Inferior petrosal sinus sampling in the diagnostic evaluation of Cushing's syndrome: K.E.M. experience.

INTRODUCTION: An overlap in the clinical and biochemical features of the more common pituitary Cushing's disease and the rare ectopic ACTH secreting tumors often leads to a diagnostic dilemma. High quality computed imaging modalities have a poor sensitivity and do not always help in localising the tumor. Inferior petrosal sinus sampling (IPSS) with measurement of ACTH levels localizes the source of excess ACTH secretion and aids in the differential diagnosis of ACTH dependant Cushing's syndrome. AIMS AND OBJECTIVES: To analyze the efficacy of inferior petrosal sinus sampling in the basal state and its role in the diagnostic evaluation in patients of Cushing's syndrome. MATERIAL AND METHODS: Forty four patients of proven Cushing's syndrome underwent HDDS and pituitary imaging followed by IPSS (unstimulated). The data was analysed in 39 patients with definite histopathological diagnosis which included 34 patients with Cushing's disease, four with ectopic Cushing's syndrome and one with adrenal carcinoma. A centre:periphery ratio of plasma ACTH levels of > or =2 was considered diagnostic of Cushing's disease. RESULTS: Cannulation rate was 100%. No neurological complications were encountered. IPSS could correctly localize the lesion in 23 of 34 patients of Cushing's disease (sensitivity: 67.6%). All patients of ectopic Cushing's syndrome and adrenal carcinoma had a ratio of <2 (specificity: 100%). IPSS helped in localization of the lesion and improved the diagnostic yield from 26.7% to 73.5%. CONCLUSIONS: IPSS helps in localization in patients of Cushing's syndrome with a diagnostic dilemma and should be carried out only in centers with suitable expertise.

Endovascular management of intracranial pial arterio-venous fistulas.

From 1996-2002 we treated 5 consecutive cases of pial fistula. There were 3 patients with a single hole-single channel pial fistula and two patients had a complex pial fistula. Three patients presented with intracerebral hematoma and had a focal neurological deficit. One patient presented with history of seizures and 1 patient had headache. The results of the treatment were analyzed both clinically and angiographically. The follow-up period ranged from 6 months to 6 years. All fistulas were treated with concentrated glue. The glue cast included the distal part of the feeding artery, A-V connection and the proximal part of the vein. Post-embolisation angiography showed complete occlusion of two single-hole fistulas and one complex pial A-V fistula and near total occlusion of one single-hole and one complex pial A-V fistula. Four patients had excellent clinical outcome. One patient with single-hole fistula had a hemorrhagic venous infarct resulting in transient hemiparesis.

Endovascular treatment of ruptured intradural ophthalmic artery aneurysm. A case report and literature review.

We present a unique case of ruptured intradural ophthalmic artery aneurysm in a young man who presented with subarachnoid hemorrhage. By endovascular technique we successfully excluded the aneurysm from the circulation with preservation of antegrade flow in the ophthalmic artery. The presenting features and the technique of the treatment are described with a review of the literature.

Heparin or local thrombolysis in the management of cerebral venous sinus thrombosis?

SUMMARY: Patients with acute cerebral venous sinus thrombosis treated with Heparin or in situ thrombolysis in our department were evaluated in an attempt to rationalize treatment with heparin or thrombolysis. 279 patients with angiographically proven acute cerebral venous sinus thrombosis were included in the study. Patients were classified into mild and severe clinical grade. The study was divided into three phases. Phase I included 27 patients treated with systemic heparin. Phase II included 72 patients, 30 in severe grade and 42 in mild. 26 were thrombolysed with 14 in severe and 12 in mild grade. Phase III included 180 patients treated according to a defined protocol. 133 were in mild grade and 47 in severe. 67 patients were thrombolysed. In the thrombolysed group 27 patients were in mild grade and 40 in severe. 113 patients were treated with systemic heparin. Following acute management all were anticoagulated for six months. The baseline characteristics were found to be same in all three phases. On comparison of outcome in Phase III with Phase 1 the likelihood ratio was found to be statistically significant in favor of Phase III (p<0.0001). The likelihood ratio was found to be statistically significant in mild and severe clinical grade in favor of thrombolysis in Phase III (p 0.039 in mild and p 0.00001 in Severe clinical grade). This ratio was insignificant (p=0.716) for intracranial bleed; however, local puncture site bleeding was found to be significant in the thrombolysed group (0.00005).