To determine the efficacy of bilateral inferior petrosal sinus sampling in differentiating Cushing disease from ectopic Cushing syndrome

2020 ◽  
pp. 1-11
Author(s):  
Muhammad Azeemuddin ◽  
Tanveer Ul Haq ◽  
Shahmeer Khan ◽  
Raza Sayani ◽  
Ayesha Shoukat Hussain ◽  
...  
Keyword(s):  
Cushing Syndrome ◽  
Case Series ◽  
Invasive Procedure ◽  
University Hospital ◽  
Inferior Petrosal Sinus ◽  
Cushing Disease ◽  
Post Contrast ◽  
Inferior Petrosal Sinus Sampling ◽  
Positive Results

Abstract Management of endogenous Cushing syndrome is based on its aetiology. Increased Adrenocorticotropic Hormone (ACTH) levels are the most common cause of this disorder and, therefore, it is critical to determine the source of ACTH before further management. Dynamic post contrast MRI is currently the most common investigation implied to diagnose pituitary adenoma; however, it comes with the drawback of low specificity and high false positive results. Inferior petrosal sinus sampling (IPSS) is an established invasive procedure performed to differentiate central versus peripheral source of ACTH which, in turn, results in hypercortesolaemia. This is a series of 14 patients who underwent IPSS at the Department of Radiology, Aga Khan University Hospital, Karachi, from January 2006 to December 2018. The case series emphasises the role of IPSS in the management of ACTH-dependent Cushing syndrome and combined efficacy of Dynamic post-contrast MRI and the procedure under focus. Continuous....

scholarly journals Pitfalls in Performing and Interpreting Inferior Petrosal Sinus Sampling: Personal Experience and Literature Review

2021 ◽  
Author(s):  
Jordan E Perlman ◽  
Philip C Johnston ◽  
Ferdinand Hui ◽  
Guy Mulligan ◽  
Robert J Weil ◽  
...  
Keyword(s):  
Personal Experience ◽  
Cushing Syndrome ◽  
Evidence Synthesis ◽  
Ectopic Acth Syndrome ◽  
Inferior Petrosal Sinus ◽  
Cushing Disease ◽  
Ectopic Acth ◽  
Inferior Petrosal Sinus Sampling ◽  
Operator Experience ◽  
Biochemical Testing

Abstract Context Inferior petrosal sinus sampling (IPSS) helps differentiate the source of ACTH-dependent hypercortisolism in patients with inconclusive biochemical testing and imaging, and is considered the gold standard for distinguishing Cushing disease (CD) from ectopic ACTH syndrome. We present a comprehensive approach to interpreting IPSS results by examining several real cases. Evidence Acquisition We performed a comprehensive review of the IPSS literature using PubMed since IPSS was first described in 1977. Evidence Synthesis IPSS cannot be used to confirm the diagnosis of ACTH-dependent Cushing syndrome (CS). It is essential to establish ACTH-dependent hypercortisolism before the procedure. IPSS must be performed by an experienced interventional or neuroradiologist because successful sinus cannulation relies on operator experience. In patients with suspected cyclical CS, it is important to demonstrate the presence of hypercortisolism before IPSS. Concurrent measurement of IPS prolactin levels is useful to confirm adequate IPS venous efflux. This is essential in patients who lack an IPS-to-peripheral (IPS:P) ACTH gradient, suggesting an ectopic source. The prolactin-adjusted IPS:P ACTH ratio can improve differentiation between CD and ectopic ACTH syndrome when there is a lack of proper IPS venous efflux. In patients who have unilateral successful IPS cannulation, a contralateral source cannot be excluded. The value of the intersinus ACTH ratio to predict tumor lateralization may be improved using a prolactin-adjusted ACTH ratio, but this requires further evaluation. Conclusion A stepwise approach in performing and interpreting IPSS will provide clinicians with the best information from this important but delicate procedure.

VENOUS SAMPLING FOR CUSHING DISEASE: COMPARISON OF INTERNAL JUGULAR VEIN AND INFERIOR PETROSAL SINUS SAMPLING

2016 ◽  
Vol 22 (9) ◽  
pp. 1057-1061 ◽  
Author(s):  
Martin G. Radvany ◽  
Alfredo Quinones-Hinojosa ◽  
Gary L. Gallia ◽  
Gary S. Wand ◽  
Roberto Salvatori
Keyword(s):  
Internal Jugular Vein ◽  
Jugular Vein ◽  
Inferior Petrosal Sinus ◽  
Venous Sampling ◽  
Cushing Disease ◽  
Inferior Petrosal Sinus Sampling

scholarly journals Transsphenoidal Surgery for Cushing Disease After Nondiagnostic Inferior Petrosal Sinus Sampling

Neurosurgery ◽  
2012 ◽  
Vol 71 (1) ◽  
pp. 14-22 ◽  
Author(s):  
Sameer A. Sheth ◽  
Matthew K. Mian ◽  
Jonathan Neal ◽  
Nicholas A. Tritos ◽  
Lisa Nachtigall ◽  
...  
Keyword(s):  
Predictive Value ◽  
Transsphenoidal Surgery ◽  
Adrenocorticotropic Hormone ◽  
Remission Rate ◽  
Inferior Petrosal Sinus ◽  
Cushing Disease ◽  
Inferior Petrosal Sinus Sampling ◽  
Course Of Action ◽  
Anatomic Variants ◽  
Sensitivity Specificity

Abstract BACKGROUND: Inferior petrosal sinus sampling (IPSS) is a useful technique for confirming a pituitary source of adrenocorticotropic hormone (ACTH) overproduction in Cushing disease. Uncertainty remains regarding the appropriate course of therapy when an ectopic tumor is predicted by IPSS but none can be found and in circumstances when the procedure cannot be successfully completed owing to technical or anatomic limitations. OBJECTIVE: To determine an appropriate course of action after nondiagnostic IPSS. METHODS: We reviewed 288 IPSS procedures in 283 patients between 1986 and 2010 at our center. An IPS:peripheral ACTH ratio ≥ 2 at baseline or ≥ 3 after corticotrophin-releasing hormone was considered predictive of a pituitary source of ACTH. A procedure was considered nondiagnostic if the procedure was successfully performed and the results predicted an ectopic source but none could be found despite extensive imaging or if the IPS could not be bilaterally cannulated because of technical difficulties or anatomic variants. RESULTS: The sensitivity, specificity, positive predictive value, and negative predictive value of IPSS for detecting a pituitary source in Cushing disease were 94%, 50%, 98%, and 29%, respectively. We identified 3 categories of nondiagnostic IPSS comprising 44 of the total procedures. These patients underwent exploratory transsphenoidal surgery, and in 42 of these patients (95%), a pituitary source was surgically proven, with a remission rate of 83%. CONCLUSION: Transsphenoidal surgery should be considered in cases of ACTH-dependent Cushing disease and noncentralized or technically unsuccessful IPSS without evidence of ectopic tumor.

Bilateral inferior petrosal sinus sampling: experience in 327 patients

2016 ◽  
Vol 9 (2) ◽  
pp. 196-199 ◽  
Author(s):  
Amy Deipolyi ◽  
Alexander Bailin ◽  
Joshua A Hirsch ◽  
T Gregory Walker ◽  
Rahmi Oklu
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Inferior Petrosal Sinus ◽  
Technical Success ◽  
Cushing Disease ◽  
Inferior Petrosal Sinus Sampling ◽  
Technical Success Rate ◽  
Technical Failures ◽  
Groin Hematoma

ObjectiveTo describe findings and outcomes of 331 bilateral inferior petrosal sinus sampling (BIPSS) procedures performed in 327 patients evaluated for Cushing disease (CD).Materials and methodsThe radiology department's electronic database was searched to identify all BIPSS procedures (1990–2013). Electronic medical records were used to identify demographics, laboratory, procedural, surgical and pathologic findings.ResultsA total of 331 BIPSS procedures were performed in 327 patients (254 F, 73 M), mean age 41 (range 7–81) years. The overall technical success rate was 88% for bilateral cannulation, though nearly two-thirds of the technical failures had unilateral sampling that diagnosed CD. Of the 331 BIPSS procedures, 40 were performed without, and 291 with stimulation by Acthrel or desmopressin. Sensitivity was 89–94% for unstimulated BIPSS, 96% for stimulated BIPSS, and 77% for MRI. BIPSS lateralization was accurate in about half of patients, compared with 75% accuracy for MRI. Mean inferior petrosal sinus (IPS):peripheral adrenocorticotropic hormone ratio was 17.3 (SE 1.8) at baseline, and 99.2 (SE 14.8) at 3 min, with decreasing values over time. All patients with follow-up after surgical resection for centralizing BIPSS were reported to be cured, with cortisol levels significantly decreased from 19 to 4 μg/dL (p<0.0001). Complications from BIPSS were rare, including groin hematoma (2.5%), but no thromboembolic complications were seen.ConclusionsBIPSS remains the ‘gold standard’ for diagnosing CD. Stimulation with Acthrel or desmopressin is key to increasing specificity. When only one IPS can be successfully cannulated, results may still be diagnostic. BIPSS findings cannot be used to accurately lateralize lesions within the pituitary.

scholarly journals The role of inferior petrosal sinus sampling in ACTH-dependent Cushing's syndrome: review and joint opinion statement by members of the Italian Society for Endocrinology, Italian Society for Neurosurgery, and Italian Society for Neuroradiology

2015 ◽  
Vol 38 (2) ◽  
pp. E5 ◽  
Author(s):  
Francesca Pecori Giraldi ◽  
Luigi Maria Cavallo ◽  
Fabio Tortora ◽  
Rosario Pivonello ◽  
Annamaria Colao ◽  
...  
Keyword(s):  
Cushing’S Syndrome ◽  
Adrenocorticotropic Hormone ◽  
Dynamic Testing ◽  
Cushing's Syndrome ◽  
Italian Society ◽  
The Other ◽  
Inferior Petrosal Sinus ◽  
Etiological Diagnosis ◽  
Inferior Petrosal Sinus Sampling

In the management of adrenocorticotropic hormone (ACTH)–dependent Cushing's syndrome, inferior petrosal sinus sampling (IPSS) provides information for the endocrinologist, the neurosurgeon, and the neuroradiologist. To the endocrinologist who performs the etiological diagnosis, results of IPSS confirm or exclude the diagnosis of Cushing's disease with 80%–100% sensitivity and over 95% specificity. Baseline central-peripheral gradients have suboptimal accuracy, and stimulation with corticotropin-releasing hormone (CRH), possibly desmopressin, has to be performed. The rationale for the use of IPSS in this context depends on other diagnostic means, taking availability of CRH and reliability of dynamic testing and pituitary imaging into account. As regards the other specialists, the neuroradiologist may collate results of IPSS with findings at imaging, while IPSS may prove useful to the neurosurgeon to chart a surgical course. The present review illustrates the current standpoint of these 3 specialists on the role of IPSS.

scholarly journals An algorithm to improve lateralization accuracy of inferior petrosal sinus sampling: procedural nuances for complex patterns of venous drainage. Patient series

2021 ◽  
Vol 2 (13) ◽  
Author(s):  
Abhijith V. Matur ◽  
Alaina M. Body ◽  
Mark D. Johnson ◽  
Matthew S. Smith ◽  
Ruchi Bhabhra ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Imaging Finding ◽  
Case Series ◽  
Optimal Sampling ◽  
Inferior Petrosal Sinus ◽  
Retrospective Case ◽  
Inferior Petrosal Sinus Sampling ◽  
Drainage Patterns ◽  
Sinus Drainage ◽  
Tumor Laterality

BACKGROUND Inferior petrosal sinus sampling (IPSS) is a useful technique in the diagnosis of Cushing’s disease (CD) when the imaging finding is negative or equivocal. Different authors have reported considerable variability in the ability to determine tumor laterality with IPSS. Here the authors present a retrospective case series of 7 patients who underwent IPSS using a systematic algorithm to improve lateralization accuracy by identifying optimal sampling sites on the basis of individual cavernous sinus drainage patterns in each patient. OBSERVATIONS Of the 7 patients identified, 6 were determined to have CD and subsequently underwent surgery. IPSS was accurate in all patients from whom laterality was predicted. Arterial and venous angiography were used to define cavernous sinus drainage patterns and determine optimal sampling sites. All patients who underwent surgery achieved hormonal cure. LESSONS All IPSS predictions of lateralization were correct when available, and all patients who underwent surgery achieved hormonal cure. Advances in angiographic techniques for identification of the site of primary drainage from the cavernous sinus and subsequent optimization of microcatheter placement may improve the ability to predict tumor laterality.

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