Hunan Provincial Brain Hospital: Accurate diagnosis, pull out the rare "Cushing syndrome"

Multidisciplinary consultation.

Red Net Moment December 21 (Correspondent Zhang Yu Shi Rong) A few days ago, the Department of Endocrinology and Neurosurgery of Hunan Brain Hospital (Hunan Second People's Hospital) successfully carried out the hospital's first bilateral hypoglusal sinus vein blood collection technology (BIPSS), helping a patient with Cushing syndrome to accurately identify the location of the lesion and win the opportunity for treatment. This also marks that Hunan Brain Hospital has become one of the few hospitals in China that can carry out this technology, and is moving towards the leading level in the diagnosis and treatment of Cushing syndrome in China.

Ms. Liu (pseudonym), who lives in Changsha, Hunan Province, 60 years old this year, due to the increase in blood sugar for 3 years, fatigue, weight loss in April, aggravated for one week, recently visited the Department of Endocrinology of Hunan Brain Hospital. Xia Cui, the deputy chief physician who received the consultation, found that the patient had a full face, slender limbs, and obvious abdominal obesity, and performed relevant examinations, which showed that the patient not only had high blood sugar, but also had a series of metabolic disorders such as hypertension, hypokalemia, osteoporosis, and significantly elevated ACTH. Imaging examination: lung CT suggested nodular lesions, right kidney CT suggested: right kidney abnormal intensification lesions did not exclude tumor-like lesions, pituitary MRI suggested pituitary adenoma may occur.

According to the patient's clinical manifestations and related examinations, Xia Cui considered that these symptoms of the patient were caused by Cushing's syndrome, but the source of a large amount of ACTH secretion in the patient's body and the location of the lesion could not be determined.

Cushing syndrome is clinically manifested as a full moon face, buffalo back, multi-blood appearance, as well as purple streaks that can be seen in the body on examination, and concentric obesity and other clinical features.

The most common cause of Cushing's syndrome is Cushing's disease, which is an increase in cortisol caused by excessive hormone (ACTH) secreted by the pituitary gland; however, a small number of patients have ACTH from non-pituitary lesions, such as bronchial carcinoid carcinoma and small cell lung cancer. Therefore, it is important to determine the source of the patient's ACTH, which will directly affect the patient's treatment plan and prognosis.

In order to clarify the diagnosis, Zhang Haitao, director of the Department of Endocrinology, has repeatedly invited multidisciplinary experts from the first ward of neurosurgery in the hospital, neurosurgery, radiology, oncology, and urology to discuss difficult medical records. In the end, experts in various disciplines agreed that according to domestic and foreign guidelines and expert consensus, bilateral subligonal sinus vein blood collection (BIPSS) is the gold standard for the diagnosis of Cushing's disease when it is difficult to distinguish Cushing's disease or ectopic ACTH syndrome. The patient's condition is indicated for bilateral sub lithosal sinus vein blood collection.

Liu Kun, director of the Department of Neurosurgery in cerebrovascular diseases, introduced: The hypoglutic sinus is the dural sinus located in the lower margin of the rock cone behind the rock cone of the temporal bone. Anterior passage of the cavernous sinuses, in which the jugular venous superior ball or sigmoid sinus is injected into the jugular vein foramen. Blood in the hypoglutic sinuses is mainly returned by the pituitary gland, where blood sample specimens are taken to directly reflect the output of pituitary hormones, and by comparing the levels of adrenocorticotropic hormone (ACTH) in the sinuses and peripheral vein blood, a precise etiology and localization diagnosis of Cushing's syndrome can be made.

In order to make a clear diagnosis and accurately locate the lesion, it is imperative to collect blood from the sinuses under the rock. On December 17, 2021, with the active cooperation of patients and their families, the Department of Endocrinology, Neurosurgery of Cerebrovascular Disease, the Department of Interventional Medicine, the Department of Laboratory Medicine and other multi-departments joined forces to successfully conduct bilateral hypoglycemic sinus vein blood collection and desmopressin (DDAVP) stimulation test for patients, strictly achieving synchronous blood collection between the left and right hypoglia sinuses and peripherals, and the specimen specification preservation and rapid testing, and finally confirmed that ACTH originated from pituitary mass.

At present, the patient's vital signs are stable, and he is about to be transferred to neurosurgery for precise minimally invasive surgery to remove the lesion and achieve the purpose of cure.

Zhang Haitao said that bilateral hypoglyctic sinus blood collection (BIPSS) is a minimally invasive interventional operation technology, with small trauma, few side effects, fast recovery, and combined with desmopressin (DDAVP) stimulation test, the specificity of the examination results is high, the sensitivity is high, and it provides important medical evidence for the diagnosis and surgical treatment of Cushing's disease. However, the technology is more complex, and only a few general hospitals in China have the strength to carry out this technology. This time, the Department of Endocrinology and Neurosurgery and other departments of Hunan Brain Hospital successfully carried out this technology, marking the further improvement of the hospital's diagnosis and treatment capacity of secondary hypertension, Cushing syndrome and pituitary diseases, and also demonstrating the level of high-quality medical services jointly provided by the hospital's multidisciplinary cooperation, as well as further progress towards precision medicine.