Internal Jugular Vein Sampling Research Articles

Measurement of Noradrenaline and Serotonin Metabolites With Internal Jugular Vein Sampling: An Indicator of Brain Monoamine Turnover in Depressive Illness and Panic Disorder.

In research spanning three decades we have estimated brain monoamine turnover (approximately equating with synthesis rate) with sampling from the internal jugular veins and measurement of trans-cerebral plasma monoamine metabolite concentration gradients. Here we report indices of brain noradrenaline and serotonin turnover in patients with major depressive illness (MDD) and panic disorder (PD). Brain noradrenaline turnover was assessed from the combined flux into the internal jugular veins of the metabolites dihydroxyphenylglycol (DHPG) and 3-hydroxy-4-methoxyphenylglycol (MHPG), and brain serotonin turnover from the overflow of the primary metabolite, 5-hydroxyindole acetic acid (5HIAA). Comparison was made with matched healthy research participants. In both MD and PD the estimate of brain noradrenaline turnover provided by metabolite overflow was unremarkable. In contrast, in both patient groups the estimate of brain serotonin turnover provided by 5HIAA overflow was increased 3–4-fold (P < 0.01). This neurotransmitter abnormality was normalized in MDD and PD in clinical remission, during selective serotonin reuptake blocker (SSRI) dosing. We cannot be sure if the brain serotonergic abnormality we find in MDD and PD is causal or a correlate. Measurements in PD were not made during a panic attack. The increased estimated serotonin turnover here may possibly be a substrate for panic attacks; serotonergic raphe nuclei participate in anxiety responses in experimental animals. It is puzzling that the findings were identical in MDD and PD, although it may be pertinent that these psychiatric diagnoses are commonly comorbid. It is unlikely that activation of brain serotonergic neurons is driving the sympathetic nervous activation present, which contributes to cardiovascular risk, persistent sympathetic activation in MDD and episodic activation in PD during panic attacks. We have previously demonstrated that the mechanism of activation of human central sympathetic outflow in other contexts (hypertension, heart failure) is activation of noradrenergic brainstem neurons projecting to the hypothalamus and amygdala.

Venous Sampling for Cushing Disease: Comparison of Internal Jugular Vein and Inferior Petrosal Sinus Sampling

Because magnetic resonance imaging (MRI) fails to detect many adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas, inferior petrosal sinus sampling (IPSS) is considered the gold standard to differentiate Cushing disease (CD) from ectopic ACTH secretion syndrome (EAS). Some authors have suggested internal jugular vein sampling (IJVS) as an alternative to IPSS. We simultaneously compared IJVS to IPSS in 30 consecutive patients referred for ACTH-dependent Cushing syndrome and equivocal MRI exams. Five sites were simultaneously sampled in each patient (right and left IPS, right and left IJV, and femoral vein) before and after the administration of corticotrophin-releasing hormone or desmopressin. The test was considered consistent with CD when the IPS to peripheral ratio was >2 at baseline or >3 after stimulus and the IJV to peripheral ratio was >1.7 at baseline or >2 after stimulus. In 27 of 30 patients, IPSS results were consistent with a central source of ACTH. Two of the other 3 patients had EAS (one lung carcinoid and one occult), and 1 patient had pathology-proven CD. The sensitivity of IPSS was 96.4%. Only 64.2% of these patients had results meeting criteria for a central source of ACTH by IJVS criteria. Twenty patients with centralizing IPPS have undergone pituitary surgery. Of these, the central origin of excessive ACTH was confirmed with certainty in 16 patients. Among these 16 patients, the IPSS sensitivity was 93.8%, whereas 5 patients had false-negative IJVS (68.7% sensitivity). These results do not support the routine use of IJVS in establishing if the pituitary is the source of excessive ACTH. ACTH = adrenocorticotropic hormone CD = Cushing disease CRH = corticotrophin-releasing hormone CS = Cushing syndrome DDAVP = desmopressin EAS = ectopic ACTH secretion IJVS = internal jugular vein sampling IPSS = inferior petrosal sinus sampling JVS = jugular venous sampling MRI = magnetic resonance imaging.

Laterality of central venous sampling: lack of effect on the accuracy of intraoperative parathyroid hormone monitoring

BackgroundThe purpose of this study was to determine if laterality of internal jugular vein (IJV) sampling affects the accuracy of intraoperative parathyroid hormone (PTH) monitoring during parathyroidectomy for primary hyperparathyroidism. MethodsIn this study, 109 patients underwent parathyroidectomy (82 with unilateral disease, 27 with multigland disease). PTH samples were taken from both the left and the right IJV at these time points: preincision (baseline) and then at 5, 10, and, in selected patients, 20 minutes after excision. The Miami criterion was used to determine operative success. ResultsIn all 109 patients combined, the mean decreases in intraoperative PTH levels were 73.8 ± 22.2% for the left IJV and 71.9 ± 23.0% for the right IJV (P = .22). The Miami criterion was met in 105 patients: in 100 (95%) left IJV samples and 99 (94%) right IJV samples (P = 1.00). ConclusionsNo difference was found in the accuracy of intraoperative PTH monitoring between patients' left and right IJV samples. Central venous laterality did not affect fulfillment of the Miami criterion.

Split central venous sampling of parathyroid hormone: An adjunct to surgical exploration

Minimally invasive parathyroid surgery mandates preoperative localization of the adenoma for a targeted operative approach. This technique uses split internal jugular vein parathyroid hormone (PTH) samples to determine a gradient that then directs the surgical exploration. Blood samples were drawn low in the neck from the jugular veins after the neck was opened. The p values for the difference in PTH between the right and left internal jugular veins were calculated with independent sample t tests. For left-sided adenomas, the left internal jugular vein mean was significantly higher than the right p = .001). For right-sided adenomas, the right internal jugular vein mean was significantly higher than the left (p = .004). In hyperplasia, there was no significant difference (p = .43). This study demonstrates the usefulness of split PTH internal jugular vein samples in patients in whom preoperative localization failed. Eighty percent of these patients with a gradient were treated with site-directed unilateral exploration.

Comparison of Analytical Methods of Cerebral Oxygenation during CPB: Hypothermia versus Normothermia

Background: Cerebral oxygen saturation during cardiopulmonary bypass (CPB) has been known to affect the postoperative neurological sequelae. In this study, we compared the oxygen saturation determined by cerebral oxymeter (INVOS 5100) or direct internal jugular vein sampling. Methods: Thirty patients scheduled for elective coronary artery bypass graft surgery were randomly divided into two groups. Group 1 underwent surgery during hypothermia and group 2 underwent surgery during normothermia. The regional oxygen saturation (rSO2) and the juglar venous oxygen saturation (SjvO2) were measured by a spectrophotometer probe attached to the mid-forehead and by a catheter inserted into the left jugular bulb, respectively. Results: In hypothermic group, the SjvO2 tended to increase during CPB but the rSO2 was significantly decreased. After CPB weaning, both the SjvO2 and the rSO2 were returned to control value. In normothermic group, the SjvO2 and the rSO2 were decreased during CPB and there was no difference between two values. No neurological sequelae were seen in both groups. Conelusions: These results suggest that the rSO2 may not reflect the SjvO2 accurately during hypothermic CPB unlikely to normothermic bypass. (Korean J Anesthesiol 2001; 40 : 448~454)

Surgical management of primary hyperparathyroidism

Ectopic parathyroid glands are not rare. They are usually located between the mandible and mediastinum, and usually localized with standard imaging modalities (99mTc-sestamibi subtraction scintigraphy and 4D-CT). We report the case of a 67-year-old woman with severe hypercalcemia due to symptomatic primary hyperparathyroidism whose preoperative 99mTc-sestamibi and 4D-CT scans were non-localizing. During 4-gland exploration, one hypercellular parathyroid was excised, two normocellular parathyroids were biopsied, and bilateral low internal jugular vein sampling showed similar parathyroid hormone (PTH) levels. Despite treatment with zolendronic acid and cinacalcet, symptomatic PHPT persisted. A99mTc-sestamibi study using a modified anterior and posterior whole-body scintigraphy protocol with SPECT/CT revealed mild focal uptake in the right para-tracheal area, correlating with a mass on SPECT/CT. Sestamibi uptake was visually more conspicuous on posterior projection whole-body image. Thoracoscopic resection of this mass revealed a parathyroid gland (2.6 × 1.5 × 0.7 cm) composed almost entirely of chief cells. The lack of identifiable oxyphil content could explain the lack of or limited radiotracer uptake. The modified protocol differed from standard parathyroid imaging in the timing of radiotracer administration, timing of image capture, and types of images obtained could account for the eventual visualization of the ectopic tissue, and may be considered in challenging cases of suspected ectopic parathyroid gland.

Experience with Selective Venous Sampling in Diagnosis of ACTH-Dependent Cushing’s Syndrome

Twenty-three patients with adrenocorticotrophic hormone-(ACTH)-dependent Cushing's syndrome were subjected to selective venous catheterisation and sampling for ACTH on a total of 26 occasions. Out of 10 patients with pituitary-dependent disease, nine had raised ACTH concentrations in one or both high internal jugular vein samples. Eight patients had 11 proved sites of ectopic hormone production: of these, six were correctly identified by the sampling technique, and in four of them this was the only accurate method of localisation. The results of one catheterisation were misleading, and on 10 occasions they were inconclusive; five patients remained undiagnosed by any method. Overall, 15 of the 26 catheterisations provided diagnostically valuable information. Selective venous catheterisation and sampling for ACTH is effective in confirming a pituitary source of the hormone and may be valuable in locating the source of ectopic ACTH production in some cases.

Experience with selective venous sampling in diagnosis of ACTH-dependent Cushing's syndrome.

Twenty-three patients with adrenocorticotrophic hormone-(ACTH)-dependent Cushing's syndrome were subjected to selective venous catheterisation and sampling for ACTH on a total of 26 occasions. Out of 10 patients with pituitary-dependent disease, nine had raised ACTH concentrations in one or both high internal jugular vein samples. Eight patients had 11 proved sites of ectopic hormone production: of these, six were correctly identified by the sampling technique, and in four of them this was the only accurate method of localisation. The results of one catheterisation were misleading, and on 10 occasions they were inconclusive; five patients remained undiagnosed by any method. Overall, 15 of the 26 catheterisations provided diagnostically valuable information. Selective venous catheterisation and sampling for ACTH is effective in confirming a pituitary source of the hormone and may be valuable in locating the source of ectopic ACTH production in some cases.