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Patients with repeatedly equivocal results should be reevaluated after several months or undergo a corticotropin-releasing hormone (CRH) stimulation test following low-dose dexamethasone suppression to help rule out pseudo-Cushing states. The presence of low morning serum adrenocorticotropic hormone (ACTH) levels then distinguishes primary adrenal hypercortisolism from Cushing disease and the ectopic ACTH syndrome. Patients with moderate ACTH levels can undergo CRH stimulation testing to clarify the underlying disease because those with an ACTH-independent disorder have blunted subsequent ACTH levels. Once ACTH-dependent hypercortisolemia is detected, magnetic resonance (MR) imaging of the pituitary gland can be performed to detect a pituitary neoplasm. Normal or equivocal MR imaging results revealing small pituitary lesions should be followed up with inferior petrosal sinus sampling, a highly specific measure for the diagnosis of Cushing disease in experienced hands. If necessary, body imaging may be used in turn to detect sources of ectopic ACTH.<\/jats:p>","DOI":"10.3171\/foc.2007.23.3.2","type":"journal-article","created":{"date-parts":[[2008,1,24]],"date-time":"2008-01-24T07:25:20Z","timestamp":1201159520000},"page":"1-7","source":"Crossref","is-referenced-by-count":7,"title":["Diagnostic approach to Cushing disease"],"prefix":"10.3171","volume":"23","author":[{"given":"Bradley A.","family":"Gross","sequence":"first","affiliation":[{"name":"Departments of Neurological Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefan A.","family":"Mindea","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anthony J.","family":"Pick","sequence":"additional","affiliation":[{"name":"Endocrinology, The Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James P.","family":"Chandler","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"H. 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