- Email: [email protected]
Guidewire Breakage During Cavernous Sinus Sampling: A Rare Complication and Its Treatment
Accepted Manuscript Guidewire Breakage During Cavernous Sinus Sampling: A Rare Complication and Its Treatment Necmettin Tanriover, M.D., Baris Kucukyuruk, M.D., Saffet Tuzgen, M.D., Nil Comunoglu, M.D., Osman Kizilkilic, M.D., Nurperi Gazioglu, M.D. PII:
S1878-8750(17)31403-1
DOI:
10.1016/j.wneu.2017.08.102
Reference:
WNEU 6352
To appear in:
World Neurosurgery
Received Date: 9 May 2017 Revised Date:
12 August 2017
Accepted Date: 14 August 2017
Please cite this article as: Tanriover N, Kucukyuruk B, Tuzgen S, Comunoglu N, Kizilkilic O, Gazioglu N, Guidewire Breakage During Cavernous Sinus Sampling: A Rare Complication and Its Treatment, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.08.102. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Guidewire Breakage During Cavernous Sinus Sampling: A Rare Complication and Its Treatment
RI PT
Necmettin Tanriover, M.D. Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey. Email: [email protected]
Baris Kucukyuruk, M.D. Department of Neurosurgery, Cerrahpasa Faculty of Medicine,
SC
Istanbul University, Istanbul, Turkey. Email: [email protected]
Saffet Tuzgen, M.D. Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul
M AN U
University, Istanbul, Turkey. Email: [email protected]
Nil Comunoglu, M.D. Division of Neuropathology, Department of Pathology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey. Email: [email protected] Osman Kizilkilic, M.D. Division of Neuroradiology, Department of Radiology, Cerrahpasa
TE D
Faculty of Medicine, Istanbul University, Istanbul, Turkey. Email: [email protected] Nurperi Gazioglu, M.D. Department of Neurosurgery, Cerrahpasa Faculty of Medicine,
EP
Istanbul University, Istanbul, Turkey. Email: [email protected]
AC C
Correspondence to: Necmettin Tanriover
Adress: Cerrahpasa Tip Fakultesi. Beyin ve Sinir Cerrahisi ABD. Kocamustafapasa. Fatih. Istanbul. Turkey. 34198 Tel: +90 537 8998467 Email: [email protected]
ACCEPTED MANUSCRIPT Keywords: Cavernous sinus sampling, complication, Cushing’s disease, Endoscopic endonasal approach, skullbase endoscopy
BIPSS: bilateral inferior petrosal sinus sampling
SC
CD: Cushing’s disease
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EP
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MRI: magnetic resonance imaging
M AN U
CSS: cavernous sinus sampling CT: Computed tomography
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Abbreviations list:
ACCEPTED MANUSCRIPT Abstract: Background: Venous sampling methods are valuable tools for the diagnosis of pituitary adenomas. However, these interventions also have their complications, which may complicate
RI PT
the treatment process. Case Description: A forty-nine year old female pituitary adenoma patient with preliminary diagnosis of Cushing’s disease underwent cavernous sinus sampling (CSS) to delineate the
SC
adenoma. The micro guidewire broke during the procedure and the distal part of the micro guidewire had to be left within the right cavernous sinus. Eventually, the broken part of the
M AN U
guidewire was removed following the removal of the tumor through an endoscopic endonasal approach.
Conclusions: Current surgical experience on endoscopic skull base surgery allows management of diagnostic complications related to cavernous sinus, such as safe access to
AC C
EP
interventions.
TE D
materials which were inadvertently left during CSS without the necessity for further
ACCEPTED MANUSCRIPT Introduction: Venous sampling methods are valuable diagnostic tools in differential diagnosis of ACTH-dependent Cushing’s syndrome. However, they are prone to procedural complications
RI PT
due to their invasiveness. In this report, we present a patient with Cushing’s disease (CD) investigated with cavernous sinus sampling (CSS), during which the guidewire was broken within the cavernous sinus. We present the treatment of this rare complication and discuss the
SC
safety of the CSS through this case. Case report:
M AN U
A forty-nine year old female patient was investigated due to new onset drug resistant hypertension. Computed tomography (CT) of abdomen showed adrenal hyperplasia. Blood biochemical panels proved Cushing’s syndrome, which was further investigated with magnetic resonance imaging (MRI), which showed a pituitary tumor (figure 1). At the time of
TE D
admission, the patient did not present with any of the classical features of CD, apart being overweight,. Her physical examination showed no neurological deficit. With the preliminary diagnosis of an ACTH secreting adenoma or an incidentaloma, the patient underwent a CSS
EP
during which the guidewire was broken and a large piece had to be left within the cavernous sinus (figure 2). The result of the CSS revealed an ACTH secreting adenoma. The patient was
AC C
operated via endoscopic endonasal transsphenoidal route. After the removal of the soft and gray-colored tumor, the guidewire was identified embedded in the medial wall of the right cavernous sinus and was removed with the help of fine micro dissectors and forceps (figure 3 and supplementary electronic video file). On postoperative examination, there were no vascular or neurological deficits. Histopathological examination proved the diagnosis of CD and sella MRI at postoperative 3rd month showed total removal of the tumor (figure 4). Discussion:
ACCEPTED MANUSCRIPT ACTH-dependent causes, which form clinical features in four of 5 patients with endogenous Cushing’s syndrome, are due to pituitary CD in 80% of patients and ectopic secretion of ACTH in 20% 1, 2. Mainstay treatment of CD is surgical removal of the causative ACTH-secreting adenoma. On the other hand, treatment options for ectopic secretion of
RI PT
ACTH vary by the origin of the causative lesion, which may be a small-cell carcinoma of the lung, bronchial carcinoid tumor, or any other endocrine tumor 2. Therefore, differentiating between these two entities is of the utmost importance. However, none of the noninvasive
SC
biochemical tests has ensured 100% diagnostic accuracy in large series 1.
Another challenge in this patient group is identifying the pituitary lesion. Conventional
M AN U
neuroradiological imaging techniques such as CT and MRI have poor sensitivity and specificity; a lesion may be not be detected up to 40%–50% of CD cases 3. Moreover, presence of an incidentaloma, a possibly nonfunctional pituitary lesion that may show up in 10% of normal population, may complicate the diagnosis and correct lateralization of the
TE D
tumor within the pituitary gland, as suspected in our case preoperatively
2, 3
.
Venous sampling methods have been useful in solving these diagnostic dilemmas 3. In
EP
our clinic, 536 pituitary adenoma patients were operated via fully endoscopic endonasal route between September 2007 and November 2016, and 95 were diagnosed as CD after
AC C
postoperative histopathological examination. Forty-four CD patients (46.3%) underwent venous sampling procedures due to uncertain localization or lateralization. In a large review of clinical series, Newell-Price et al. reported bilateral inferior petrosal sinus sampling (BIPSS) had 96% sensitivity and 100% specificity in differentiating CD from ectopic secretion of ACTH 4. Other studies stated similar success rates, 90% to 100% sensitivity and specificity, for BIPSS 5-8. However, BIPSS has been theoretically criticized in its ability to localize the tumor within the pituitary gland, which has been attributed to asymmetric shunting of the pituitary venous drainage toward the dominant side 8-11. Moreover, Lin et al.
ACCEPTED MANUSCRIPT stated that BIPPS may provide unsatisfactory lateralization in patients who undergone pituitary surgery previously 12. CSS has been described as an alternative method that collects the sample anatomically closer to the pituitary gland and therefore may provide superior lateralization compared to
RI PT
BIPSS 3, 13, 14. However, some authors suggested that advancing guidewires into the more distally located cavernous sinus may be technically more difficult and may carry greater risk of complications compared to BIPSS 8, 9.
SC
Since BIPPS is more widely used in clinical series in the literature than CSS,
M AN U
comparison of complication rates of two procedures is not suitable. However, current literature suggests that BIPPS is not free from complications: venous subarachnoid hemorrhage, venous thrombo-embolism, brainstem infarction, pontine-hemorrhage have been reported 15-18. On the other hand, in limited number of articles, CSS was reported to be safe with no or minimal complications without any permanent deficits. Graham et al. reported a
TE D
series of ninety-three patients underwent CSS and described no complications 9. Lefournier et al. reported two transient 6th cranial nerve palsies, which were stated to be due to relatively
EP
longer time spent in cavernous sinuses during their procedures 19. In our case, breakage of the micro guidewire probably occurred due to the aggressive
AC C
manipulation of the material to advance the guidewire through tight septae within the cavernous sinus. The medial wall of the cavernous sinus might have been pierced by the micro guidewire tip and manipulation to remove it may have caused the breakage. Tomycz and Horowitz pointed out that handling the catheter within a distally located sinus is technically more difficult 8, which may also have a role in our case. Interventional neuroradiologists are already familiar with leaving metallic materials within the cavernous sinus in the treatment of carotid-cavernous fistulas without any serious
ACCEPTED MANUSCRIPT complications. The breakage of the guidewire did not cause any complications for our case. Therefore, no emergent surgery was indicated and removal of the broken guidewire was performed at the same operation with the tumor resection. Angled endoscopic view promoted
AC C
EP
TE D
M AN U
SC
any neurological or vascular complications.
RI PT
safe removal of the guidewire from the medial wall of the cavernous sinus without causing
ACCEPTED MANUSCRIPT References
1.
Lau JH, Drake W, Matson M. The current role of venous sampling in the localization
2.
Newell-Price J, Bertagna X, Grossman AB, Nieman LK. Cushing's syndrome. Lancet. May 13 2006;367(9522):1605-1617.
Gazioglu N, Ulu MO, Ozlen F, et al. Management of Cushing's disease using
SC
3.
RI PT
of endocrine disease. Cardiovasc Intervent Radiol. Jul-Aug 2007;30(4):555-570.
M AN U
cavernous sinus sampling: effectiveness in tumor lateralization. Clin Neurol Neurosurg. Apr 2008;110(4):333-338.
4.
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. Oct
5.
TE D
1998;19(5):647-672.
Invitti C, Pecori Giraldi F, Cavagnini F. Inferior petrosal sinus sampling in patients
EP
with Cushing's syndrome and contradictory responses to dynamic testing. Clin
6.
AC C
Endocrinol (Oxf). Aug 1999;51(2):255-257.
Colao A, Faggiano A, Pivonello R, Pecori Giraldi F, Cavagnini F, Lombardi G. Inferior petrosal sinus sampling in the differential diagnosis of Cushing's syndrome: results of an Italian multicenter study. Eur J Endocrinol. May 2001;144(5):499-507.
7.
Hernandez I, Espinosa-de-los-Monteros AL, Mendoza V, et al. Ectopic ACTHsecreting syndrome: a single center experience report with a high prevalence of occult tumor. Arch Med Res. Nov 2006;37(8):976-980.
ACCEPTED MANUSCRIPT 8.
Tomycz ND, Horowitz MB. Inferior petrosal sinus sampling in the diagnosis of sellar neuropathology. Neurosurg Clin N Am. Jul 2009;20(3):361-367.
9.
Graham KE, Samuels MH, Nesbit GM, et al. Cavernous sinus sampling is highly
RI PT
accurate in distinguishing Cushing's disease from the ectopic adrenocorticotropin syndrome and in predicting intrapituitary tumor location. J Clin Endocrinol Metab. May 1999;84(5):1602-1610.
Findling JW, Aron DC, Tyrrell JB, et al. Selective venous sampling for ACTH in
SC
10.
M AN U
Cushing's syndrome: differentiation between Cushing disease and the ectopic ACTH syndrome. Ann Intern Med. May 1981;94(5):647-652.
11.
Booth GL, Redelmeier DA, Grosman H, Kovacs K, Smyth HS, Ezzat S. Improved diagnostic accuracy of inferior petrosal sinus sampling over imaging for localizing
TE D
pituitary pathology in patients with Cushing's disease. J Clin Endocrinol Metab. Jul 1998;83(7):2291-2295.
Lin LY, Teng MM, Huang CI, et al. Assessment of bilateral inferior petrosal sinus
EP
12.
sampling (BIPSS) in the diagnosis of Cushing's disease. J Chin Med Assoc. Jan
13.
AC C
2007;70(1):4-10.
Fujimura M, Ikeda H, Takahashi A, Ezura M, Yoshimoto T, Tominaga T. Diagnostic value of super-selective bilateral cavernous sinus sampling with hypothalamic stimulating hormone loading in patients with ACTH-producing pituitary adenoma. Neurol Res. Jan 2005;27(1):11-15.
ACCEPTED MANUSCRIPT 14.
Liu C, Lo JC, Dowd CF, et al. Cavernous and inferior petrosal sinus sampling in the evaluation of ACTH-dependent Cushing's syndrome. Clin Endocrinol (Oxf). Oct 2004;61(4):478-486.
Bonelli FS, Huston J, 3rd, Meyer FB, Carpenter PC. Venous subarachnoid
RI PT
15.
hemorrhage after inferior petrosal sinus sampling for adrenocorticotropic hormone. AJNR Am J Neuroradiol. Feb 1999;20(2):306-307.
Obuobie K, Davies JS, Ogunko A, Scanlon MF. Venous thrombo-embolism following
SC
16.
2000;23(8):542-544.
17.
M AN U
inferior petrosal sinus sampling in Cushing's disease. J Endocrinol Invest. Sep
Gandhi CD, Meyer SA, Patel AB, Johnson DM, Post KD. Neurologic complications
18.
TE D
of inferior petrosal sinus sampling. AJNR Am J Neuroradiol. Apr 2008;29(4):760-765.
Miller DL, Doppman JL, Peterman SB, Nieman LK, Oldfield EH, Chang R. Neurologic complications of petrosal sinus sampling. Radiology. Oct
Lefournier V, Martinie M, Vasdev A, et al. Accuracy of bilateral inferior petrosal or
AC C
19.
EP
1992;185(1):143-147.
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. Jan 2003;88(1):196-203.
ACCEPTED MANUSCRIPT Acknowledgement: Possible conflicts of interest, sources of financial support, corporate involvement, patent
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EP
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M AN U
SC
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holdings, etc. do not exist.
ACCEPTED MANUSCRIPT Figure Legend: Figure 1: Preoperative magnetic resonance imaging revealed a pituitary lesion adjacent to the right cavernous sinus with minimal suprasellar extension in size of 14x13x11 mm. The lesion was hyperintense on coronal T2-weighted images (A), and hypointense on coronal (B and C)
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and sagittal (D-F) T1-weighted images after Gadolinium administration.
Figure 2: Computed tomography following cavernous sinus sampling. Coronal sections from
SC
the level of the sphenoid sinus to the clivus (A-D), axial view (E), and sagittal sections (F-H) showed the remaining catheter tip in the right cavernous sinus. (*: sphenoid sinus)
M AN U
Figure 3: Intraoperative view. A. Removal of the tumor after the opening of the dura. B. The catheter embedded to the medial wall of the right cavernous sinus. C and D. Removal of the catheter with endoscopic forceps.
Figure 4: Magnetic resonance imaging at three months after surgery. A and B. Magnetic
TE D
resonance imaging at third month postoperatively revealed total removal of the tumor. C. Histopathological image. Pituitary adenoma cells. Hematoxylin and eosin staining.
AC C
EP
Magnification x400. D. ACTH immunpositive cells. ACTH stain. Magnification x400.
Legend for Supplementary Digital Content Video
00.00: View of inferior, middle and superior turbinates, sphenoid ostium and choana through right nostril.
00.05: View of Eustachian tube orifice through right nostril. 00.17: Opening of the sellar duramater 00.24: Removal of the tumor
ACCEPTED MANUSCRIPT 00.31: View of micro guidewire within the right cavernous sinus (view from 30 degree
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EP
TE D
M AN U
SC
RI PT
endoscope)
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
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ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Highlights: Venous sampling methods are valuable diagnostic tools in the treatment of pituitary adenomas. However, their use risks facing medical teams with complications.
AC C
EP
TE D
M AN U
SC
RI PT
Current surgical experience on endoscopic skull base surgery allows handling some of these complications of cavernous sinus sampling methods.
S1878-8750(17)31403-1
DOI:
10.1016/j.wneu.2017.08.102
Reference:
WNEU 6352
To appear in:
World Neurosurgery
Received Date: 9 May 2017 Revised Date:
12 August 2017
Accepted Date: 14 August 2017
Please cite this article as: Tanriover N, Kucukyuruk B, Tuzgen S, Comunoglu N, Kizilkilic O, Gazioglu N, Guidewire Breakage During Cavernous Sinus Sampling: A Rare Complication and Its Treatment, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.08.102. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Guidewire Breakage During Cavernous Sinus Sampling: A Rare Complication and Its Treatment
RI PT
Necmettin Tanriover, M.D. Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey. Email: [email protected]
Baris Kucukyuruk, M.D. Department of Neurosurgery, Cerrahpasa Faculty of Medicine,
SC
Istanbul University, Istanbul, Turkey. Email: [email protected]
Saffet Tuzgen, M.D. Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul
M AN U
University, Istanbul, Turkey. Email: [email protected]
Nil Comunoglu, M.D. Division of Neuropathology, Department of Pathology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey. Email: [email protected] Osman Kizilkilic, M.D. Division of Neuroradiology, Department of Radiology, Cerrahpasa
TE D
Faculty of Medicine, Istanbul University, Istanbul, Turkey. Email: [email protected] Nurperi Gazioglu, M.D. Department of Neurosurgery, Cerrahpasa Faculty of Medicine,
EP
Istanbul University, Istanbul, Turkey. Email: [email protected]
AC C
Correspondence to: Necmettin Tanriover
Adress: Cerrahpasa Tip Fakultesi. Beyin ve Sinir Cerrahisi ABD. Kocamustafapasa. Fatih. Istanbul. Turkey. 34198 Tel: +90 537 8998467 Email: [email protected]
ACCEPTED MANUSCRIPT Keywords: Cavernous sinus sampling, complication, Cushing’s disease, Endoscopic endonasal approach, skullbase endoscopy
BIPSS: bilateral inferior petrosal sinus sampling
SC
CD: Cushing’s disease
AC C
EP
TE D
MRI: magnetic resonance imaging
M AN U
CSS: cavernous sinus sampling CT: Computed tomography
RI PT
Abbreviations list:
ACCEPTED MANUSCRIPT Abstract: Background: Venous sampling methods are valuable tools for the diagnosis of pituitary adenomas. However, these interventions also have their complications, which may complicate
RI PT
the treatment process. Case Description: A forty-nine year old female pituitary adenoma patient with preliminary diagnosis of Cushing’s disease underwent cavernous sinus sampling (CSS) to delineate the
SC
adenoma. The micro guidewire broke during the procedure and the distal part of the micro guidewire had to be left within the right cavernous sinus. Eventually, the broken part of the
M AN U
guidewire was removed following the removal of the tumor through an endoscopic endonasal approach.
Conclusions: Current surgical experience on endoscopic skull base surgery allows management of diagnostic complications related to cavernous sinus, such as safe access to
AC C
EP
interventions.
TE D
materials which were inadvertently left during CSS without the necessity for further
ACCEPTED MANUSCRIPT Introduction: Venous sampling methods are valuable diagnostic tools in differential diagnosis of ACTH-dependent Cushing’s syndrome. However, they are prone to procedural complications
RI PT
due to their invasiveness. In this report, we present a patient with Cushing’s disease (CD) investigated with cavernous sinus sampling (CSS), during which the guidewire was broken within the cavernous sinus. We present the treatment of this rare complication and discuss the
SC
safety of the CSS through this case. Case report:
M AN U
A forty-nine year old female patient was investigated due to new onset drug resistant hypertension. Computed tomography (CT) of abdomen showed adrenal hyperplasia. Blood biochemical panels proved Cushing’s syndrome, which was further investigated with magnetic resonance imaging (MRI), which showed a pituitary tumor (figure 1). At the time of
TE D
admission, the patient did not present with any of the classical features of CD, apart being overweight,. Her physical examination showed no neurological deficit. With the preliminary diagnosis of an ACTH secreting adenoma or an incidentaloma, the patient underwent a CSS
EP
during which the guidewire was broken and a large piece had to be left within the cavernous sinus (figure 2). The result of the CSS revealed an ACTH secreting adenoma. The patient was
AC C
operated via endoscopic endonasal transsphenoidal route. After the removal of the soft and gray-colored tumor, the guidewire was identified embedded in the medial wall of the right cavernous sinus and was removed with the help of fine micro dissectors and forceps (figure 3 and supplementary electronic video file). On postoperative examination, there were no vascular or neurological deficits. Histopathological examination proved the diagnosis of CD and sella MRI at postoperative 3rd month showed total removal of the tumor (figure 4). Discussion:
ACCEPTED MANUSCRIPT ACTH-dependent causes, which form clinical features in four of 5 patients with endogenous Cushing’s syndrome, are due to pituitary CD in 80% of patients and ectopic secretion of ACTH in 20% 1, 2. Mainstay treatment of CD is surgical removal of the causative ACTH-secreting adenoma. On the other hand, treatment options for ectopic secretion of
RI PT
ACTH vary by the origin of the causative lesion, which may be a small-cell carcinoma of the lung, bronchial carcinoid tumor, or any other endocrine tumor 2. Therefore, differentiating between these two entities is of the utmost importance. However, none of the noninvasive
SC
biochemical tests has ensured 100% diagnostic accuracy in large series 1.
Another challenge in this patient group is identifying the pituitary lesion. Conventional
M AN U
neuroradiological imaging techniques such as CT and MRI have poor sensitivity and specificity; a lesion may be not be detected up to 40%–50% of CD cases 3. Moreover, presence of an incidentaloma, a possibly nonfunctional pituitary lesion that may show up in 10% of normal population, may complicate the diagnosis and correct lateralization of the
TE D
tumor within the pituitary gland, as suspected in our case preoperatively
2, 3
.
Venous sampling methods have been useful in solving these diagnostic dilemmas 3. In
EP
our clinic, 536 pituitary adenoma patients were operated via fully endoscopic endonasal route between September 2007 and November 2016, and 95 were diagnosed as CD after
AC C
postoperative histopathological examination. Forty-four CD patients (46.3%) underwent venous sampling procedures due to uncertain localization or lateralization. In a large review of clinical series, Newell-Price et al. reported bilateral inferior petrosal sinus sampling (BIPSS) had 96% sensitivity and 100% specificity in differentiating CD from ectopic secretion of ACTH 4. Other studies stated similar success rates, 90% to 100% sensitivity and specificity, for BIPSS 5-8. However, BIPSS has been theoretically criticized in its ability to localize the tumor within the pituitary gland, which has been attributed to asymmetric shunting of the pituitary venous drainage toward the dominant side 8-11. Moreover, Lin et al.
ACCEPTED MANUSCRIPT stated that BIPPS may provide unsatisfactory lateralization in patients who undergone pituitary surgery previously 12. CSS has been described as an alternative method that collects the sample anatomically closer to the pituitary gland and therefore may provide superior lateralization compared to
RI PT
BIPSS 3, 13, 14. However, some authors suggested that advancing guidewires into the more distally located cavernous sinus may be technically more difficult and may carry greater risk of complications compared to BIPSS 8, 9.
SC
Since BIPPS is more widely used in clinical series in the literature than CSS,
M AN U
comparison of complication rates of two procedures is not suitable. However, current literature suggests that BIPPS is not free from complications: venous subarachnoid hemorrhage, venous thrombo-embolism, brainstem infarction, pontine-hemorrhage have been reported 15-18. On the other hand, in limited number of articles, CSS was reported to be safe with no or minimal complications without any permanent deficits. Graham et al. reported a
TE D
series of ninety-three patients underwent CSS and described no complications 9. Lefournier et al. reported two transient 6th cranial nerve palsies, which were stated to be due to relatively
EP
longer time spent in cavernous sinuses during their procedures 19. In our case, breakage of the micro guidewire probably occurred due to the aggressive
AC C
manipulation of the material to advance the guidewire through tight septae within the cavernous sinus. The medial wall of the cavernous sinus might have been pierced by the micro guidewire tip and manipulation to remove it may have caused the breakage. Tomycz and Horowitz pointed out that handling the catheter within a distally located sinus is technically more difficult 8, which may also have a role in our case. Interventional neuroradiologists are already familiar with leaving metallic materials within the cavernous sinus in the treatment of carotid-cavernous fistulas without any serious
ACCEPTED MANUSCRIPT complications. The breakage of the guidewire did not cause any complications for our case. Therefore, no emergent surgery was indicated and removal of the broken guidewire was performed at the same operation with the tumor resection. Angled endoscopic view promoted
AC C
EP
TE D
M AN U
SC
any neurological or vascular complications.
RI PT
safe removal of the guidewire from the medial wall of the cavernous sinus without causing
ACCEPTED MANUSCRIPT References
1.
Lau JH, Drake W, Matson M. The current role of venous sampling in the localization
2.
Newell-Price J, Bertagna X, Grossman AB, Nieman LK. Cushing's syndrome. Lancet. May 13 2006;367(9522):1605-1617.
Gazioglu N, Ulu MO, Ozlen F, et al. Management of Cushing's disease using
SC
3.
RI PT
of endocrine disease. Cardiovasc Intervent Radiol. Jul-Aug 2007;30(4):555-570.
M AN U
cavernous sinus sampling: effectiveness in tumor lateralization. Clin Neurol Neurosurg. Apr 2008;110(4):333-338.
4.
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. Oct
5.
TE D
1998;19(5):647-672.
Invitti C, Pecori Giraldi F, Cavagnini F. Inferior petrosal sinus sampling in patients
EP
with Cushing's syndrome and contradictory responses to dynamic testing. Clin
6.
AC C
Endocrinol (Oxf). Aug 1999;51(2):255-257.
Colao A, Faggiano A, Pivonello R, Pecori Giraldi F, Cavagnini F, Lombardi G. Inferior petrosal sinus sampling in the differential diagnosis of Cushing's syndrome: results of an Italian multicenter study. Eur J Endocrinol. May 2001;144(5):499-507.
7.
Hernandez I, Espinosa-de-los-Monteros AL, Mendoza V, et al. Ectopic ACTHsecreting syndrome: a single center experience report with a high prevalence of occult tumor. Arch Med Res. Nov 2006;37(8):976-980.
ACCEPTED MANUSCRIPT 8.
Tomycz ND, Horowitz MB. Inferior petrosal sinus sampling in the diagnosis of sellar neuropathology. Neurosurg Clin N Am. Jul 2009;20(3):361-367.
9.
Graham KE, Samuels MH, Nesbit GM, et al. Cavernous sinus sampling is highly
RI PT
accurate in distinguishing Cushing's disease from the ectopic adrenocorticotropin syndrome and in predicting intrapituitary tumor location. J Clin Endocrinol Metab. May 1999;84(5):1602-1610.
Findling JW, Aron DC, Tyrrell JB, et al. Selective venous sampling for ACTH in
SC
10.
M AN U
Cushing's syndrome: differentiation between Cushing disease and the ectopic ACTH syndrome. Ann Intern Med. May 1981;94(5):647-652.
11.
Booth GL, Redelmeier DA, Grosman H, Kovacs K, Smyth HS, Ezzat S. Improved diagnostic accuracy of inferior petrosal sinus sampling over imaging for localizing
TE D
pituitary pathology in patients with Cushing's disease. J Clin Endocrinol Metab. Jul 1998;83(7):2291-2295.
Lin LY, Teng MM, Huang CI, et al. Assessment of bilateral inferior petrosal sinus
EP
12.
sampling (BIPSS) in the diagnosis of Cushing's disease. J Chin Med Assoc. Jan
13.
AC C
2007;70(1):4-10.
Fujimura M, Ikeda H, Takahashi A, Ezura M, Yoshimoto T, Tominaga T. Diagnostic value of super-selective bilateral cavernous sinus sampling with hypothalamic stimulating hormone loading in patients with ACTH-producing pituitary adenoma. Neurol Res. Jan 2005;27(1):11-15.
ACCEPTED MANUSCRIPT 14.
Liu C, Lo JC, Dowd CF, et al. Cavernous and inferior petrosal sinus sampling in the evaluation of ACTH-dependent Cushing's syndrome. Clin Endocrinol (Oxf). Oct 2004;61(4):478-486.
Bonelli FS, Huston J, 3rd, Meyer FB, Carpenter PC. Venous subarachnoid
RI PT
15.
hemorrhage after inferior petrosal sinus sampling for adrenocorticotropic hormone. AJNR Am J Neuroradiol. Feb 1999;20(2):306-307.
Obuobie K, Davies JS, Ogunko A, Scanlon MF. Venous thrombo-embolism following
SC
16.
2000;23(8):542-544.
17.
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inferior petrosal sinus sampling in Cushing's disease. J Endocrinol Invest. Sep
Gandhi CD, Meyer SA, Patel AB, Johnson DM, Post KD. Neurologic complications
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of inferior petrosal sinus sampling. AJNR Am J Neuroradiol. Apr 2008;29(4):760-765.
Miller DL, Doppman JL, Peterman SB, Nieman LK, Oldfield EH, Chang R. Neurologic complications of petrosal sinus sampling. Radiology. Oct
Lefournier V, Martinie M, Vasdev A, et al. Accuracy of bilateral inferior petrosal or
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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. Jan 2003;88(1):196-203.
ACCEPTED MANUSCRIPT Acknowledgement: Possible conflicts of interest, sources of financial support, corporate involvement, patent
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holdings, etc. do not exist.
ACCEPTED MANUSCRIPT Figure Legend: Figure 1: Preoperative magnetic resonance imaging revealed a pituitary lesion adjacent to the right cavernous sinus with minimal suprasellar extension in size of 14x13x11 mm. The lesion was hyperintense on coronal T2-weighted images (A), and hypointense on coronal (B and C)
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and sagittal (D-F) T1-weighted images after Gadolinium administration.
Figure 2: Computed tomography following cavernous sinus sampling. Coronal sections from
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the level of the sphenoid sinus to the clivus (A-D), axial view (E), and sagittal sections (F-H) showed the remaining catheter tip in the right cavernous sinus. (*: sphenoid sinus)
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Figure 3: Intraoperative view. A. Removal of the tumor after the opening of the dura. B. The catheter embedded to the medial wall of the right cavernous sinus. C and D. Removal of the catheter with endoscopic forceps.
Figure 4: Magnetic resonance imaging at three months after surgery. A and B. Magnetic
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resonance imaging at third month postoperatively revealed total removal of the tumor. C. Histopathological image. Pituitary adenoma cells. Hematoxylin and eosin staining.
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Magnification x400. D. ACTH immunpositive cells. ACTH stain. Magnification x400.
Legend for Supplementary Digital Content Video
00.00: View of inferior, middle and superior turbinates, sphenoid ostium and choana through right nostril.
00.05: View of Eustachian tube orifice through right nostril. 00.17: Opening of the sellar duramater 00.24: Removal of the tumor
ACCEPTED MANUSCRIPT 00.31: View of micro guidewire within the right cavernous sinus (view from 30 degree
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endoscope)
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ACCEPTED MANUSCRIPT Highlights: Venous sampling methods are valuable diagnostic tools in the treatment of pituitary adenomas. However, their use risks facing medical teams with complications.
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Current surgical experience on endoscopic skull base surgery allows handling some of these complications of cavernous sinus sampling methods.