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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 650-652

Inferior petrous sinus sampling after nasal desmopressin stimulation: A new technique in the diagnostic evaluation of ACTH-dependent Cushing's syndrome


1 Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology. Medical College P.O- 695 011, Thiruvananthpuram, Kerala, India
2 Department of Neurology,Sree Chitra Tirunal Institute for Medical Sciences and Technology. Medical College P.O- 695 011, Thiruvananthpuram, Kerala, India

Date of Web Publication29-Dec-2012

Correspondence Address:
Kamble Jayaprakash Harsha
Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology. Medical College P.O- 695 011, Thiruvananthpuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.105208

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How to cite this article:
Harsha KJ, Jayadevan E R, Jagtap S, Almpath P, Kannath S. Inferior petrous sinus sampling after nasal desmopressin stimulation: A new technique in the diagnostic evaluation of ACTH-dependent Cushing's syndrome. Neurol India 2012;60:650-2

How to cite this URL:
Harsha KJ, Jayadevan E R, Jagtap S, Almpath P, Kannath S. Inferior petrous sinus sampling after nasal desmopressin stimulation: A new technique in the diagnostic evaluation of ACTH-dependent Cushing's syndrome. Neurol India [serial online] 2012 [cited 2020 Oct 29];60:650-2. Available from: https://www.neurologyindia.com/text.asp?2012/60/6/650/105208


Sir,

A 55-year-old female presented with slowly evolving features of Cushing's syndrome over a period of 10 years and the clinical features included excessive weight gain, hirsuitism, menstrual irregularities, personality change, fatigability, and generalized weakness. In addition she also had uncontrolled diabetes mellitus, hypertension, and coronary artery disease for which she is being treated appropriately. Her biochemical tests revealed elevated night serum cortisol levels of 43.36 μg/dl (normal values: AM-5.49 to 28.76, PM-2.46 to 17.15 μg/dl), suppression of serum cortisol (27.17 μg/dl) after overnight 1 mg dexamethasone challenge test, increased adrenocorticotrophic hormone (ACTH) levels of 85.2 pg/ml (N < 60 pg/ml). Magnetic resonance images revealed normal pituitary gland size and signal intensity without focal lesion. Computed tomography of abdomen revealed bilateral adrenal gland hyperplasia. She underwent inferior petrosal sinus sampling for localization of source of excess ACTH secretion (pituitary vs. extrapituitary source as well for pituitary lateralization). Initially 4 ml of blood samples were collected slowly over period of 2 min, from right inferior petrous sinus (IPS), left IPS and from left common femoral vein (labeled as Peripheral) at the same time, labeled as 0 min [Figure 1]. Approximately 40 mcg of desmopressin nasal puffs were administered. Following this, blood samples from the same three sites were again collected at 5-7 min, 13-15 min, 18-20 min, 60 min after desmopressin challenge with appropriate labeling of samples. All blood samples were sent immediately to laboratory maintaining cold chain for ACTH evaluation. All ACTH values obtained from laboratory are given in [Table 1]. Initially central vs. peripheral gradient was calculated from baseline ACTH (13.64) and from desmopressin challenge peak values (20.6). Baseline IPS/P ≥ 2 or corticotrophin-releasing hormone (CRH) stimulated IPS/P ≥ 3 confirms Cushing Disease. [1] Inter-sinus ratio was calculated, which in our case was 2.8 at the baseline and 4.5 at 1 hour. Inter-sinus ratio of at least 1.4 was considered as evidence of ipsilateral localization of an adenoma. Though baseline ratio was indicative of right sided localization, ratios over period of 1 hour showed progressive elevation of ACTH values in left IPS; hence a left localization was made.
Figure 1: (a) AP and lateral view of cerebral DSA, left cavernous sinus injection depicting bilateral cavernous and inferior petrosal sinuses (b) Final position of microcatheter tips at the midportion of bilateral inferior petrosal sinus for blood sampling

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Table 1: ACTH levels in right IPS, left IPS, peripheral samples from 0 min to 1 hour (Normal ‑7.2 to 63.3 pg/ml)

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Several modifications were done in IPS sampling technique since its usefulness was first described in 1977 as described in [Table 2]. [2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16] CRH and IV desmopressin availability is limited in developing countries, while nasal desmopressin spray is available in all countries which are used mainly for central diabetes insipidus. 1 ml (0.1 mg) of intranasal desmopressin has an antidiuretic activity of about 400 IU; 10 mcg of desmopressin acetate is equivalent to 40 IU. One nasal spray delivers approximately 10 mcg of desmopressin acetate. The usual IV desmopressin dose used for stimulation in IPS sampling is 10 mcg. In an attempt to increase the bioavailability of nasal sprays, we used two sprays in each nostril accounting for ~40 mcg. Also the blood samples were collected for longer duration of upto 1 hour after desmopressin challenge. No adverse effect was noted during post procedure period. Hence we conclude the use of nasal desmopressin spray alone for ACTH stimulation in conjunction with IPS sampling is feasible and safe technique.
Table 2: Technical developments in inferior petrosal sinus sampling

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 » References Top

1.Javorsky BR, Findling JW. Inferior petrosal sampling for the differential diagnosis of ACTH-dependent Cushing's syndrome. In: Bronstein MD, editor. Cushing's syndrome: Pathophysiology, diagnosis and treatment. New York: Humana Press; 2010.  Back to cited text no. 1
    
2.Corrigan DF, Schaaf M, Whaley RA, Czerwinski CL, Earll JM. Selective venous sampling to differentiate ectopic ACTH secretion from pituitary Cushing's syndrome. N Engl J Med 1977;296:861-2.  Back to cited text no. 2
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3.Oldfield EH, Chrousos GP, Schulte HM, Schaaf M, McKeever PE, Krudy AG, et al. Preoperative lateralization of ACTH-secreting pituitary microadenomas by bilateral and simultaneous inferior petrosal venous sinus sampling. N Engl J Med 1985;312:100-3.  Back to cited text no. 3
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4.Landolt AM, Valavanis A, Girard J, Eberle AN. Corticotrophin-releasing factor-test used with bilateral, simultaneous inferior petrosal sinus blood-sampling for the diagnosis of pituitary-dependent Cushing's disease. Clin Endocrinol (Oxf) 1986;25:687-96.  Back to cited text no. 4
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5.Oldfield EH, Doppman JL, Nieman LK, Chrousos GP, Miller DL, Katz DA, et al. Petrosal sinus sampling with and without corticotropin-releasing hormone for the differential diagnosis of Cushing's syndrome. N Engl J Med 1991;325:897-905.  Back to cited text no. 5
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6.Doppman JL, Nieman LK, Chang R, Yanovski J, Cutler GB Jr, Chrousos GP, et al. Selective venous sampling from the cavernous sinuses is not a more reliable technique than sampling from the inferior petrosal sinuses in Cushing's syndrome. J Clin Endocrinol Metab 1995;80:2485-9.  Back to cited text no. 6
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7.Cuneo RC, Lee W, Harper J, Mitchell K, Ward G, Atkinson RL, et al. Metyrapone pre-treated inferior petrosal sinus sampling in the differential diagnosis of ACTH-dependent Cushing's syndrome. Clin Endocrinol (Oxf) 1997;46:607-18.  Back to cited text no. 7
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8.Tsagarakis S, Vassiliadi D, Kaskarelis IS, Komninos J, Souvatzoglou E, Thalassinos N. The application of the combined corticotropin-releasing hormone plus desmopressin stimulation during petrosal sinus sampling is both sensitive and specific in differentiating patients with Cushing's disease from patients with the occult ectopic adrenocorticotropin syndrome. J Clin Endocrinol Metab 2007;92:2080-6.  Back to cited text no. 8
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9.Ilias I, Chang R, Pacak K, Oldfield EH, Wesley R, Doppman J, et al. Jugular venous sampling: An alternative to petrosal sinus sampling for the diagnostic evaluation of adrenocorticotropic hormone-dependent Cushing's syndrome. J Clin Endocrinol Metab 2004;89:3795-800.  Back to cited text no. 9
    
10.Liu C, Lo JC, Dowd CF, Wilson CB, Kunwar S, Aron DC, et al. Cavernous and inferior petrosal sinus sampling in the evaluation of ACTH-dependent Cushing's syndrome. Clin Endocrinol (Oxf) 2004;61:478-86.  Back to cited text no. 10
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11.Findling JW, Kehoe ME, Raff H. Identification of patients with Cushing's disease with negative pituitary adrenocorticotropin gradients during inferior petrosal sinus sampling: Prolactin as an index of pituitary venous effluent. J Clin Endocrinol Metab 2004;89:6005-9.  Back to cited text no. 11
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12.Fujimura M, Ikeda H, Takahashi A, Ezura M, Yoshimoto T, Tominaga T. Diagnostic value of super-selective bilateral cavernous sinus sampling with hypothalamic stimulating hormone loading in patients with ACTH-producing pituitary adenoma. Neurol Res 2005;27:11-15.  Back to cited text no. 12
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13.Gannagé-Yared MH, Slaba S, Rizk T, Chidiac Wehbe RM. Use of desmopressin as an alternative to corticotropin-releasing hormone during inferior petrosal sinus sampling in a child with Cushing›s disease. J Endocrinol Invest 2007;30:434-8.  Back to cited text no. 13
    
14.Castinetti F, Morange I, Dufour H, Jaquet P, Conte-Devolx B, Girard N, et al. Desmopressin test during petrosal sinus sampling: A valuable tool to discriminate pituitary or ectopic ACTH-dependent Cushing's syndrome. Eur J Endocrinol 2007;157:271-7.  Back to cited text no. 14
    
15.Machado MC, de Sa SV, Domenice S, Fragoso MC, Puglia P Jr, Pereira MA, et al. The role of desmopressin in bilateral and simultaneous inferior petrosal sinus sampling for differential diagnosis of ACTH-dependent Cushing's syndrome. Clin Endocrinol (Oxf) 2007;66:136-42.  Back to cited text no. 15
    
16.Tsagarakis S, Kaskarelis IS, Kokkoris P, Malagari C, Thalassinos N. The application of a combined stimulation with CRH and desmopressin during bilateral inferior petrosal sinus sampling in patients with Cushing's syndrome. Clin Endocrinol (Oxf) 2000;52:355-61.  Back to cited text no. 16
    


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