Anesthetic Management of a Patient of Pituitary Microadenoma with Low Ejection Fraction for Inferior Petrosal Sinus Sampling

Cushing’s disease is caused by adrenocorticotrophic hormone (ACTH)–secreting pituitary adenomas, which are often difficult to identify on standard 1.5-T or 3-T MRI, including dynamic contrast imaging. Inferior petrosal and cavernous sinus sampling remains the gold standard for MRI-negative Cushing’s disease.The authors report on a 27-year-old woman with Cushing’s disease in whom the results of standard 1.5-T and 3-T MRI, including 1.5-T dynamic contrast imaging, were negative. Inferior petrosal sinus sampling showed a high central-to-peripheral ACTH ratio (148:1) as well as a right-to-left ACTH gradient (19:1), suggesting a right-sided pituitary microadenoma. The patient underwent 7-T MRI, which showed evidence of a right-sided pituitary lesion with focal hypoenhancement not visualized on 1.5-T or 3-T MRI. The patient underwent an endoscopic endonasal transsphenoidal operation, with resection of a right-sided pituitary mass. Postoperatively, she developed clinical symptoms suggestive of adrenal insufficiency and a nadir cortisol level of 1.6 μg/dl on postoperative day 3, and hydrocortisone therapy was initiated. Permanent histopathology specimens showed Crooke’s hyaline change and ACTH-positive cells suggestive of an adenoma.MRI at 7 T may be beneficial in identifying pituitary microadenoma location in cases of standard 1.5-T and 3-T MRI-negative Cushing’s disease. In the future, 7-T MRI may preempt inferior petrosal sinus sampling and help in cases of standard and dynamic contrast 1.5-T and 3-T MRI-negative Cushing’s disease.

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Incidentally detected sellar spine in a patient with Cushing’s syndrome: a case report

Journal of International Medical Research ◽

10.1177/0300060520940159 ◽

2020 ◽

Vol 48 (7) ◽

pp. 030006052094015

Author(s):

Hyo-jae Lee ◽

Yun Young Lee ◽

Byung Hyun Baek ◽

Woong Yoon ◽

Seul Kee Kim

Keyword(s):

Cushing’S Syndrome ◽

Cushing's Syndrome ◽

Inferior Petrosal Sinus ◽

Resonance Imaging ◽

Operative Field ◽

Anatomical Variant ◽

Inferior Petrosal Sinus Sampling ◽

Pituitary Microadenoma ◽

Bony Spur ◽

Exploratory Surgery

Sellar spine, a bony spur extending anteriorly from the dorsum sellae, is a very rare anatomical variant. Several hypotheses regarding its etiology have been proposed, including the strongly supported theory of a cephalic ossified notochordal remnant. Sellar spine is usually detected incidentally in patients who have no definite symptoms, but several cases have reportedly accompanied endocrinopathies such as precocious puberty, hypopituitarism, or galactorrhea/oligomenorrhea. However, no published reports have described sellar spine in a patient with Cushing’s syndrome. We herein report a case of sellar spine detected during the evaluation of Cushing’s disease in a 29-year-old woman who underwent inferior petrosal sinus sampling, computed tomography, magnetic resonance imaging, and exploratory surgery. There was no evidence of a pituitary microadenoma, but a sellar spine was present in the operative field. Thus, the sellar spine might have caused Cushing’s syndrome in this case, although the exact mechanism is unknown.

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