (1). In
patients who survived SAH, high rates of functional limitations are found along
with quality-of-life impairment, such as fatigue, decreased mobility, loss of
motivation, reduced independence in activities of daily living and decreased
social functioning (1,2).
The residual functional problems in patients after SAH are often unexplained,
but may largely resemble those occurring in patients with untreated
hypopituitarism. Corticotrophin and TSH deficiency may present with symptoms
such as fatigue, weakness, headache, altered mental activity or impaired
memory. Symptoms attributable to Growth Hormone deficiency include lack of
vigor, decreased exercise tolerance and decreased social functioning with loss
of quality of life (2).
Recent studies in long-term survivors of SAH have shown varying incidences
(from 20 up to 50%) of hypopituitarism, with growth hormone deficiency (GHD)
occurring in 15 - 25% of patients (3,2,4,5). This neuroendocrine dysfunction
could be the result of damage to the hypothalamic/pituitary system caused by
post hemorrhagic local tissue pressure, toxic effects of the extravasated
blood, ischemia caused by vasospasm, high intracranial pressure, hydrocephalus
or local destruction during cerebral surgery. At present, it is not possible to
identify which SAH patients are at risk of developing hypopituitarism. The
clinical effects of optimal hormone replacement therapy on residual symptoms in
SAH patients is unknown.


Measuring Healthy controls.
Adequate norm values for the SAH patients concerning fitness, muscle strength
and activity pattern are lacking. However, these norm values are necessary to
interpret the results for evaluating the effects of SAH on physcial
functioning. This knowledge can be used to optimise rehabilitation programs
after SAH which may reduce the residual complaints.

To determine the incidence of hypopituitarism in patients after SAH
To identify neurological parameters that predict hypopituitarism after SAH
To determine the value of a Ghrelin test shortly after SAH, to identify
subjects with GHD.
To determine the impact of hypopituitarism on physical functioning, activity
pattern and participation.
To evaluate the effect of GH replacement on residual functional physical
fitness, fatigue and quality of life.

To evaluate physical functioning (cardiorespiratory and neuromuscular fitness),
activity pattern and fatigue in patients post SAH.

This is a prospective clinic-based cohort study

The study consists of 7 visits to our hspital for patients with
hypopituitarism. Patient without hypopituitaris only need to bring two vists to
our hospital. During these visits which will last for 66 weeks, we will
evaluate the patients by specific questionnaires. Bloodsampling will take place
according to the study flowchart in every visit. Two of the visits in week 24
and 60 will take longer than normal because of more extensive evaluation, the
visit in week 24 is only for patients with hypopituitarism and in week 60 for
all the patients included in the study. Patients with hypopituitarism will be
treated by the endocronologist comitted to this study.

Measuring Healthy controls.
All tests can be taken during one session of approximately 2,5 hours. The
measurements take place in the human movement laboratory of the department of
Rehabilitation Medicine and Physical Therapy of Erasmus MC. Controls will be
screened using a Par-Q quenstionaire, a Sportmedical questionaire and a
physical examintion before maximal testing.