Lateralization of inferior petrosal sinus sampling in Cushing's disease correlates with cavernous sinus venous drainage patterns, but not tumor lateralization

Abstract. Pre-operative bilateral simultaneous inferior petrosal sinus sampling with assessment of ACTH levels in the left and right sinuses and the periphery was performed in 9 patients with pituitary dependent Cushing's disease who were subsequently found at surgery to have basophil microadenomata. The novel observation of this study was the pattern of secretion of other pituitary hormones so that significant inter-sinus gradients ≥ 1.4:1 were seen for β-endorphin (2.8 ± 1.3, mean ± sem), PRL (4.2 ± 1.3) and GH (6.9 ± 2.4) as well as for ACTH (5.1 ± 1.1). There was no inter-sinus gradient for LH, FSH and TSH. In these 9 patients with adenomata, the correlations between the inter-sinus gradients for ACTH and β-endorphin were r = 0.95 (P <0.01), ACTH and PRL r = 0.90 (P < 0.01) and for ACTH and GH r = 0.89 (P <0.05). This close association between the gradients for ACTH and other anterior pituitary hormones could be due either to cosecretion of β-endorphin, PRL and GH by the ACTH-producing pituitary adenomata or to a paracrine effect of β-endorphin from the tumours on adjacent pituitary tissue. By reflecting the central pituitary hormone milieu, petrosal sinus sampling can give information about pituitary function unobtainable from peripheral hormone levels.

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Cyclic Cushing's disease with misleading inferior petrosal sinus sampling results during a trough phase

Neurosurgical FOCUS ◽

10.3171/2014.12.focus14780 ◽

2015 ◽

Vol 38 (2) ◽

pp. E7 ◽

Cited By ~ 9

Author(s):

Vivien Bonert ◽

Namrata Bose ◽

John D. Carmichael

Keyword(s):

Cushing’S Syndrome ◽

Cushing’S Disease ◽

Adrenocorticotropic Hormone ◽

Diagnostic Testing ◽

Cushing's Syndrome ◽

Cushing's Disease ◽

Inferior Petrosal Sinus ◽

Inferior Petrosal Sinus Sampling ◽

Acth Secreting ◽

Transsphenoidal Resection

Diagnosing Cushing's syndrome is challenging and is further hampered when investigations are performed in a patient with cyclic Cushing's syndrome. A subset of patients with Cushing's syndrome exhibit periods of abnormal cortisol secretion with interspersed normal secretion. Patients can have periods of clinical improvement during these quiescent phases or remain symptomatic. Initial diagnostic testing can be challenging because of the unpredictable durations of the peak and trough phases, and it is especially challenging when the diagnosis of cyclic Cushing's syndrome has not yet been determined. Here, the authors present the case of a patient with Cushing's disease with a pathology-proven adrenocorticotropic hormone (ACTH)–secreting pituitary adenoma and whose initial inferior petrosal sinus sampling (IPSS) results were deemed indeterminate; further studies elucidated the diagnosis of cyclic Cushing's syndrome. Repeat IPSS was diagnostic of a central source for ACTH secretion, and the patient was treated successfully with transsphenoidal resection. Literature concerning the diagnosis and management of cyclic Cushing's syndrome is also reviewed.

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Erratum. Value of pituitary gland MRI at 7 T in Cushing's disease and relationship to inferior petrosal sinus sampling: case report

Journal of Neurosurgery ◽

10.3171/2018.4.jns171969a ◽

2019 ◽

Vol 130 (2) ◽

pp. 661

Author(s):

Meng Law

Keyword(s):

Case Report ◽

Pituitary Gland ◽

Cushing’S Disease ◽

Cushing's Disease ◽

Inferior Petrosal Sinus ◽

Inferior Petrosal Sinus Sampling

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

Journal of Neurosurgery: Case Lessons ◽

10.3171/case21374 ◽

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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