Accuracy of Bilateral Inferior Petrosal or Cavernous Sinuses Sampling in Predicting the Lateralization of Cushing’s Disease Pituitary Microadenoma: Influence of Catheter Position and Anatomy of Venous Drainage

Abstract

Bilateral inferior petrosal sinus sampling (BIPSS) is the most reliable procedure for distinguishing Cushing's disease from ectopic ACTH secretion. However, it is less reliable at predicting the lateralization of the pituitary corticotroph microadenoma. We sought to determine whether this could be improved by taking into account the pattern of venous drainage and the precise location of the catheters. We retrospectively studied data from 86 patients who underwent BIPSS. Cushing's disease was predicted in 74 patients, of whom 69 underwent transsphenoidal surgery. Surgical cure was obtained in 65 patients, with identification of a corticotroph microadenoma in 58 cases. In 49 patients the location of the microadenoma predicted by the intersinus ACTH gradient could be compared with the pathologist's data. BIPSS accurately predicted the lateralization of the microadenoma in only 57% of these patients. Prediction was improved to 71% when both venograms and catheters were symmetric (35 patients). In this subgroup accuracy was 86% in patients with both catheters in the inferior petrosal sinuses compared with 50% in patients with both catheters in the cavernous sinuses (CS). Two transient sixth nerve palsies occurred during CS catheterization. Our data suggest that BIPSS results are much improved when venous drainage is symmetric. Catheterization of CS did not improve the results and was less safe.

Ectopic ACTH syndrome: our experience with 25 cases

“…It should be stressed that in cases of central to peripheral ACTH gradient not reaching the threshold for pituitary disease, CRH response may provide improved diagnostic accuracy and transsphenoidal pituitary approach considered as has been reported recently (53). The incidence of severe complications secondary to IPSS, such as stroke and perforation of the atrial wall is around 0.2%, whereas hematomas and transitory arrhythmias can occur in 20% of the cases (27,28). Since none of the dynamic non-invasive tests provide 100% accuracy, 7 out of our 25 cases were submitted to IPSS.…”

“…For ACTH-dependent differential diagnosis, patients underwent HDDST (8 mg) (14)(15)(16), desmopressin test (17,18), corticotropin-releasing hormone (CRH) test (19)(20)(21)(22)(23), growth hormone releasing peptide (GHRP)-6 test (24,25), and IPSS (26)(27)(28) with desmopressin stimulus indicated when magnetic resonance imaging (MRI) was negative for a pituitary lesion. IPSS was performed by collecting blood samples simultaneously from the inferior petrosal sinuses and a peripheral vein before and 3, 5, and 10 min after 10 mg of IV desmopressin (DDAVP, Ferring Pharmaceuticals, Limhamn, Sweden) (29 (31)(32)(33).…”

Reduction of a Pancreatic Tumor after Total Removal of an ACTH Secreting Pituitary Tumor: Differential Diagnosis of Cushing's Syndrome

“…The accuracy of determining lateralization by means of bilateral inferior petrosal sinus sampling is reported to be approximately 75% [28], and that by means of bilateral CSS ranges widely from 40% to 94% [19,29,30]. In this case, the basal left-to-right gradient showed 1.24, but the normalized ACTH/PRL left-to-right gradient showed 1.34, which was near 1.4.…”

Aspectos técnicos e funcionais da cateterização dos seios petrosos inferiores na síndrome de Cushing ACTH dependente

“…Entretanto, a confiabilidade da lateralização para a programação cirúrgica deve ser interpretada com cuidado, sendo acurácia para a localização do adenoma de 50% a 100% (23). A análise incorreta pode ser explicada por variações anatômicas e pela drenagem venosa hipofisária assimétrica, que pode ocorrer em até 40% dos indivíduos (24). Assim, propõe-se que a lateralização seja valorizada nas situações em que o gradiente seja > 1,4 e a visualização angiográfica possa inferir a respeito da simetria da drenagem venosa pelos SPI (1).…”