RESUMO
PURPOSE: Deep brain stimulation (DBS) has been established as a safe and efficient method for the treatment of various movement disorders. As the emerging applications continue to expand and more centers become eligible for the procedure, complication rates and complication avoidance become increasingly important. Our aim was to report the DBS-related complication in our department over the last 7 years, compare our rates with those reported in the literature, and highlight those practices that will aid complications avoidance. PATIENTS AND METHODS: Since 2003, 106 patients underwent DBS for various pathologies in our department. There were 38 (36%) females and 68 (64%) males with a mean age of 57 years. Preoperative diagnoses included Parkinson's disease (n = 88), dystonia (n = 12), tremor (n = 3), epilepsy (n = 1), obsessive-compulsive disorder (n = 1), and central pain syndrome (n = 1). Surgical and hardware-related complications, their treatment, and outcome were recorded and compared with those reported in the literature. RESULTS: There were 12 procedure-related complications (11.3% of patients, 5.7% of the procedures). These included death (n = 1), aborted procedure (n = 1), postoperative respiratory distress (n = 3), intracranial hemorrhage (n = 2), epilepsy (n = 1), postoperative confusion or agitation (n = 3), and malignant neuroleptic syndrome (n = 1). Hardware-related complications presented in 4.3% of the procedures and included infection (five patients, 4.7%), electrode breakage (0.94%), lead migration or misplacement (0.94%), and stricture formation (two patients, 1.9%). CONCLUSIONS: Complication rates after DBS surgery remain low, proving that DBS is not only effective but also safe. Certain strategies do exist in order to minimize complications.
Assuntos
Estimulação Encefálica Profunda/efeitos adversos , Estimulação Encefálica Profunda/instrumentação , Eletrodos Implantados/efeitos adversos , Avaliação de Resultados em Cuidados de Saúde/métodos , Complicações Pós-Operatórias/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Estimulação Encefálica Profunda/métodos , Eletrodos Implantados/normas , Feminino , Grécia/epidemiologia , Hospitais de Ensino/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/classificação , Estudos Retrospectivos , Adulto JovemRESUMO
This technical note presents the advantages of a modified nasal speculum for the translabial-endonasal transsphenoidal approach to the sphenoid sinus and sella for surgery on lesions of the pituitary. The width of the upper lateral wings of the speculum was reduced by half over approximately three fourths of their length. This increases interior clearance and makes it easier to introduce the instruments used during transsphenoidal operations. We performed 50 transsphenoidal procedures for pituitary adenomas using the remodeled speculum. Three experienced surgeons evaluated the visual field and instrument passage through it, and they found it superior to the conventional design. The modification resulted in marked reduction of the overall operation duration. In conclusion, the more open translabial-transnasal speculum described here definitely facilitates the transsphenoidal approach to the pituitary.
Assuntos
Adenoma/cirurgia , Procedimentos Neurocirúrgicos/instrumentação , Hipófise/cirurgia , Neoplasias Hipofisárias/cirurgia , Osso Esfenoide/cirurgia , Instrumentos Cirúrgicos , Adulto , Idoso , Fossa Craniana Média/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cavidade Nasal/cirurgia , Procedimentos Neurocirúrgicos/métodos , Sela Túrcica/cirurgiaRESUMO
This study is designed based on the retrospective analysis of patients treated in the Neurosurgical Department of two major hospitals and review of the literature. The aim of this study is to evaluate the efficacy of surgery and address controversial issues in the treatment of symptomatic lumbar intraspinal synovial cysts. Spinal juxtafacet cysts (synovial and ganglion cysts) are a rare cause of low back and radicular leg pain. Although the relevant reports in the international literature are increasing, the controversy about conservative versus surgical treatment and the need for concomitant fusion still exists. Data from seven patients (age range 58-69 years, mean age 61 years) with low back and radicular leg pain due to a lumbar facet joint cyst were retrospectively analyzed. Demographic data, cyst level, presence of concomitant local pathology, treatment and results of treatment were recorded. A follow-up of at least 6 months (range 6-48 months) was conducted and results were noted. All patients had back pain, while five also experienced unilateral radicular leg pain and one had bilateral leg pain. One patient had neurogenic claudication. MRI identified the cyst and highlighted underlying pathology in all cases. All patients underwent surgical cyst excision. No fusion was performed. Post-operatively, all patients showed a total resolution of symptoms with sustained benefit at final evaluation. Review of the literature revealed a trend towards surgery, as this is correlated to a more favorable outcome compared with conservative treatment. Fusion should be performed on a case-by-case basis only. Surgery is a safe and effective treatment choice in this increasingly appearing ailment. A prospective, randomized trial should clarify issues under debate.
Assuntos
Doenças da Coluna Vertebral/diagnóstico , Doenças da Coluna Vertebral/cirurgia , Cisto Sinovial/diagnóstico , Cisto Sinovial/cirurgia , Idoso , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Doenças da Coluna Vertebral/etiologia , Cisto Sinovial/etiologia , Tomografia Computadorizada por Raios XRESUMO
The case of a 38-year-old man with a history of chronic migraine is reported. Despite a 3 week history of changes in his migraine pattern, a normal neurologic examination led to conservative treatment. He later presented with worsening headaches and imbalance; tendon reflexes were increased on the right side, and brain computed tomography and magnetic resonance imaging revealed a massive subacute subdural hematoma over the left hemisphere, developing on the grounds of bilateral temporal agenesis. The presence of bilateral temporal arachnoid cysts along with bitemporal agenesis altered clinical findings, causing only mild symptoms where an otherwise acute and devastating neurologic deterioration would be expected.
Assuntos
Cistos Aracnóideos/complicações , Hematoma Subdural/complicações , Hematoma Subdural/etiologia , Transtornos de Enxaqueca/etiologia , Adulto , Cistos Aracnóideos/fisiopatologia , Cistos Aracnóideos/cirurgia , Hematoma Subdural/cirurgia , Humanos , Imageamento por Ressonância Magnética , Masculino , Lobo Temporal/anormalidades , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Surgery for benign brain tumors in elderly patients without severe general health problems is an acceptable practice, as results are comparable with the ones of younger patients. Nevertheless, the hypothesis that operative complications and perioperative incidents could differ between the 2 age groups should be controlled; and age-specific strategies in operative technique and perioperative care may be useful. METHODS: Medical records of 348 patients were reviewed. Demographic data (age, sex), rate of excision, complications of the immediate postoperative period, neurological outcome, and mortality were recorded; and statistical evaluation comparing 2 age groups (19-64 and 65-84 years of age) was performed. RESULTS: The "young" age group consisted of 240 patients, whereas the "elderly" one had 108. Tumor removal rate was not significantly different in the 2 groups. The elderly age group included significantly more "complicated cases." Regarding each complication, postoperative hematoma, infections, and deep vein thrombosis were more frequent in elderly patients, presenting various degrees of statistical significance, whereas postoperative brain edema, hydrocephalus, and cardiorespiratory incidents presented no statistically significant difference. Finally, more elderly patients presented neurological deterioration, although mortality was not significantly different. CONCLUSIONS: Operation for intracranial meningioma in elderly patients is justified as long as detailed preoperative evaluation is performed. Planning of modified protocols including intraoperative technical aspects, careful use of steroids antibiotics, and prophylactic low molecular weight heparin, and early mobilization is necessary for optimizing operative outcome of elderly patients.
Assuntos
Meningioma/cirurgia , Complicações Pós-Operatórias/epidemiologia , Neoplasias Supratentoriais/cirurgia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/etiologia , Craniotomia , Feminino , Seguimentos , Humanos , Masculino , Meningioma/mortalidade , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/epidemiologia , Procedimentos Neurocirúrgicos , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Neoplasias Supratentoriais/mortalidade , Resultado do TratamentoRESUMO
PURPOSE: To estimate the functional benefit in patients with severe spasticity treated with intrathecal baclofen infusion through an implantable pump and to stress the need for functional assessment of these patients with a functional scale. PATIENTS AND METHODS: Between 1999 and 2003, 22 patients with a long history of severe and disabling pharmaceutically intractable spasticity, underwent implantation of a pump for continuous intrathecal baclofen infusion. The patients were subdivided into two categories according to the aetiology of spasticity: 15 had Multiple Sclerosis and seven had suffered a Spinal Cord Injury at different levels (from C4 to T11). Clinical status was assessed with the Ashworth and Penn spasm scales. Functional benefits were evaluated with the Barthel index score and pain relief with a self-reported visual analogue pain scale. RESULTS: Postoperatively, all patients presented improvement in spasticity, reduction of spasm frequency, significant improvement in functional status, enhancement of life comfort and reduction of pain. CONCLUSION: Reduction of spasticity and spasms achieved with intrathecally delivered baclofen, leads to functional improvement and pain relief.
Assuntos
Atividades Cotidianas , Baclofeno/administração & dosagem , Relaxantes Musculares Centrais/administração & dosagem , Espasticidade Muscular/tratamento farmacológico , Recuperação de Função Fisiológica , Adulto , Feminino , Seguimentos , Humanos , Bombas de Infusão Implantáveis , Infusões Parenterais , Masculino , Pessoa de Meia-Idade , Esclerose Múltipla/complicações , Espasticidade Muscular/etiologia , Índice de Gravidade de Doença , Traumatismos da Medula Espinal/complicações , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: To investigate the incidence, pattern, and magnitude of neuroendocrine changes in long-term survivors of aneurysmal subarachnoid hemorrhage (SAH). METHODS: Thirty patients (16 women) with a mean age of 50+/-13 years underwent endocrine assessment between 12 and 24 months after aneurysmal SAH. SAH severity was graded clinically by the Hunt & Hess scale (median, II) and radiologically by the Fisher classification (median, II). Patients underwent measurement of basal hormone levels and dynamic assessment by the low-dose (1 microg) corticotropin stimulation test. Functional outcome was examined concurrently with endocrine testing by the modified Rankin Scale and the Barthel Index. RESULTS: Of the 30 patients tested, 14 patients (47%) showed isolated or combined endocrine abnormalities. These included low insulin-like growth factor 1 levels compatible with growth hormone deficiency in 37%, hypogonadism in 13%, and cortisol hyporesponsiveness to the low-dose corticotropin stimulation test in 10%; thyroid dysfunction in the form of subclinical hypothyroidism was observed in 7% of patients. Median modified Rankin Scale and Barthel Index at the time of endocrine testing were 1 and 100, respectively. There was no correlation between the presence of endocrine dysfunction and SAH severity indices or functional outcome scores. CONCLUSIONS: Long-term survivors of aneurysmal SAH frequently exhibit endocrine changes, with growth hormone and gonadal deficiencies predominating. Thus, screening of pituitary function is recommended in patients surviving SAH. The relationship between late hormonal alterations and functional outcome in patients with SAH warrants further study.
Assuntos
Doenças do Sistema Endócrino/etiologia , Hormônios/metabolismo , Sistemas Neurossecretores/fisiologia , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/fisiopatologia , Atividades Cotidianas , Adulto , Idoso , Doenças do Sistema Endócrino/diagnóstico , Feminino , Humanos , Hipogonadismo/etiologia , Hipopituitarismo/etiologia , Hipotireoidismo/etiologia , Masculino , Pessoa de Meia-Idade , SobreviventesRESUMO
OBJECTIVE: To investigate adrenal responses to the low-dose corticotropin (ACTH) stimulation test in acute traumatic or non-traumatic brain injury (BI) and to assess its value in predicting outcome. DESIGN: Prospective study. SETTING. Intensive care unit (ICU) in a university hospital. PATIENTS AND PARTICIPANTS: Seventy-five patients with acute BI, with a median age of 45 years were investigated. BI was due to trauma ( n=51), ischemic stroke ( n=17), subarachnoid hemorrhage ( n=4) or intracerebral hemorrhage (n=3). INTERVENTIONS: Blood was taken on day 16 (median) after admission to the ICU to determine baseline cortisol and ACTH. Thereafter, a low-dose stimulation test (LDST) was performed: 1 microg of tetracosactrin was injected and 30 min later a second blood specimen was obtained to measure stimulated cortisol. Patients having a stimulated cortisol below 500 nmol/l were defined as non-responders to the LDST. MEASUREMENTS AND RESULTS: Median baseline and stimulated cortisol were 491 nmol/l and 690 nmol/l, respectively. The median increment in cortisol was 154 nmol/l (range 5-579 nmol/l). Mean ACTH was 46+/-21 pg/ml. Ten (13%) patients were non-responders to the LDST; these had a higher mortality rate compared to patients with adequate cortisol production (70 vs 32%, p=0.034). Logistic regression analysis revealed that APACHE II ( p<0.001), Glasgow Coma Scale (GCS) ( p=0.04) and age ( p=0.02) were independent outcome predictors. In contrast, the increment in cortisol ( p=0.26) did not add to outcome prediction. CONCLUSIONS: Adrenal hypo-responsiveness in the setting of acute traumatic or non-traumatic BI is not an independent outcome predictor in the presence of high APACHE II, low GCS and older age.
Assuntos
Insuficiência Adrenal/epidemiologia , Hormônio Adrenocorticotrópico , Lesões Encefálicas/diagnóstico , Hemorragias Intracranianas/diagnóstico , Acidente Vascular Cerebral/diagnóstico , Adolescente , Testes de Função do Córtex Suprarrenal , Insuficiência Adrenal/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas/mortalidade , Feminino , Grécia/epidemiologia , Humanos , Hidrocortisona/sangue , Incidência , Hemorragias Intracranianas/mortalidade , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Acidente Vascular Cerebral/mortalidadeRESUMO
OBJECTIVE: To investigate the incidence and type of endocrine abnormalities in critical care patients with traumatic brain injury (TBI) and to examine their relationships to possible predisposing factors. DESIGN: Prospective study. SETTING: General intensive care unit in a university hospital. PATIENTS AND PARTICIPANTS: Thirty-four TBI patients (27 men, 7 women), having a mean age of 37+/-16 years, were studied after weaning from mechanical ventilation. INTERVENTIONS: Baseline endocrine assessment was carried out by measuring cortisol, corticotropin, dehydroepiandrosterone sulfate, free thyroxine, thyrotropin (TSH), testosterone, oestradiol, follicle stimulating hormone (FSH), luteinizing hormone, prolactin, growth hormone and insulin-like growth factor I. Dynamic evaluation was performed by human corticotropin releasing hormone and growth hormone releasing hormone in all patients. Male patients underwent additional investigation with gonadotropin-releasing hormone. Severity of neurological derangement was graded according to Glasgow Coma Scale (GCS), Marshall Computerized Tomographic Classification and intracranial pressure (ICP) levels. MEASUREMENTS AND RESULTS: Eighteen of the 34 patients (53%) had an abnormal result in at least one hormonal axis tested, with cortisol hyporesponsiveness and gonadal dysfunction being equally common, affecting 24% of patients. Endocrine abnormalities were associated with a higher brain CT-scan classification score ( p=0.02). The GCS on admission correlated positively with baseline FSH (r=0.37, p=0.03), peak FSH (r=0.41, p=0.03), testosterone (r=0.44, p=0.02) and TSH (r=0.39, p=0.03). There were no relations between ICP(max) and any baseline or dynamic hormone measurements. CONCLUSIONS: Patients with TBI receiving critical care show changes in their neuroendocrine responses, which depend upon clinical and radiological measures of head injury severity. Most common abnormalities include cortisol hyporesponsiveness and hypogonadism.
Assuntos
Lesões Encefálicas/complicações , Doenças do Sistema Endócrino/etiologia , Adulto , Análise de Variância , Causalidade , Doenças do Sistema Endócrino/epidemiologia , Doenças do Sistema Endócrino/fisiopatologia , Feminino , Grécia/epidemiologia , Humanos , Incidência , Masculino , Estudos Prospectivos , Estatísticas não ParamétricasRESUMO
We report the case of a 65-year-old woman who presented with severe neurologic complications after envenomation by a viper snake. A computed tomography (CE) scan revealed multiple brain hemorrhagic infarcts. Conservative treatment in this case proved to be sufficient and repetitive CT scans displayed a complete resolution of the radiologic findings. Possible mechanisms for the cerebral infarctions are discussed. The mechanism of infarctions in this case was believed to be the vasomotor and coagulation disorders caused by the toxins present in the snake's venom and was one of the reasons that led to conservative treatment.
Assuntos
Infarto Cerebral/diagnóstico , Infarto Cerebral/etiologia , Mordeduras de Serpentes/complicações , Viperidae , Idoso , Animais , Infarto Cerebral/diagnóstico por imagem , Diagnóstico Diferencial , Feminino , Pé , Humanos , Tomografia Computadorizada por Raios XRESUMO
Cerebral metastasis is a common finding in patients with systemic carcinoma and is an indication for progress of the disease. When brain metastases occur, they lead to a considerable decrease in both survival and the quality of life, in patients who otherwise might be functional. Furthermore, the location, size and number of such lesions, play a decisive role in management and prognosis. Even though early diagnosis and treatment is curative in rare cases, it may lead to a useful remission of the central nervous system (CNS) symptoms, enhance the patient's quality of life and prolong survival. The radiological exams established in the diagnosis of this condition, include computed tomography (CT) scan or magnetic resonance imaging (MRI). In cases of "micrometastatic" disease though, these exams may be pronounced as normal. This retrospective study was performed in patients with advanced systemic disease, who presented with neurological findings of intracranial mass lesion, in the absence of radiological evidence. Early-occurring symptoms were evaluated in accordance to location of the primary disease and follow-up with repetitive MRI scans was performed, in an attempt to confirm the diagnosis and facilitate prompt and appropriate treatment.
Assuntos
Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/secundário , Adulto , Encéfalo/patologia , Neoplasias Encefálicas/complicações , Neoplasias da Mama/patologia , Carcinoma Pulmonar de Células não Pequenas/patologia , Neoplasias do Colo/patologia , Feminino , Seguimentos , Humanos , Avaliação de Estado de Karnofsky , Neoplasias Pulmonares/patologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Fatores de TempoAssuntos
Divertículo do Colo/induzido quimicamente , Glucocorticoides/efeitos adversos , Metilprednisolona/efeitos adversos , Administração Oral , Idoso , Divertículo do Colo/diagnóstico , Divertículo do Colo/cirurgia , Feminino , Glucocorticoides/administração & dosagem , Humanos , Metilprednisolona/administração & dosagem , RupturaRESUMO
One of the reasons for shunt infection is valve erosion through the skin. In such cases, it is common practice to instantly relocate the shunt to avoid infection. We present a 77-year-old female patient with a 15-month history of hydrocephalus valve extrusion. Despite her poor mental status, clinical condition and hygiene, and the prolonged extrusion period, she developed neither a local nor a cerebrospinal fluid (CSF) infection. The patient was ultimately treated with shunt removal and repositioning. An extensive literature review revealed no previous report of such a case. This case indicates that under rare conditions, central nervous system (CNS) implantable devices might not become contaminated and may remain functional, even if they remain exposed for prolonged periods.
Assuntos
Hidrocefalia de Pressão Normal/cirurgia , Derivação Ventriculoperitoneal/instrumentação , Idoso , Pressão do Líquido Cefalorraquidiano , Remoção de Dispositivo , Falha de Equipamento , Feminino , Seguimentos , Humanos , Hidrocefalia de Pressão Normal/fisiopatologia , Reoperação , Fatores de TempoRESUMO
INTRODUCTION: Endocrine abnormalities in critically ill patients with stroke during the early recovery period have not been well characterized. METHODS: To investigate this issue, 33 consecutive mechanically ventilated patients (27 men) with hemorrhagic (n = 21) or ischemic (n = 12) stroke having a mean age of 57 +/- 12 years were studied. Glasgow Coma Scale score on admission in the hospital was 8 +/- 3. The following basal hormones were measured within 72 hours postextubation: cortisol, corticotropin (ACTH), free thyroxine, tri-iodothyronine, thyroid-stimulating hormone, testosterone, estradiol, follicle-stimulating hormone, luteinizing hormone, growth hormone, and insulin-like growth factor (IGF)-1. Subsequently, a low-dose (1 microg) ACTH stimulation test was performed. RESULTS: Twenty-six (79%) patients showed endocrine alterations. The most common change was low IGF-1 levels compatible with growth hormone deficiency (45%), followed by hypogonadism (39%), thyroid dysfunction (36%), and cortisol hyporesponsiveness (33%). CONCLUSION: Neuroendocrine changes occur with high frequency in critically ill patients with stroke during the early recovery period. It remains to be determined whether these changes have implications for functional and/or clinical outcome.
Assuntos
Doenças do Sistema Endócrino/etiologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/patologia , Idoso , Isquemia Encefálica/complicações , Hemorragia Cerebral/complicações , Estado Terminal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Respiração ArtificialRESUMO
The authors report the case of a 69-year old female with a persistent history of low back pain. Plain lumbar radiographs, performed at symptom initiation, revealed lumbar spondylolisthesis. Low back pain was attributed to this, and the patient received conservative treatment with partial relief of symptoms. Four years later, and as a result of acute onset of radicular symptoms, a lumbar spine magnetic resonance imaging scan was performed, revealing an epidural cystic lesion. The cyst was removed, and histopathology revealed a synovial cyst.
Assuntos
Dor Lombar/etiologia , Cisto Sinovial/complicações , Doença Aguda , Idoso , Feminino , Humanos , Laminectomia , Dor Lombar/diagnóstico , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/patologia , Vértebras Lombares/cirurgia , Imageamento por Ressonância Magnética , Radiculopatia/complicações , Cisto Sinovial/patologia , Cisto Sinovial/cirurgia , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
The effective treatment of intracranial abscess remains controversial. Progress in technology, linked with the development of neuronavigational systems, has made stereotactic aspiration and drainage of intracerebral abscesses effective and valid alternatives to traditional methods, namely, conservative medical treatment or open surgical excision. Between 1995 and 2002, 12 patients at our hospital underwent drainage of intracerebral abscesses under stereotactic guidance. Ten patients had solitary lesions and two had multiple abscesses. The appropriate antibiotic schemes were administered following culture of the aspirated material. The size of the abscess, the mass effect, and response to antibiotic treatment were followed up by repeated CT scans. All patients showed improvement and, at the end of treatment, returned to their previous activities. There were neither deaths nor any postoperative complication. A second aspiration was required in one patient due to recurrence of the abscess. The CT-guided stereotactic aspiration of brain abscesses helps achieve all treatment goals. It drains the contents of the abscess, reduces mass effect, and confirms diagnosis. It is minimally invasive, carries minimal morbidity and mortality, and can be performed on compromised patients under local anesthesia.
Assuntos
Abscesso Encefálico/diagnóstico por imagem , Abscesso Encefálico/cirurgia , Drenagem , Técnicas Estereotáxicas , Cirurgia Assistida por Computador , Tomografia Computadorizada por Raios X , Adulto , Idoso , Abscesso Encefálico/patologia , Feminino , Seguimentos , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de TempoRESUMO
OBJECTIVE: To investigate hypothalamic-pituitary-adrenal axis function in patients requiring mechanical ventilation for traumatic brain injury and to assess the relation of hypothalamic-pituitary-adrenal axis abnormalities with vasopressor dependence and peripheral cytokine levels. DESIGN: Prospective study. SETTING: General intensive care unit in a university teaching hospital. PATIENTS: Forty patients (33 men and 7 women) with moderate to severe traumatic brain injury (mean age, 37 +/- 16 yrs) were studied the day after termination of mechanical ventilation (7-60 days after trauma). INTERVENTIONS: First, a morning blood sample was obtained to measure baseline cortisol, corticotropin, interleukin-6, and tumor necrosis factor alpha. Subsequently, 1 microg of synthetic corticotropin was injected intravenously, and 30 mins later, a second blood sample was drawn to determine stimulated plasma cortisol. Based on data derived from healthy volunteers, patients having stimulated cortisol levels <18 microg/dL were defined as nonresponders to the low-dose stimulation test. Thirty-one patients underwent also a human corticotropin releasing hormone test. MEASUREMENTS AND MAIN RESULTS: In traumatic brain injury patients, mean baseline and low-dose stimulation test-stimulated cortisol levels were 17.2 +/- 5.4 microg/dL and 24.0 +/- 6.6 microg/dL, respectively. The median increment in cortisol was 5.9 microg/dL. Basal corticotropin levels ranged from 3.9 to 118.5 pg/mL. Six of the 40 patients (15%) failed the low-dose stimulation test. The human corticotropin releasing hormone test (performed in 26 responders and five nonresponders) revealed diminished cortisol release only in the low-dose stimulation test nonresponder patients. Corticotropin responses to corticotropin releasing hormone were consistent with both primary (three patients) and/or secondary (two patients) adrenal dysfunction. In retrospect, nonresponders to the low-dose stimulation test more frequently required vasopressors (6/6 [100%] vs. 16/34 [47%]; p =.02) and for a longer time interval (median, 0 vs. 293 hrs; p =.006) compared with responders. Furthermore, nonresponders had higher interleukin-6 levels compared with responders (56.03 vs. 28.04 pg/mL; p =.01), whereas tumor necrosis factor alpha concentrations were similar in the two groups (2.42 vs. 1.55 pg/mL; p =.53). CONCLUSIONS: Adrenal cortisol secretion after dynamic stimulation is deficient in a subset of critically ill patients with moderate to severe head injury. This disorder is associated with prior vasopressor dependency and higher interleukin-6 levels.