2. Horvath E, Kovacs K, Killinger DW, Smyth HS, Platts ME, Singer W. Silent Download full-text
corticotroph adenomas of the human pituitary gland: a histologic, immunocytologic,
and ultrastructural study. Am J Pathol. 1980;98(3):617-638.
Although the prevalence of obesity in 2000 was lower than it is
now, the proportion of patients with Cushing syndrome (CS) has
not changed in parallel.1CS was present in , 0.6% of 433
morbidly obese subjects. Interestingly, bariatric surgery in these
patients normalized slightly elevated preoperative thyrotropin
levels.2Screening for CS, including a 1-mg dexamethasone
suppression test, in 150 obese patients identified CS in 9%
(14 patients), whereas elevated levels of 24-hour urinary free
cortisol were recorded in 24% (37 patients).3Similarly, the
observed prevalence rates of CS in patients with type 2 diabetes
mellitus vary and range from 0% to 9%,4underscoring that the
cons surpass the pros for screening for CS at present.5Biochemical
evaluation should take into account the limitations of assays
including heterophil antibodies.6In obese patients with type 2
diabetes mellitus without clinical features of CS, ruling in
cortisol of 90%, and 1-mg dexamethasone suppression test of
72%.7In our patient,8initial early-morning serum cortisol was
15.7 mg/dL (433 nmol/L), in line with findings in the literature on
silent corticotroph pituitary adenomas (343 6 112 nmol/L) and
(790 nmol/L) or micro-ACTHomas (653 nmol/L).9
Dr Koch has received consulting fees from Corcept and Ipsen.
Christian A. Koch
1. Koch CA. Endocrine hypertension: what is new? Rev Port Endocrinol Diabetes.
2. Jankovic D, Wolf P, Anderwald CH, et al. Prevalence of endocrine disorders in
morbidly obese patients and the effects of bariatric surgery on endocrine and
metabolic parameters. Obes Surg. 2012;22(1):62-69.
3. Tiryakioglu O, Ugurlu S, Yalin S, et al. Screening for Cushing’s syndrome in obese
patients. Clin (Sao Paulo). 2010;65(1):9-13.
4. Krarup T, Hagen C. Do patients with type 2 diabetes mellitus have an increased
prevalence of Cushing’s syndrome? Diabetes Metab Res Rev. 2012;28(3):219-227.
5. Tabarin A, Perez P. Pros and cons of screening for occult Cushing syndrome. Nat
Rev Endocrinol. 2011;7(8):445-455.
6. Melcescu E, Ng KK, Grebe SK, et al. False positive ACTH caused by heterophil
antibody in an obese patient considered for possible Cushing’s syndrome. Endocr
7. Ellis E, Chin PK, Hunt PJ, et al. Is late-night salivary cortisol a better screening test
for possible cortisol excess than standard screening tests in obese patients with type 2
diabetes? N Z Med J. 2012;125(1353):47-58.
8. Melcescu E, Gannon AW, Parent AD, et al. Silent or subclinical corticotroph
pituitary macroadenoma transforming into Cushing disease: 11-year follow-up.
9. Raverot G, Wierinchx A, Jouanneau E, et al. Clinical, hormonal and molecular
characterization of pituitary ACTH adenomas without (silent corticotroph
adenomas) and with Cushing’s disease. Eur J Endocrinol. 2010;163(1):35-43.
Intracranial Aneurysms With Small Basal Outpouching
To the Editor:
IfoundthearticlebyParketal1very interesting. We know that
procedure-related ruptures are one of the most significant
complications of coiling, and very small aneurysms are found
to be associated with a higher risk of rupture. This study showed
that the basal outpouching was identified as the rupture point in
31% of the aneurysm cases with basal outpouchings, and
endovascular coiling carried high risk of intraprocedural rebleed-
ing in this group of patients.
However, I have some comments regarding to this article. First of
first angiographic evaluation of the patient. When I reviewed the
article, I saw that the basal outpouching was evaluated based on 3-
dimensional reconstruction digital subtraction angiographic images
respectively. I could not find any information about which of these 2
is obvious that this information is reliable only in surgical cases if you
compare the preoperative angiographic findings with operative
findings. But this information about the superiority of the imaging
patients with ruptured aneurysms in planning further management.
One of the comments given in the article had emphasized the
importance of the high-quality imaging by rotational angiography.
My second comment about this article is related to the planning
team.Ideally,the managementstrategy fortheruptured aneurysms
endovascular teams. In the planning the approach, catheter
angiography is seen to be more feasible and suitable for both
groups, but the decision regarding the approach depends on the
procedure to the endovascular team if the hospital has equally
experienced both microsurgical and endovascular teams. On the
other hand, microvascular surgeons will become more confident
when they are recommending surgery to their patients. But all
around the world, because of the lack of the experienced microvas-
cularsurgeons,itwouldnot affectthe planningofthemanagement
of the treatment in most hospitals. I hope that the development of
the new coiling technologies will solve this problem and provide
a safer approach to the treatment of this kind of aneurysm in near
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