Pre-Procedure Planning

Inferior petrosal sinus sampling (IPSS) involves a team of radiology and laboratory technicians to interventional radiologists, endocrinologists, nurses, and anesthetists. Miller and Doppman have emphasized teamwork during the procedure with each member of the team performing their role.^[19]

Equipment

In addition to the microcatheters and other interventional radiology equipment, labeled red Vacutainers, EDTA Vacutainers, syringes, oCRH, hCRH, and heparin for infusion should be kept ready and rechecked prior to the start of the procedure.

Patient Preparation

If the patient is receiving aspirin, clopidogrel, metyrapone, and/or ketoconazole, these medications should be discontinued at least 5-7 days before the procedure, with prior consent of the physician who prescribed them.

The patient’s coagulation profile, full blood cell count, blood urea, and electrolytes are checked a day prior to the procedure.

The patient’s blood type is checked, and blood is saved in case a blood transfusion is required during the procedure.

The patient should be kept fasting for at least 4 hours prior to the procedure.

The patient’s groin should be shaved and prepared.

Monitoring & Follow-up

The patient is cautioned against moving his or her limbs for a few hours after the procedure and is prescribed analgesics, if required.

Technique

Raff H. Cushing syndrome: update on testing. Endocrinol Metab Clin North Am. 2015 Mar. 44 (1):43-50. [QxMD MEDLINE Link].
Bansal V, El Asmar N, Selman WR, Arafah BM. Pitfalls in the diagnosis and management of Cushing's syndrome. Neurosurg Focus. 2015 Feb. 38 (2):E4. [QxMD MEDLINE Link].
Prabhu NK, Moorthy S, Sreekumar KP, Nair V, Kumar H, Pillai AK. Indian Journal of Radiology and Imaging. 2002. 12 (1):13—20.
Newell-Price J, Trainer P, Besser M, Grossman A. The diagnosis and differential diagnosis of Cushing's syndrome and pseudo-Cushing's states. Endocr Rev. 1998 Oct. 19(5):647-72. [QxMD MEDLINE Link].
Law M, Wang R, Liu CJ, Shiroishi MS, Carmichael JD, Mack WJ, et al. Value of pituitary gland MRI at 7 T in Cushing's disease and relationship to inferior petrosal sinus sampling: case report. J Neurosurg. 2018 Mar 23. 23:1-5. [QxMD MEDLINE Link].
Raghuram K, Durgam A, Sartin S. Assessment of the Inferior Petrosal Sinus on T1-Weighted Contrast-Enhanced Magnetic Resonance Imaging. J Clin Imaging Sci. 2018. 8:22. [QxMD MEDLINE Link]. [Full Text].
Corrigan DF, Schaaf M, Whaley RA, Czerwinski CL, Earll JM. Selective venous sampling to differentiate ectopic ACTH secretion from pituitary Cushing's syndrome. N Engl J Med. 1977 Apr 14. 296(15):861-2. [QxMD MEDLINE Link].
Radvany MG, Quinones-Hinojosa A, Gallia GL, Wand GS, Salvatori R. VENOUS SAMPLING FOR CUSHING DISEASE: COMPARISON OF INTERNAL JUGULAR VEIN AND INFERIOR PETROSAL SINUS SAMPLING. Endocr Pract. 2016 Sep. 22 (9):1057-61. [QxMD MEDLINE Link].
Shaikh ST, Karmarkar VS, Deopujari CE. Pediatric Cushing's Disease: Dichotomy in Lateralization between Imaging and Inferior Petrosal Sinus Sampling with Review of Literature. J Pediatr Neurosci. 2017 Oct-Dec. 12 (4):349-352. [QxMD MEDLINE Link].
Kakade HR, Kasaliwal R, Jagtap VS, et al. Ectopic ACTH-Secreting Syndrome: A Single-Center Experience. Endocr Pract. 2013 Nov-Dec. 19(6):1007-14. [QxMD MEDLINE Link].
Doppman JL, Oldfield E, Krudy AG, Chrousos GP, Schulte HM, Schaaf M. Petrosal sinus sampling for Cushing syndrome: anatomical and technical considerations. Work in progress. Radiology. 1984 Jan. 150(1):99-103. [QxMD MEDLINE Link].
Oldfield EH, Doppman JL, Nieman LK, Chrousos GP, Miller DL, Katz DA. Petrosal sinus sampling with and without corticotropin-releasing hormone for the differential diagnosis of Cushing's syndrome. N Engl J Med. 1991 Sep 26. 325(13):897-905. [QxMD MEDLINE Link].
Nieman LK, Cutler GB Jr, Oldfield EH, Loriaux DL, Chrousos GP. The ovine corticotropin-releasing hormone (CRH) stimulation test is superior to the human CRH stimulation test for the diagnosis of Cushing's disease. J Clin Endocrinol Metab. 1989 Jul. 69(1):165-9. [QxMD MEDLINE Link].
Graham KE, Samuels MH, Nesbit GM, Cook DM, O'Neill OR, Barnwell SL. Cavernous sinus sampling is highly accurate in distinguishing Cushing's disease from the ectopic adrenocorticotropin syndrome and in predicting intrapituitary tumor location. J Clin Endocrinol Metab. 1999 May. 84(5):1602-10. [QxMD MEDLINE Link].
Teramoto A, Nemoto S, Takakura K, Sasaki Y, Machida T. Selective venous sampling directly from cavernous sinus in Cushing's syndrome. J Clin Endocrinol Metab. 1993 Mar. 76(3):637-41. [QxMD MEDLINE Link].
Lefournier V, Martinie M, Vasdev A, Bessou P, Passagia JG, Labat-Moleur F. Accuracy of bilateral inferior petrosal or cavernous sinuses sampling in predicting the lateralization of Cushing's disease pituitary microadenoma: influence of catheter position and anatomy of venous drainage. J Clin Endocrinol Metab. 2003 Jan. 88(1):196-203. [QxMD MEDLINE Link].
Ilias I, Chang R, Pacak K, Oldfield EH, Wesley R, Doppman J. Jugular venous sampling: an alternative to petrosal sinus sampling for the diagnostic evaluation of adrenocorticotropic hormone-dependent Cushing's syndrome. J Clin Endocrinol Metab. 2004 Aug. 89(8):3795-800. [QxMD MEDLINE Link].
Oklu R, Deipolyi AR, Wicky S, et al. Identification of small compound biomarkers of pituitary adenoma: a bilateral inferior petrosal sinus sampling study. J Neurointerv Surg. 2013 Sep 4. [QxMD MEDLINE Link].
Miller DL, Doppman JL. Petrosal sinus sampling: technique and rationale. Radiology. 1991 Jan. 178(1):37-47. [QxMD MEDLINE Link].
Utz A, Biller BM. The role of bilateral inferior petrosal sinus sampling in the diagnosis of Cushing's syndrome. Arq Bras Endocrinol Metabol. 2007 Nov. 51(8):1329-38. [QxMD MEDLINE Link].
Shiu PC, Hanafee WN, Wilson GH, Rand RW. Cavernous sinus venography. Am J Roentgenol Radium Ther Nucl Med. 1968 Sep. 104(1):57-62. [QxMD MEDLINE Link].
Mamelak A,Dowd C, Tyrell J, McDonald J, Wilson C. Venous angiography is needed to interpret inferior petrosal sinus and cavernous sinus sampling data for lateralising adrenocorticotropin-secreting adenomas. J. Clin. Endocrinol Metab 1996: 81: 475-81. Venous angiography is needed to interpret inferior petrosal sinus and cavernous sinus sampling data for lateralising adrenocorticotropin-secreting adenomas. J. Clin. Endocrinol Metab. 1996. 81:475-81.
Doppman JL, Chang R, Oldfield EH, Chrousos G, Stratakis CA, Nieman LK. The hypoplastic inferior petrosal sinus. A potential source of false negative results in petrosal sampling for Cushing’s disease. J. Clin Endocrinol Metab. 1999. 84:53-40.
Bonelli FS, Huston J 3rd, Carpenter PC, Erickson D, Young WF Jr, Meyer FB. Adrenocorticotropic hormone-dependent Cushing's syndrome: sensitivity and specificity of inferior petrosal sinus sampling. AJNR Am J Neuroradiol. 2000 Apr. 21(4):690-6. [QxMD MEDLINE Link].
Booth GL, Redelmeier DA, Grosman H, Kovacs K, Smyth HS, Ezzat S. Improved diagnostic accuracy of inferior petrosal sinus sampling over imaging for localizing pituitary pathology in patients with Cushing's disease. J Clin Endocrinol Metab. 1998 Jul. 83(7):2291-5. [QxMD MEDLINE Link].
Wind JJ, Lonser RR, Nieman LK, DeVroom HL, Chang R, Oldfield EH. The lateralization accuracy of inferior petrosal sinus sampling in 501 patients with Cushing's disease. J Clin Endocrinol Metab. 2013 Jun. 98(6):2285-93. [QxMD MEDLINE Link]. [Full Text].
Sharma ST, Nieman LK. Is Prolactin Measurement of Value during Inferior Petrosal Sinus Sampling in Patients with ACTH-dependent Cushing's Syndrome?. J Endocrinol Invest. 2013 Jul 26. [QxMD MEDLINE Link].
Jarial KDS, Bhansali A, Gupta V, Singh P, Mukherjee KK, Sharma A, et al. Diagnostic accuracy and comparison of BIPSS in response to lysine vasopressin and hCRH. Endocr Connect. 2018 Mar. 7 (3):425-432. [QxMD MEDLINE Link].
Kotwal N, Kumar Y, Upreti V, Singh A, Garg MK. Bilateral inferior petrosal sinus sampling using vasopressin. Indian J Endocrinol Metab. 2016 May-Jun. 20 (3):399-403. [QxMD MEDLINE Link].
Feng M, Liu Z, Liu X, Zhang X, Bao X, Yao Y, et al. Tumour lateralization in Cushing's disease by inferior petrosal sinus sampling with desmopressin. Clin Endocrinol (Oxf). 2018 Feb. 88 (2):251-257. [QxMD MEDLINE Link].
Diez JJ, Iglesias P. Pulmonary thromboembolism after inferior petrosal sinus sampling in Cushing's syndrome. Clin Endocrinol (Oxf). 1997 Jun. 46(6):777. [QxMD MEDLINE Link].
Obuobie K, Davies JS, Ogunko A, Scanlon MF. Venous thrombo-embolism following inferior petrosal sinus sampling in Cushing's disease. J Endocrinol Invest. 2000 Sep. 23(8):542-4. [QxMD MEDLINE Link].
Sturrock ND, Jeffcoate WJ. A neurological complication of inferior petrosal sinus sampling during investigation for Cushing's disease: a case report. J Neurol Neurosurg Psychiatry. 1997 May. 62(5):527-8. [QxMD MEDLINE Link].
Lefournier V, Gatta B, Martinie M, Vasdev A, Tabarin A, Bessou P. One transient neurological complication (sixth nerve palsy) in 166 consecutive inferior petrosal sinus samplings for the etiological diagnosis of Cushing's syndrome. J Clin Endocrinol Metab. 1999 Sep. 84(9):3401-2. [QxMD MEDLINE Link].
Vassiliadi DA, Mourelatos P, Kratimenos T, Tsagarakis S. Inferior petrosal sinus sampling in Cushing's syndrome: usefulness and pitfalls. Endocrine. 2021 Sep. 73 (3):530-539. [QxMD MEDLINE Link].