Application Of Bilateral Inferior Petrosal Sinus Sampling In Diagnosis Of Cushing’s Disease

Objective:Cushing’s syndrome(CS),also known as hypercortisolism,is characterized by a series of clinical symptoms caused by excessive glucocorticoid secretion from the adrenal gland,including centripetal obesity,skin purple lines,moon face,buffalo back,hypertension and hyperlipidemia.Cushing’s disease(CD)is a group of adrenocorticotropic hormones(ACTH)secreted by pituitary adrenocorticotropic hormone adenoma,which leads to excessive adrenocortical hormone secretion.CD is the most common cause of Cushing’s syndrome,accounting for about 68%.Since the first report of bilateral inferior petrosal sinus blood sampling(BIPSS)in the 1970s,BIPSS has been used as a diagnostic tool to differentiate pituitary-dependent Cushing’s syndrome from non-pituitary-dependent Cushing’s syndrome.The purpose of this study is to explore the value of bilateral inferior petrosal sinus blood sampling in the diagnosis of Cushing’s disease,to predict the location of pituitary adenomas,to explore the reasons for the different effects of bilateral inferior petrosal sinus blood sampling,and to explore its learning curve.The blood collection of inferior petrosal sinus was summarized.To explore the clinical value of bilateral inferior petrosal sinus blood collection and provide reference for clinical work.Methods:In this paper,retrospective analysis was performed on the 31 cases diagnosed as Cushing’s disease who were admitted to the department of neurosurgery of qilu hospital of shandong university from May 2012 to January 2019,and blood samples of bilateral inferior rock sinus vein were collected at the same time.The age,gender,ACTH data in blood samples,bilateral inferior sinus venous pressure and postoperative pathological data of the patients were summarized and analyzed,and the indicators such as MRI,blood samples of inferior sinus and inferior sinus pressure were compared,and the variance was applied for statistical analysis.Results:Among the 31 patients included in this study,there were 4 males(13.3%)and 27 females(86.7%).The average age of the patients was 43.39±11.06 years,and the age of onset was mainly 41-50 years.Among the 31 patients,29 received surgical treatment and 29 improved imaging examination.(note:2 patients received surgical treatment without imaging examination,and 2 patients received surgical treatment without imaging examination.)in the 29 patients who received imaging examination,all patients received surgical treatment.Postoperative pathological report showed:pituitary adenoma,ACTH(+).In the 29 cases of patients,there are 21 people imaging data to diagnose space-occupying lesions in saddle area,the remaining eight imaging findings were negative(including one other related inspection were negative,but also did not receive surgery),combined with the current research data discovery imaging examination of true positive rate was 72.4%,true negative rate was 3.5%,false negative rate was 24.1%.In all the 31 patients,on the basis of previous literature explained under the rock of sinus blood ACTH concentration/peripheral blood ACTH concentration>2 the diagnostic criteria for diagnosis meaning of May 28 people diagnosed with Cushing disease,one due to the negatie results of imaging examination,then the line has not surgery,and another 2 are the imaging examination of the saddle area space-occupying lesions,and then to neural endoscopic nasal adjustment in the saddle area space-occupying lesion resection。postoperative pathology:pituitary adenoma,ACTH(+).Supports the diagnosis of Cushing’s disease.According to the statistical analysis,the true positive rate,true negative rate and true negative rate of simultaneous blood sampling of bilateral inferior sinus vein were 90.3%,3.2%and 6.5%,respectively.Previous literatures have pointed out that the side with relatively high ACTH concentration in inferior petrosal sinus blood is compared with the side with relatively low ACTH concentration.If the above ratio is>1.4,it indicates that the tumor is located on the side with relatively high ACTH.In this study,ACTH concentration in blood samples collected from 27 patients with inferior petrosal sinus showed that one side of inferior petrosal sinus was higher than the other side and greater than 1.4 times,including 19 patients with a high right side and 8 patients with a high left side.When the above ratio is<1.4,it can preliminarily determine that the patient is pituitary diffuse hyperplasia or the tumor is located in the middle part of the pituitary gland.None of the patients included in this study met the diagnostic criteria.Due to technical problems in the laboratory,the content of ACTH in blood samples collected from the inferior petrosal sinus of one of the 28 patients included in this study was higher on both sides,both of which exceeded the scope of laboratory examination,so the comparative analysis could not be carried out.Meanwhile,the patient was too old to receive surgical treatment.Therefore,the above 4 patients were excluded temporarily in the statistical analysis and comparison of tumor side.Due to the absence of relevant clinical data,only 21 patients had complete surgical data.Intraoperative exploration confirmed the tumor location of the patients and confirmed the postoperative pathology.However,among the 21 patients,there were no significant differences between the blood samples collected from the inferior petrosal sinus of 2 patients and the peripheral blood samples,so they were excluded.Therefore,only 19 patients could be compared and analyzed.Among the case data included in this study,only 10 cases of preoperative tumor location were confirmed by intraoperative exploration and postoperative pathology,so the coincidence rate of blood collection from the inferior petrosal sinus in left and right side tumor location prediction was 52.63%,which was basically consistent with previous literature reports.Among the 31 patients included in this study,all patients successfully performed bilateral inferior rock sinus blood collection,with a technical success rate of 100%,and no obvious complications during and after surgery.Among them,9 patients underwent pressure measurement of bilateral inferior petrologic sinus.According to the analysis of pressure data,the average pressure of patients’ inferior petrologic sinus was 11.89～1.99mmH2O.By comparing the pressure value with the blood sample results of bilateral inferior sinus,it was found that there was a negative correlation between them.Conclusions:Bilateral inferior petrosal sinus sampling is a very effective method for the diagnosis of Cushing’s disease and it can differentiate pituitary-derived from non-pituitary-derived Cushing’s syndrome.In addition,the application of bilateral inferior petrosal sinus sampling technique can improve the positive rate of diagnosis of ACTH adenoma.Inferior petrosal sinus sampling can more intuitively summarize the blood reflux of inferior petrosal sinus.The pressure of bilateral inferior petrosal sinus can be determined by manometry.If there is no significant difference between the pressure of bilateral inferior petrosal sinus,the laterality of tumors can be preliminarily determined by simply combining the sampling results.If the measured bilateral pressures are not equal,the existing data should be fully analyzed to predict the location of the tumors.This study further clarifies that bilateral inferior petrosal sinus sampling combined with imaging examination can provide help for pituitary adenoma localization and provide reliable basis for clinical diagnosis of Cushing’s disease.