Inferior Petrosal Sinus Sampling

in Cushing’s Syndrome

Lia Neto

Neuroradiology Department – Santa Maria University Hospital, Lisbon - Portugal

IPSS in Cushing’s Syndrome

Cortisol

- Cushing´s Syndrome -

IPSS in Cushing’s Syndrome

80%

- ACTH Dependent Vs ACTH Independent -

IPSS in Cushing’s Syndrome

80%

- Biochemical Tests -

IPSS in Cushing’s Syndrome

80%

• Sensitivity (40-50%)

• Adenoma Dimensions

• May enhance = parenchyma

•“Incidentalomas” (6-10%)

- Imaging Tests -

IPSS in Cushing’s Syndrome

• Sensitivity 88-100%

• Specificity 70-100%

• Lateralization 70%

- Inferior Petrous Sinus Sampling -

IPSS in Cushing’s Syndrome

Pre 5’ 10’ 15’R-IPSL-IPSPV

CRH (100µg)

ACTH

IPS / PV ≥ 2 (≥ 3 post CRH) –Pituitary Cushing Synd.

IPS / PV 2 – Ectopic Cushing’s Synd.

R-PS / L-PS ≥ 1,4 - Lateralization

- Inferior Petrous Sinus Sampling -

IPSS in Cushing’s Syndrome

Objective :

Evaluate the role of simultaneous bilateral catheterization

of the Inferior Petrosal Sinuses: • in the differential diagnosis of Cushing’s Syndrome

• in the lateralization assessment of pituitary adenomas

IPSS in Cushing’s Syndrome

Material and Methods:

• Retrospective analysis: 6 patients with CS (1♂ 5♀); 28 – 70 yr

• IPSS between 2007-2010

• Sedation & Anticoagulation (5000 U)

• Bilateral femoral vein puncture – Bilateral IPS catheterization

• Venogram

• IPS and peripheral blood sampling pre and post CRH

• IPS/peripheral ACTH ratio: Pituitary Vs Ectopic Cushing’s Syndrome

• In Cushing’s Disease: lateralization assessment

IPSS in Cushing’s Syndrome

Results:

• Catheterization and sampling was possible in

all patients

• No complications (technical or clinical)

• 2 patients with ectopic ACTH source

• 4 patients with Cushing’s Disease

IPSS in Cushing’s Syndrome

Results: • Clinically (+)• Biochemically (+)• Imaging (-) 35 yr ♀

IPSS in Cushing’s Syndrome

35 yr ♀

• Clinically (+)• Biochemically (+)• Imaging (-)

Results:

IPSS in Cushing’s Syndrome

Pre 5’ 10’ 15’

R-IPS 58 132 165 56

L-IPS 175 496 509 218

PV 14 14 17 16

• IPS / PV – 12,5 / 35

• L-IPS / R-IPS – 4

35 yr ♀

• Clinically (+)• Biochemically (+)• Imaging (-)

Results:

IPSS in Cushing’s Syndrome

70 yr ♀

• Clinically (+)• Biochemically (+)• Imaging (inconclusive)

Results:

IPSS in Cushing’s Syndrome

Pre 5’ 10’ 15’

R-IPS 162 235 206 140

L-IPS 33,7 39,5 68,4 101

PV 32,6 43,5 79,8 110

70 yr ♀

• Clinically (+)• Biochemically (+)• Imaging (inconclusive)

• IPS / PV – 5

• R-IPS / E-IPS – 6

Results:

IPSS in Cushing’s Syndrome

32 yr ♀

• Clinically (+)• Biochemically (+)• Imaging (-)

Results:

IPSS in Cushing’s Syndrome

Antes 5min 10min 15min

SPI Dto 1142 5104 5916 289

SPI Esq 2114 2461 2363 1169

Veia Perif. 60.7 178 201 202

32 yr ♀

• Clinically (+)• Biochemically (+)• Imaging (-)

• IPS / PV – 35

• R-IPS / E-IPS – inconclusive

Results:

IPSS in Cushing’s Syndrome

• Originally described by Corrigan and colleagues in 1977

(unilateral venous sampling)

• Oldfield et al introduced the bilateral IPSS in the 80´s

and in the 90´s the IPSS with and without CRH.

IPSS in Cushing’s Syndrome

IPSS in Cushing’s Syndrome

• The validity of IPSS relies on successful cannulation of

the vessels• Anatomic Variations• Alternative Sampling Methods – Cavernous Sinus,

Jugular Vein

• Possible Complications (0,2%-1,1%) – vein / venule

thrombosis or rupture, SAH, ischemia (...)

IPSS in Cushing’s Syndrome

•IPSS is a safe and well tolerated procedure

•Effective in the differential diagnosis of Cushing’s Syndrome

•Useful in the localization of microadenomas and surgical

planning

Conclusion :

IPSS in Cushing’s Syndrome

The high diagnostic sensitivity, specificity, and accuracy

of IPSS have made it a gold standard tool in the

investigation of ACTH - dependent Cushing´s syndrome.

Conclusion :