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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

Kamble Jayaprakash Harsha1, ER Jayadevan1, Sujith Jagtap2, Praveen Almpath1, Santhosh Kannath1,  
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

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




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;60:650-652


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 2021 Jan 22 ];60:650-652
Available from: https://www.neurologyindia.com/text.asp?2012/60/6/650/105208


Full Text

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}{Table 1}

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}

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