Departments of1Neurologic Surgery and.
2Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota.
J Neurosurg. 2023 Aug 11;140(2):386-392. doi: 10.3171/2023.6.JNS2320. Print 2024 Feb 1.
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.
岩下窦（IPS）取样（IPSS）是一种用于指导影像学阴性促肾上腺皮质激素（ACTH）分泌性垂体微腺瘤的诊断定位的诊断程序。然而，IPSS 在准确定位腺瘤方面的效果并不理想，降低了手术治愈率，并由于额外的探查导致了意外的垂体功能障碍。偶尔出现不精确的一个原因是存在连接 IPS 的双侧的额外岩下窦侧支通道，这可能导致在取样过程中出现错误的定位结果。本研究旨在探讨 IPS 血管结构的正常解剖变异与随后的 IPS 试验中获得的 ACTH 结果之间的潜在联系。
对 1998 年至 2013 年间在一家机构接受 IPS 治疗的影像学不确定垂体微腺瘤患者的所有病例进行回顾性分析。对手术或病理报告中记录的肿瘤侧别，以及 IPS 之间存在血管造影交叉充盈的证据进行了审查。此外，记录了右和左 IPS 在基础状态和促肾上腺皮质激素释放激素（CRH）给药后 2、5 和 10 分钟时的 ACTH 水平。对于每个患者，计算了最大反应（10 分钟）时测量的 ACTH 水平与初始反应（2 分钟）时测量的水平之间的变化的比值，并根据其血管造影交叉充盈状态对患者之间进行了比较。
共有 41 例经组织病理学证实的右侧或左侧 ACTH 分泌性垂体微腺瘤患者接受了术前 IPS。在这些患者中，28 例（68%）显示 IPS 之间存在血管造影交叉充盈，13 例无交叉充盈。平均而言，在有血管造影交叉充盈的患者中，对侧 IPS 中的 ACTH 水平增加了 3.91±0.77 倍，而无交叉充盈的患者中仅增加了 1.80±0.27 倍（p=0.014）。相比之下，在有交叉充盈的患者中，同侧 IPS 中的 ACTH 水平增加了 2.01±0.57 倍，而无交叉充盈的患者中增加了 8.78±7.30 倍（p=0.373）。
血管造影交叉充盈的存在，表明右和左 IPS 之间存在更大程度的血管通道网络，是影响 IPS 中 ACTH 变化率测量的重要因素，可能影响该测试在术前准确确定微腺瘤侧别的特异性。
