Bilateral inferior petrosal sinus sampling

Simultaneous bilateral inferior petrosal sinus sampling (BIPSS) plays a crucial role in the diagnostic work-up of Cushing’s syndrome. It is the most accurate procedure in the differential diagnosis of hypercortisolism of pituitary or ectopic origin, as compared with clinical, biochemical and imaging analyses, with a sensitivity and specificity of 88–100% and 67–100%, respectively. In the setting of hypercortisolemia, ACTH levels obtained from venous drainage of the pituitary are expected to be higher than the levels of peripheral blood, thus suggesting pituitary ACTH excess as the cause of hypercortisolism. Direct stimulation of the pituitary corticotroph with corticotrophin-releasing hormone enhances the sensitivity of the procedure. The procedure must be undertaken in the presence of hypercortisolemia, which suppresses both the basal and stimulated secretory activity of normal corticotrophic cells: ACTH measured in the sinus is, therefore, the result of the secretory activity of the tumor tissue. The poor accuracy in lateralization of BIPSS (positive predictive value of 50–70%) makes interpetrosal ACTH gradient alone not sufficient for the localization of the tumor. An accurate exploration of the gland is recommended if a tumor is not found in the predicted area. Despite the fact that BIPSS is an invasive procedure, the occurrence of adverse events is extremely rare, particularly if it is performed by experienced operators in referral centres.

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The role of bilateral inferior petrosal sinus sampling in the diagnosis of Cushing's syndrome

Arquivos Brasileiros de Endocrinologia & Metabologia ◽

10.1590/s0004-27302007000800019 ◽

2007 ◽

Vol 51 (8) ◽

pp. 1329-1338 ◽

Cited By ~ 22

Author(s):

Andrea Utz ◽

Beverly M.K. Biller

Keyword(s):

Cushing’S Syndrome ◽

Venous Drainage ◽

Cushing's Syndrome ◽

Blood Levels ◽

Inferior Petrosal Sinus ◽

Ectopic Acth ◽

Inferior Petrosal Sinus Sampling ◽

Neoplastic Lesion ◽

Before And After ◽

Acth Secreting

Adrenocorticotropin hormone (ACTH)-dependent Cushing's syndrome is most often due to a pituitary corticotroph adenoma, with ectopic ACTH-secreting tumors representing approximately 15% of cases. Biochemical and radiological techniques have been established to help distinguish between these two entities, and thus aid in the localization of the neoplastic lesion for surgical resection. The test that offers the highest sensitivity and specificity is bilateral inferior petrosal sinus sampling (BIPSS). BIPSS is an interventional radiology procedure in which ACTH levels obtained from venous drainage very near the pituitary gland are compared to peripheral blood levels before and after corticotropin hormone (CRH) stimulation. A gradient between these two locations indicates pituitary Cushing's, whereas the absence of a gradient suggests ectopic Cushing's. Accurate BIPSS results require hypercortisolemia to suppress normal corticotroph ACTH production and hypercortisolemia at the time of the BIPSS to assure excessive ACTH secretion. In some cases, intrapituitary gradients from side-to-side can be helpful to localize small corticotroph adenomas within the sella. BIPSS has rare complications and is considered safe when performed at centers with experience in this specialized technique.

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

Heliyon ◽

10.1016/j.heliyon.2020.e05299 ◽

2020 ◽

Vol 6 (10) ◽

pp. e05299

Author(s):

Mohammad Ghorbani ◽

Hamideh Akbari ◽

Christoph J. Griessenauer ◽

Christoph Wipplinger ◽

Alireza Dastmalchi ◽

...

Keyword(s):

Cavernous Sinus ◽

Cushing’S Disease ◽

Venous Drainage ◽

Cushing's Disease ◽

Inferior Petrosal Sinus ◽

Inferior Petrosal Sinus Sampling ◽

Drainage Patterns

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

Journal of the Pakistan Medical Association ◽

10.47391/jpma.752 ◽

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....

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Dual bronchial carcinoids and Cushing's syndrome with a paradoxical response to dexamethasone and a false positive outcome of inferior petrosal sinus sampling

Acta Endocrinologica ◽

10.1530/eje-08-0385 ◽

2008 ◽

Vol 159 (4) ◽

pp. 483-488 ◽

Cited By ~ 6

Author(s):

Pia Burman ◽

ÅsaLinda Lethagen ◽

Krasnodar Ivancev ◽

Leif Johansson ◽

Anders Sundin

Keyword(s):

Cushing’S Syndrome ◽

False Positive ◽

Somatostatin Receptor ◽

Cushing's Syndrome ◽

Inferior Petrosal Sinus ◽

Biochemical Tests ◽

Inferior Petrosal Sinus Sampling ◽

Bronchial Carcinoids ◽

Work Up ◽

Dexamethasone Suppression

ContextEstablishing the cause of Cushing's syndrome (CS) can be a considerable challenge, in particular in ectopic adrenocorticotropic hormone (ACTH) syndrome, and often requires a combination of biochemical tests and imaging procedures.SubjectA 27-year-old man presented with signs of CS. P-ACTH levels were three times above the upper limit of normal (ULN) and free urinary cortisol around 2000 nmol/24 h. The work-up showed remarkable results.ResultsA 2-day low-dose dexamethasone suppression test demonstrated paradoxical increases in cortisol. Sampling from the bilateral inferior petrosal sinus sampling (BIPSS) showed a central to peripheral ACTH ratio of 4.7 after corticotrophin-releasing hormone (CRH) stimulation, i.e. indicated pituitary disease, but magnetic resonance imaging of the pituitary was normal. Computed tomography (CT) scan of the lungs showed two oval-shaped masses, 1.3×1.8 and 1.3×2 cm, in the middle lobe. Both were positive at somatostatin receptor scintigraphy, compatible with tumors or inflammatory lesions. Subsequently, 11C-5-hydroxytryptophan-PET showed distinct uptake in the tumors but not elsewhere. Two carcinoids situated 3 cm apart, both staining for ACTH, were removed at surgery.ConclusionThis unique case with dual bronchial carcinoids inducing hypercortisolism illustrates the problems with identifying the source of ACTH in CS. Possibly, an abnormal regulation of ACTH production in response to dexamethasone, or steroid-induced tumor necrosis, explains the paradoxical outcome at dexamethasone suppression, and the false positive result at BIPSS reflects an unusual sensitivity of the pituitary corticotrophs to CRH in this patient. The work-up illustrates the great value of 11C-5-hydroxytryptophan-PET as a diagnostic procedure when other investigations have produced ambiguous results.

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Rapidly progressive glomerulonephritis as presenting feature of systemic lupus erythematosus in a Bangladeshi male patient: a rare case report

BIRDEM Medical Journal ◽

10.3329/birdem.v10i2.47748 ◽

2020 ◽

Vol 10 (2) ◽

pp. 137-138

Author(s):

Samiha Haque ◽

Ishrat Jahan ◽

Tufayel Ahmed Chowdhury ◽

Muhammad Abdur Rahim ◽

Mehruba Alam Ananna ◽

...

Keyword(s):

Systemic Lupus Erythematosus ◽

Lupus Erythematosus ◽

Venous Pressure ◽

Rapidly Progressive Glomerulonephritis ◽

Initial Response ◽

Systemic Lupus ◽

Renal Manifestation ◽

Rare Case Report ◽

Diagnostic Work ◽

Work Up

Rapidly progressive glomerulonephritis is one of the most dramatic and tragic presentations of lupus nephritis (LN) or renal manifestation of systemic lupus erythematosus (SLE). A 35-year-old Bangladeshi gentleman presented with worsening oedema, scanty, high colored, frothy urine and deteriorating renal function. He had puffy face, anaemia, oedema, normal jugular venous pressure (JVP), high blood pressure (150/90 mm Hg), ascites and bilateral pleural effusions. Diagnostic work-up confirmed SLE with class IV LN. His initial response to specific therapy showed improvement Birdem Med J 2020; 10(2): 137-138

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