Ipsilateral Inferior Petrosal Sinus Research Articles

Angiographic cross-filling between inferior petrosal sinuses and alteration of adrenocorticotropic hormone sampling results for tumor localization in Cushing disease.

Inferior petrosal sinus (IPS) sampling (IPSS) is a diagnostic procedure used to guide diagnostic localization of imaging-negative adrenocorticotropic hormone (ACTH)-secreting pituitary microadenomas. However, the efficacy of IPSS has been suboptimal at accurately lateralizing the adenoma, reducing surgical cure rates and leading to unintended pituitary dysfunction due to the added exploration. One rationale for the occasional imprecision is the existence of additional petrosal sinus collateral channels that connect the IPS bilaterally, which may lead to false localization results during sampling. The aim of this study was to explore a potential connection between normal anatomical variation in the angioarchitecture of the IPSs and the ACTH results obtained in subsequent IPSS tests. A retrospective review was performed on all cases between 1998 and 2013 involving patients at a single institution who underwent IPSS for radiographically equivocal pituitary microadenomas. Cases were reviewed for tumor laterality noted on either operative or pathology reports, as well as the presence of angiographic evidence of cross-filling between the sinuses. In addition, ACTH levels from the right and left IPSs were documented at baseline and at 2, 5, and 10 minutes after corticotropin-releasing hormone (CRH) administration. A ratio of the change in ACTH levels measured at the time of maximal response (10 minutes) versus the levels measured at the initial response (2 minutes) was computed for each patient and compared between patients by their angiographic cross-filling status. There were 41 patients with a histopathologically confirmed right- or left-sided ACTH-secreting pituitary microadenoma who underwent preoperative IPSS. Among these patients, 28 (68%) showed angiographic evidence of cross-filling between the IPSs, and 13 showed no cross-filling. On average, ACTH levels increased by a factor of 3.91 ± 0.77 in the contralateral IPS in patients with angiographic cross-filling, compared with a factor increase of only 1.80 ± 0.27 in patients without cross-filling (p = 0.014). In comparison, ACTH levels increased by a factor of 2.01 ± 0.57 in the ipsilateral IPS in patients with cross-filling, and by 8.78 ± 7.30 in those without cross-filling (p = 0.373). The presence of angiographic cross-filling, suggestive of a greater degree of vascular channel networking between the right and left IPS, is a significant factor influencing the measured rates of change of ACTH in IPSS and may impact the specificity of this test to accurately determine microadenoma laterality in the preoperative setting.

Flow diversion for indirect carotid-cavernous fistula: Still an off-label indication?

Flow diversion (FD) is an established treatment for large or giant wide-necked unruptured intracranial aneurysms. In the past few years, the use of flow diverter devices was extended to several other "off-label" indications, including solitary or adjunctive treatment to coil embolization for direct (Barrow A type) carotid cavernous fistulas (CCFs). The use of liquid embolic agents still represents the first-line treatment for indirect CCFs. Typically, the ipsilateral inferior petrosal sinus or superior ophthalmic vein (SOV) is the preferred transvenous routes to access CCFs. In some cases, vessel tortuosity or different features make the endovascular access challenging, thus requiring different approaches and strategies. The aim of the study is to discuss rational and technical aspect in treating indirect CCFs referring to the most up-to-date literature. An alternative experience-based endovascular strategy with FD is described. We report the case of a 54-year-old woman diagnosed with indirect CCF and treated with flow diverter stent. After multiple unsuccessful attempts at transarterial right SOV catheterization, a right indirect CCF fed by a single trunk at the ophthalmic origin from the internal carotid artery (ICA) was treated by ICA stand-alone FD. Blood flow was redirect and successfully reduced through the fistula, with immediately postprocedure improvement of the patient's clinical status (ipsilateral proptosis and chemosis). Ten-months radiological follow-up showed the complete obliteration of the fistula. No adjunctive endovascular treatment was performed. FD appears a reasonable alternative stand-alone endovascular strategy also for selected difficult-to-access indirect CCFs, when all conventional routes are judged unfeasible. Further investigations will be necessary to better define and support this potential lesson-learned application.

Transvenous embolization of dural arteriovenous fistula of the cavernous sinus by identifying the orifice of the occluded inferior petrosal sinus through the angle of the microguidewire

ObjectiveTo describe that the angle of the microguidwire on lateral projection under fluoroscopic image is a prediction of cannulation of the occluded inferior petrosal sinus in the transvenous embolization of cavernous sinus dural fistulas. MethodsFrom January 2018 through January 2021, 12 cavernous sinus dural fistulas with ipsilateral inferior petrosal sinus occlusion identified in 12 consecutive patients were cured by cannulation of the occluded ipsilateral inferior petrosal sinus. Clinical, radiologic and procedure data of the 12 patients were retrospectively reviewed. The angle of microguidewire between on lateral projection under fluoroscopic image between the inferior petrosal sinus and the internal jugular vein was measured. ResultsIn the 12 patients, access via the occluded ipsilateral inferior petrosal sinus was primarily attempted as the transvenous approach. During the procedure, the angle of microguidwire on lateral projection under fluoroscopic image between the inferior petrosal sinus and the internal jugular vein was 117°±7°, which is very useful to confirm the cannulation of the occluded inferior petrosal sinus. Complete occlusion was achieved in all fistulas, with no procedure-related morbidity or mortality. Postprocedural symptom was improved in all patients. ConclusionCannulation of an occluded inferior petrosal sinus is possible and reasonable as an initial access attempt for cavernous sinus dural fistulas. The angle of microguidwire on the lateral projection under fluoroscopic image can help to confirm the orifice of the occluded inferior petrosal sinus.

Efficiency of Endovascular Therapy for Bilateral Cavernous Sinus Dural Arteriovenous Fistula

The principles of endovascular treatment of bilateral cavernous sinus dural arteriovenous fistula (CS-dAVF) are not well established because of the complexity in the number of fistula tracts and their behavior, which seems to be more aggressive. We aimed to determine an efficient technique for endovascular treatment of bilateral CS-dAVF and the associated factors to achieve good clinical and angiographic outcomes. The data were analyzed from 165 consecutive patients diagnosed with CS-dAVF from January 2005 to September 2018. The demographic data included approaching route, embolization times, embolization material, sequence of embolization, number of embolization sessions, and angiographic and clinical outcomes. Interrater agreement of bilateral CS-dAVF diagnosis was performed using the κ coefficient. The factors associated with treatment outcome were analyzed using a Pearson χ2 test. Bilateral CS-dAVF was detected in 43 patients (26%). Angiographic presentations that showed evidence of sinus thrombosis, dangerous venous drainage, and higher Satomi classification were more commonly found in bilateral CS-dAVF than in unilateral CS-dAVF. Good clinical outcome and cure from angiography were obtained in 90% and 74%, respectively. Ipsilateral inferior petrosal sinus-intercavernous sinus-contralateral cavernous sinus catheterization was the major approach route of treatment. The factors associated with improved clinical outcome were transvenous approach, shunt closure, coil embolization, and sequencing the embolization (P < 0.001). Dangerous venous drainage tends to increase in bilateral CS-dAVF. Retrograde ipsilateral inferior petrosal sinus catheterization using coil embolization and sequencing the embolization are the major concerns for treatment.

Relationship between the drainage pattern of the dural venous sinuses and hearing recovery in patients with sudden sensorineural hearing loss

Although cochlear venous insufficiency has been considered to cause sudden sensorineural hearing loss (SSHL), there is insufficient clinical evidence to support this hypothesis. We sought to determine whether there is a correlation between draining patterns of the dural venous sinuses and the side of the affected ear in SSHL, as well as hearing recovery. The medical records of 109 patients diagnosed with unilateral SSHL were retrospectively reviewed. Magnetic resonance images and pure tone audiometry were performed in all patients. We measured the dominance of the inferior petrosal sinus (IPS) and transverse-sigmoid sinus (TS/SS) ipsilateral to the affected ear. Most patients were characterized by asymmetric venous drainage (IPS, 53.2%; TS/SS, 81.7%). The dominant side of the IPS or TS/SS was independent of the side of the affected ear for all patients in this study. However, in 35 patients with early recovery within 2 weeks, the dominant side of TS/SS was significantly associated with the side of the affected ear (p = 0.011). Moreover, the dominance of both the IPS and TS/SS influenced hearing outcomes at 3 months. Dominant TS/SS ipsilateral to the affected ear, particularly in the presence of ipsilateral hypoplastic IPS, is associated with a favorable hearing prognosis of SSHL.

Transarterial Embolization of Cavernous Sinus Dural Arteriovenous Fistulas with Ipsilateral Inferior Petrosal Sinus Occlusion via the Ascending Pharyngeal Artery

Although the ipsilateral inferior petrosal sinus (IPS) is preferred for treatment of cavernous sinus dural arteriovenous fistulas (CS-dAVFs), this method is problematic if ipsilateral IPS is occluded. We describe our experience in treating CS-dAVFs with ipsilateral IPS occlusion via the ascending pharyngeal artery (APA). Between January 2013 and June 2017, of 36 CS-dAVFs, 23 with ipsilateral IPS occlusion were identified. Clinical charts, procedural data, angiographic results, and follow-up data were retrospectively reviewed. Of 23 CS-dAVFs, 16 displayed a single or dominant feeding APA on cerebral angiography, of which 13 were treated via the APA initially. Fistulas were occluded successfully through the neuromeningeal trunk of the APA in 7 cases and through the superior pharyngeal branch of the APA in 3 cases. Glue leakage occurred in 2 cases via the superior pharyngeal branch of the APA, and superior pharyngeal branch rupture occurred during superselection of the microguidewire in 1 patient, who was treated by opening the occluded ipsilateral IPS. During the follow-up period, 12 of 13 patients had complete occlusion, and no cranial nerve palsy occurred. CS-dAVF with ipsilateral IPS occlusion can be treated via various methods. Embolization through the APA as an initial access is a reasonable choice.

Assessment of the Inferior Petrosal Sinus on T1-Weighted Contrast-Enhanced Magnetic Resonance Imaging.

Context:Skull base venous anatomy.Aims:While prior studies have focused on the efficacy of conventional fluoroscopic venography and multidetector computed tomography venography to evaluate the inferior petrosal sinus (IPS) before image-guided intervention (such as dural venous sinus sampling), we believe that routine magnetic resonance imaging (MRI) may provide reliable structural information helpful for planning without the need for further imaging.Settings and Design:Retrospective review of brain MRI.Materials and Methods:Retrospective analysis was carried out on IPSs on contrast-enhanced T1-weighted MR images. Qualitative measurements were made regarding the grade of patency of the IPS, variation in IPS drainage pattern, and grading of the ipsilateral transverse and sigmoid sinuses (TS and SS).Statistical Analysis Used:Pearson's product-moment correlation.Results:Evaluation of a total of 148 IPSs revealed that 91% of cases were grade 3 or grade 2 (either fully or mostly visualized), with 65% of cases demonstrating “typical” (type A) drainage directly into the internal jugular vein and no statistically significant correlation between the patency of the IPS and the dominance of the ipsilateral TS/SS. A bilateral concordance rate of 77% was also observed.Conclusions:Our analysis indicates that routine thin-slice contrast-enhanced T1-weighted MRI can provide sufficient anatomic detail to identify typical drainage pattern of the IPS in a majority of cases. In cases where routine drainage was not identified, spatial resolution was not sufficient to further delineate complex drainage anatomy. No correlation was observed between the TS/SS dominance and patency of the ipsilateral IPS.

Abducens nerve palsy due to inferior petrosal sinus thrombosis

Isolated unilateral abducens nerve palsy is usually due to ischemia, trauma or neoplasm. Dorello’s canal is the space between the petrous apex and superolateral portion of the clivus, bound superiorly by Gruber’s ligament. The abducens nerve travels with inferior petrosal sinus (IPS) though the Dorello’s canal before entering the cavernous sinus. A 31-year-old man presented with neck pain, and binocular horizontal diplopia, worse looking towards left and at distance. He had a history of intravenous drug abuse but no history of hypertension or diabetes. On examination, he had complete left 6th nerve palsy with normal fundi, pupils, and other cranial nerves. Methicillin-resistant Staphylococcus aureus bacteremia was detected with naïve tricuspid valve endocarditis and multiple septic emboli to lungs with infarcts. His cerebrospinal fluid was normal. MRI of the brain was normal. MRV of head and neck showed thrombosis of the left internal jugular vein, left sigmoid sinus and left inferior petrosal sinus with normal cavernous sinus and no evidence of mastoiditis. He was treated with broad spectrum antibiotics. He was not anticoagulated for fear of pulmonary hemorrhage from pulmonary infarcts. Although cerebral venous sinus thrombosis commonly presents with elevated intracranial pressure, isolated ipsilateral 6th nerve palsy from its compression in Dorello’s canal due to thrombosis of the ipsilateral inferior petrosal sinus is extremely rare. To our knowledge, only two patients have been reported with isolated abducens palsy due to IPS thrombosis; one caused by septic emboli and the other developed it during IPS cortisol level sampling.

Transvenous microguidewire looping technique for breach of ipsilateral inferior petrosal sinus occlusions en route to cavernous sinus dural arteriovenous fistulas.

Transarterial access to dural arteriovenous fistulas (dAVFs) has been popularized by device improvements and novel embolic materials. However, this approach is limited in the cavernous sinus (CS) because of related complications and low cure rates. Although a transvenous approach, via ipsilateral inferior petrosal sinus (IPS), may be more suitable for CS-dAVFs, microcatheter delivery is occasionally impeded by ipsilateral IPS occlusion. Described herein is a microguidewire looping method to breach such occlusions, thus enabling access to CS lesions. A microcatheter is initially advanced into the IPS orifice, and a microguidewire is passed into the occluded IPS. Looping is easily achieved through the resistance met. With greater support of the guiding catheter, the microguidewire (still looped) is then advanced into the CS. When nearing the CS, the microcatheter is further reinforced, and it is navigated along the microguidewire into the CS. This technique was applied in 10 instances of CS-dAVF with ipsilateral IPS occlusion, enabling ipsilateral access to the CS. In eight cases (80%), microdevice advancement was successful, culminating in effective transvenous coil embolization. Clinical and radiologic outcomes in all patients were excellent, with no delayed post-procedural cranial palsies. This microguidewire looping technique enables safe and effective entry into the CS during transvenous coil embolization of CS-dAVFs with ipsilateral IPS occlusion.

An innovative technique for detecting the caudal end of occluded inferior petrosal sinus in cavernous arteriovenous fistula using intravascular ultrasonography—technical note

IntroductionAlthough cavernous sinus (CS) dural arteriovenous fistulas (d-AVFs) are usually treated with transvenous embolization (TVE) via the inferior petrosal sinus (IPS), IPSs are sometimes thrombosed and angiographically invisible. In such cases, the first obstacle to TVE is detecting the entry to the IPS. We report a new technique for TVE via IPS using intravascular ultrasonography (IVUS).MethodsThree consecutive cases of CS d-AVF with ipsilateral or bilateral IPS occlusion were involved in this study. On TVE, the orifice of the IPS was investigated with IVUS placed in the jugular vein or jugular bulb.ResultsThis technique has been successfully adapted in all three cases. In two of these cases, IPS was well visualized with the help of IVUS, and TVE was successfully performed.ConclusionTo our knowledge, this is the first report to mention the usefulness of IVUS for detecting angiographically occult IPS.

Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistula With Ipsilateral Inferior Petrosal Sinus Occlusion: A Single-Center Experience.

Although a transvenous route via the ipsilateral inferior petrosal sinus (IPS) is preferred in treating cavernous sinus dural arteriovenous fistula (CSdAVF), this option may be limited if an occluded ipsilateral IPS undermines microcatheter delivery to the cavernous sinus. To describe our experience with endovascular treatment of CSdAVF complicated by ipsilateral IPS occlusion. From January 2003 through September 2014, a total of 49 CSdAVFs with ipsilateral IPS occlusion were identified in 49 patients, who then underwent endovascular treatment. Clinical and radiologic data were retrospectively reviewed. Either transvenous (n = 38) or transarterial (n = 11) access was initially elected, the latter reserved for single-hole or dominant arterial feeder fistulas. Access via occluded ipsilateral IPS was usually attempted (n = 34) by transvenous approach, with a 54.3% success rate. Anterior (n = 3) or posterior (n = 1) facial vein was alternatively used. Direct surgical exposure of ophthalmic vein (n = 3) or radiosurgery (n = 4) was performed for access failure or unsuccessful occlusion by other means. In 46 fistulas (93.9%), complete occlusion was achieved, with no procedure-related morbidity or mortality. Postprocedural symptom improvement was noted in all but 2 patients, who separately experienced paradoxical worsening of cranial nerve palsy and access failure. In patients with CSdAVF and ipsilateral IPS occlusion, various treatment strategies may be applied (given angioanatomic suitability), resulting in excellent procedural and short-term follow-up results. Reopening of an occluded IPS is reasonable as an initial access attempt.

Transvenous Coil Embolization of an Intraorbital Arteriovenous Fistula

Purely intraorbital arteriovenous fistulas (AVFs), which are rare vascular malformations that clinically mimic carotid-cavernous fistulas (CCFs), involve a fistula from the ophthalmic artery to 1 of the draining ophthalmic veins. We describe a case of an intraorbital AVF treated with transvenous endovascular coil embolization via the inferior petrosal sinus (IPS) route and review the literature on this rare entity. An 81-year-old woman sought treatment after 7 days of progressive left-sided visual acuity loss, chemosis, and lateral rectus palsy. Magnetic resonance imaging demonstrated dilated vascularity in the left orbit raising suspicions for a CCF. Cerebral angiography showed a purely intraorbital AVF with a fistula between the left ophthalmic artery and superior ophthalmic vein (SOV). Transvenous selective catheterization of the fistula was performed by successfully navigating the ipsilateral IPS to the cavernous sinus and SOV. The fistula was then embolized using detachable coils. The patient was discharged the next day. Three weeks after embolization, her ocular symptoms and findings had resolved. Intraorbital AVFs are a rare type of AVF that can be treated by direct surgical ligation, transarterial embolization, or transvenous embolization. We successfully navigated the IPS, which is frequently stenotic or occluded secondary to chronically increased fistulous drainage, and utilized this route to embolize the fistula with detachable coils.

A case of isolated transverse sigmoid sinus dural arteriovenous fistula in which ipsilateral sensory neural hearing loss developed after transvenous embolization—letter to the editor

Dear Sir, We would like to report a rare complication after transvenous embolization (TVE) of an isolated transverse sigmoid sinus (TSS) dural arteriovenous fistula (dAVF). A 72-year-old male complaining of right pulsatile tinnitus was referred to our hospital. A bruit was identified in the post-auricular region on the right side. There were no neurological deficits. Diagnostic angiography demonstrated a dAVF fed by branches of the occipital and posterior auricular artery and ending in an isolated transverse sigmoid sinus (Fig. 1a). The venous phase of the right common carotid angiography demonstrated absence of opacification of the diseased sinuses and of the ipsilateral inferior petrosal sinus (IPS) and jugular Bulb (JB) (Fig. 1b). TVE was performed under general anesthesia. A microcatheter was navigated to the diseased sinus via contralateral approach. This segment of sinuses was packed with detachable microcoils (GDC®/Targets Therapeutics, Fremont, CA, USA). Final control angiography showed complete obliteration of the shunt (Fig. 2). The pulsatile tinnitus disappeared immediately after the procedure. On postoperative day 1, the patient complained of dizziness, but MR with diffusion weighted images showed no abnormal findings. The dizziness improved within 10 days. After 10 days of hospitalization, a sudden hearing loss occurred in the right ear. Puretone audiography revealed a sensory neural hearing loss (SNHL) of 40 dB. A tentative diagnosis of sudden SNHL (SSNHL) was made by the ENT specialists. Intravenous drip infusion of corticosteroids and low molecular dextrin was initiated. Two weeks later, hearing loss had improved with 15 dB. To the best of our knowledge, no previous reports have described SNHL after TVE of a dAVF. When considering the etiology of the hearing loss in our case, two aspects must be discussed. First it should be made out whether this SNHL occurred incidentally or as a consequence of the procedure. Secondly, if the embolization caused the SNHL, the potential pathogenesis and clinical significance of the SNHL should be investigated. If the hearing loss was coincidental, the diagnosis of SSNHL would be the most likely diagnosis. Nevertheless, in the literature, the incidence of SSNHL is reported as low as 5–20/100,000 person-years [1, 2]. Moreover, it is highly unlikely that ipsilateral SSNHL would occur incidentally within 10 days after TVE. Therefore, it seems more likely that this SNHL has arisen as a consequence of the procedure. Although various reports have described SNHL caused by anesthesia [3], radiation [4], and contrast medium administration [5], these potential causes of hearing loss seem not to match for our case. Therefore, we considered that TVE itself must be responsible for this SNHL. Anatomically, the inner ear has two main venous drainage routes: the vein of the vestibular aqueduct (VVAQ) draining into the vertical portion of the sigmoid sinus or superior petrosal sinus (SPS); and the vein of cochlear aqueduct (VCAQ) draining into the JB or the caudal end of the IPS (Fig. 3a) [6]. Watanabe et al. reported the precise venous drainage of the inner ear in guinea pigs [7]. They reported the presence of minor collateral vessels between the VCAQ and the mucoperiosteal veins of the middle ear, which act as collateral channels in the event of venous congestion of the inner ear [7]. S. Yamauchi (*) :A. Nishio Department of Neurosurgery, Hokuto Hospital, 7-5 Inada, Obihiro, Hokkaido 080-0033, Japan e-mail: ymailadd@silver.ocn.ne.jp

Transvenous embolization of cavernous sinus dural arteriovenous fistulas using detachable coils and Glubran 2 acrylic glue via the inferior petrosal sinus approach

To describe the technique, efficacy, and safety of transvenous embolisation (TVE) of cavernous sinus arteriovenous fistulas (CSDAVFs) via the inferior petrosal sinus (IPS) with detachable coils and acrylic glue. Spontaneous unilateral CSDAVFs were confirmed by cerebral angiography in eight patients, with angiographic patency of the ipsilateral IPS in three and angiographic non-visualisation of the ipsilateral IPS in five. There were two patients with complete occlusion of the ipsilateral internal jugular vein (IJV). TVE with detachable coils and acrylic glue were performed through a femoral vein and an IPS approach. TVE viaipsilateral IPS was successfully performed in all eight patients in our group. The number of detachable coils for each patient ranged from 2 to 8 (mean, 5.0). Angiography immediately after TVE showed complete occlusion of the CSCAVFs in seven patients and nearly complete occlusion in one. Complete recovery of clinical symptoms was achieved in all eight patients. No recurrence of clinical symptoms was observed at follow-up. Transvenous embolisation via an IPS approach is a highly efficient and safe treatment for CSDAVFs. Embolisation with a combination of coils and acrylic glue may help to achieve complete occlusion of fistulas with fewer coils.

Posterior Fossa Dural Arteriovenous Fistula As a Probable Cause of Congestive Myelopathy -Case Report-

A 62-year-old female suffered severe occipitalgia followed by progressive tetraparesis and bulbar symptoms, although tinnitus in the left ear persisting for more than 1 year resolved spontaneously after the onset. Cerebral magnetic resonance (MR) imaging revealed swelling in the lower brainstem, and cervical T(2)-weighted MR imaging showed diffuse intramedullary hyperintensity in the medulla oblongata extending downward to the upper thoracic cord. Rim-like enhancement was localized at the C2 level after gadolinium administration. Extensive blood and cerebrospinal fluid examinations and whole body scintigraphy showed no indications of the underlying pathology. She underwent open biopsy for histological verification and decompressive maneuver to the cord. Sparse arterial distribution, and collapsed and partially thrombosed veins were recognized on the dorsal surface of the cord. Midline myelotomy yielded creamy fluid that proved to be necrotic tissue. Histological examination found the venous wall was thickened with lymphocytic infiltration. Her tetraparesis showed mild improvement postoperatively with marked resolution of the intramedullary hyperintensity on MR imaging. Postoperative cerebral angiography revealed a posterior fossa dural arteriovenous fistula (dAVF) fed by the left ascending pharyngeal and occipital arteries, with venous reflux to the ipsilateral inferior petrosal sinus. No venous drainage was found via the perimedullary vein. The dAVF was completely obliterated by transvenous coil embolization. We considered that the dAVF might have caused the congestive myelopathy. Decompressive maneuver may provide effective management for necrotizing myelopathy in selected cases.

Plasma atrial natriuretic factor levels in the inferior petrosal sinus blood of patients with Cushing's disease before and after corticotropin-releasing hormone administration.

Atrial natriuretic factor (ANF) was suggested to be involved as neurohormone in the modulation of hypothalamus-pituitary-adrenal axis in humans. However, this role is still controversial and widely discussed. In order to evaluate whether ANF is secreted in the hypothalamus-pituitary system in humans, plasma ANF concentrations were assayed in samples collected in the inferior petrosal sinus (IPS) blood of patients subjected to IPS sampling for diagnostic purposes or neurosurgical indications. In this retrospective study were included 22 patients: 10 with Cushing's disease (CD) and 12 patients with GH or PRL-secreting pituitary adenoma, used as control group. In the patients with CD, plasma ANF concentration was also assayed after CRH test (hCRH 100 micrograms as i.v. bolus with blood samples after 5, 10 and 15 min). Both in patients with CD and in patients with GH- or PRL-secreting pituitary adenoma, no significant difference was found in plasma ANF levels between IPS ipsilateral (13.0 +/- 1.5 and 12.2 +/- 1.2 pmol/l) or controlateral (13.0 +/- 1.6 and 12.2 +/- 1.4 pmol/l) to the adenoma and peripheral blood (14.2 +/- 2.0 and 13.7 +/- 1.5 pmol/l, respectively). Similarly, no difference was found between the IPS ipsilateral and controlateral to the adenoma in both groups of patients. In patients with CD, CRH administration induced a significant increase of ACTH levels (periphery: 34.9 +/- 6.2 vs 11.5 +/- 2.3 pmol/l, p < 0.05) but it did not induce any significant change of plasma ANF levels (14.0 +/- 2.0 vs 13.4 +/- 1.4 pmol/l in the ipsilateral IPS and 13.4 +/- 1.6 vs 13.4 +/- 1.5 pmol/l in the ipsilateral IPS and 13.4 +/- 1.6 vs 13.4 +/- 1.5 pmol/l in the contralateral IPS). In conclusion, the lack of ANF concentration gradient between IPS and peripheral blood, the lack of any difference in ANF concentrations between patients with CD and acromegalics or hyperprolactinemics and the absence of ANF response to CRH administration do not support the hypothesis of a role for ANF as neurohormone involved in the hypothalamus-pituitary control and particularly in the hypothalamus-pituitary-adrenal axis modulation in humans.

Tumor necrosis factor-alpha increases after corticotropin-releasing hormone administration in Cushing's disease. In vivo and in vitro studies.

The aim of this study was to evaluate the effect of acute human corticotropin (ACTH)-releasing hormone (CRH) administration (100 micrograms, as i.v. bolus) on tumor necrosis factor-alpha (TNF alpha) levels in the inferior petrosal sinuses and in the peripheral blood of 7 patients with Cushing's disease subjected to diagnostic inferior petrosal sinus sampling. Blood samples for ACTH, beta-endorphin (beta-EPH) and TNF alpha were collected from inferior petrosal sinuses and periphery simultaneously. In addition, TNF alpha concentrations were measured after CRH administration (10 nmol/l, 100 nmol/l and 1 mumol/l) in culture medium from primary cultures obtained in 3 of 7 patients. At baseline, plasma ACTH and beta-EPH levels were significantly higher in the inferior petrosal sinus ipsilateral to the ACTH-secreting adenoma than in the contralateral one and in the periphery (p < 0.001) whereas no significant difference was found as far as serum TNF alpha levels were concerned. CRH administration caused a significant increase of ACTH (p < 0.001), beta-EPH (p < 0.01) and TNF alpha (p < 0.01) levels greater in the ipsilateral inferior petrosal sinus than in the contralateral one and in the periphery. In addition, CRH increased ACTH, beta-EPH and TNF alpha levels in the culture medium of three ACTH-secreting tumors at the doses of 100 nmol/l and 1 mumol/l (greater than 300, 200 and 110% of baseline pretreatment incubation levels, respectively). These data suggest that CRH may increase TNF alpha concentrations in the inferior petrosal sinus ipsilateral to the ACTH-secreting adenoma and in the peripheral blood as well. In addition, it stimulated TNF alpha release both in vivo and in vitro. These findings suggest the possibility that an imbalanced intrapituitary TNF alpha production can be detected in ACTH-secreting adenomas.

Absence of intercavernous venous mixing: evidence supporting lateralization of pituitary microadenomas by venous sampling.

Preoperative lateralization of endocrine-active pituitary tumors may be possible by bilateral inferior petrosal sinus (IPS) sampling for hormone measurement. The reliability of this technique depends on unilateral drainage of blood from the adenoma within the pituitary gland, in its course from the gland to the ipsilateral cavernous sinus, and from the cavernous sinus to the junction of the IPS and the internal jugular vein. Anatomical studies demonstrate unilateral drainage of each hemihypophysis into the ipsilateral cavernous sinus. The degree of mixing of blood between the cavernous sinuses, via the intercavernous sinus, and between the IPSs, via the basilar plexus, is unknown. We determined the extent of mixing of blood flowing from the superior orbital vein to the junction of the IPS and the internal jugular vein in four rhesus monkeys. After catheterization of a superior orbital vein and both IPSs, 99Tc-colloidal sulfur was infused into the superior orbital vein while blood samples were taken simultaneously from both IPSs and a peripheral vein at 3-min intervals. Mean relative radioactivity was 100 +/- 14% (+/- SEM) in the ipsilateral IPS, 8 +/- 2% in the contralateral IPS, and 3 +/- 1% in a peripheral vein. Isotope reaching the ipsilateral IPS before recirculation from the periphery was 10- to 313-fold more concentrated than in the contralateral IPS. These findings suggest that mixture of blood between the cavernous sinuses and between the IPSs is insignificant and support the capability of preoperative lateralization of pituitary microadenomas by bilateral and simultaneous IPS sampling.

Preoperative lateralization of ACTH-secreting pituitary microadenomas by bilateral and simultaneous inferior petrosal venous sinus sampling.

PREVIOUS reports have established the utility of selective catheterization of the inferior petrosal sinus for determination of plasma ACTH concentrations in the diagnosis of pituitary-dependent hypercortisolism.1 2 3 4 5 Preliminary studies suggest that hormonal secretion from a laterally located microadenoma drains preferentially into the ipsilateral inferior petrosal sinus.6 7 8 If this occurs consistently, simultaneous sampling of bilateral venous blood should provide a means of localizing the microadenoma in one side of the pituitary gland, aiding the surgeon's search for small lesions or, if the microadenoma cannot be found, allowing excision of the half of the gland containing the tumor. In this study we correlated . . .