Positive predictive value and trends of inferior petrosal sinus sampling (IPSS) in diagnosing cushing disease and ectopic ACTH secretion: A systematic review and meta-analysis

Govindarajan, Vaidya; Lu, Victor M.; Clarke, Jamie E.; Luther, Evan; Eichberg, Daniel G.; Morell, Alexis A.; Shah, Ashish H.; Starke, Robert M.; Kargi, Atil Y.; Komotar, Ricardo J.; Ivan, Michael E.

doi:10.1016/j.clineuro.2022.107350

Cited by 5 publications

(3 citation statements)

References 67 publications

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“…This study widens the scope of analysis of IPSS technique to consider both time and cost-efficiency balanced against maintaining acceptable diagnostic accuracy and also lends further credence to the emerging trend that DDAVP is equal or superior to CRH for IPSS. 7 DDAVP serves as a cost-efficient and time-saving alternative to CRH, while fewer time points may serve as time-efficient and cost-efficient alternatives. Though minimalistic, potentially as few as 2 time points can be used with reasonable diagnostic accuracy.…”

Section: Discussion Study Findings and Significancementioning

confidence: 99%

“…IPSS has been shown to have high accuracy for distinguishing between central and peripheral sources. 6,7 The conventional protocol for IPSS involves administration of either corticotropic-releasing hormone (CRH) or desmopressin (DDAVP) at a time point defined as t = 0 minutes (min) as well as multiple prestimulation and poststimulation measurements, whose timing may slightly vary according to institutional convention. 8 A central diagnosis is suspected by an inferior petrosal sinus (IPS) to peripheral ACTH ratio of greater than 2 prestimulation or greater than 3 poststimulation.…”

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confidence: 99%

“…9 This work investigates the sensitivity of simplified IPSS protocols to detect CD with fewer time points. Motivated by the persisting manufacturing shortages of CRH 10,11 and mounting data showing the effectiveness of desmopressin as a substitute for ACTH stimulation, 7,12,13 we investigate the sensitivity of CD diagnosis by stimulator. Finally, this work investigates the economic savings of potentially simplified IPSS protocols with fewer time points.…”

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confidence: 99%

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Toward Optimized and Cost-Efficient Protocols for Inferior Petrosal Sinus Sampling in the Diagnosis of Cushing Disease

Abdallah,

Gersey,

Plute

et al. 2023

Neurosurgery

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BACKGROUND AND OBJECTIVE: Conventional protocols for inferior petrosal sinus sampling (IPSS) during the workup of hypercortisolemia require adrenocorticotrophic hormone (ACTH) measurement at multiple time points with corticotropic-releasing hormone (CRH) used as a stimulator. Modernized evidence-based protocols must also reflect the increased utilization of desmopressin (DDAVP) for ACTH stimulation as the manufacturing shortage of traditionally used CRH continues. We model the diagnostic accuracy and potential economic savings of DDAVP utilization and reduced time point sampling. METHODS: A single-institution, retrospective review of patients undergoing IPSS between 2007 and 2021 was performed. A computational search for the minimal set of time points which preserves conventional diagnostic accuracy was performed by testing all 1 through 5-point combinations generated using a binomial expansion. Economic savings were modeled using a publicly available hospital chargemaster. RESULTS: A total of 50 patients qualified for inclusion, 47 of whom were diagnosed with Cushing disease and 3 with ectopic Cushing syndrome. Single-point diagnostic accuracy for DDAVP-stimulated tests was 71.4%–92.9%, and seven 2-point combinations (5-25 procedural minutes) were found, which preserved conventional diagnostic accuracy. Single-point accuracy for CRH-stimulated tests was 67.9%–89.3%, and two 2-point combinations (t = −15, t = +2 and t = −15, t = +10) preserved accuracy. For every time point removed, the cost of ACTH laboratory tests was reduced by $507 from $3042 for 6-point IPSS). The shortest and most economical stimulator and time point combination that preserved conventional accuracy was DDAVP sampling at t = 0 and t = +5 or t = +2 and t = +5 minutes, which cost $2028 total compared with the most expensive 6-point IPSS option with CRH ($6392). CONCLUSION: DDAVP is a cost-efficient and effective alternative to CRH during IPSS. Our results encourage prospective evaluation of potentially fewer sampling time points in the interest of time and cost efficiency balanced with preserved accuracy.

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Section: Discussion Study Findings and Significancementioning

confidence: 99%

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confidence: 99%