Is a patient with ballism at increased risk of bleeding or other complications during a Blood Investigation, Puncture, and Sampling System (BIPSS) procedure?

Ballism Does Not Increase Bleeding Risk During BIPSS Procedure

Patients with ballism do not have an increased risk of bleeding or other complications during bilateral inferior petrosal sinus sampling (BIPSS) procedures. 1

Understanding Ballism and BIPSS

• Ballism is characterized by involuntary, vigorous, rapidly executed, poorly patterned movements of the limbs, typically affecting one side of the body (hemiballism) 2
• BIPSS is an invasive procedure used in the diagnosis of ACTH-dependent Cushing's syndrome, involving catheterization of the inferior petrosal sinuses via femoral vein puncture 3

Bleeding Risk Assessment for BIPSS

General Risk Profile of BIPSS

• BIPSS is considered a relatively safe procedure with rare complications when performed properly 4
• Major complications reported include thromboembolism, brain stem infarction, pontine hemorrhage, isolated sixth nerve palsy, and venous subarachnoid hemorrhage, but these are uncommon 4

Bleeding Risk Factors in Invasive Procedures

• Bleeding complications during invasive procedures in patients with cirrhosis are primarily related to technical factors rather than hemostatic abnormalities 1
• For TIPS procedures (which are more invasive than BIPSS), routine correction of hemostatic alterations is not recommended due to lack of supportive evidence 1

Movement Disorders and Procedural Risk

• No evidence in the guidelines suggests that movement disorders like ballism increase the risk of bleeding during invasive procedures 1
• The natural history of hemiballism typically shows gradual improvement within days or weeks 2
• Bleeding risk during procedures is primarily associated with:
  • Technical factors and operator experience 1
  • Presence of coagulopathy or severe thrombocytopenia 1
  • Concomitant conditions like infection or renal failure 1

Risk Mitigation Strategies

• Ultrasound guidance during vascular procedures significantly reduces complications and is recommended for central line placement in patients with coagulopathy 1
• For BIPSS specifically, proper technique and experienced operators are crucial to minimize complications 3
• Patients should be monitored for bleeding complications following invasive procedures, but no special monitoring is required beyond standard protocols 1

Clinical Implications

• Ballism itself does not require special hemostatic preparation before BIPSS 1
• The presence of ballism should not delay or contraindicate BIPSS when clinically indicated 1
• Patient positioning and comfort measures may be needed to manage the involuntary movements during the procedure 5
• Sedation may be considered to minimize movement during the procedure, but this should follow standard protocols 1

Practical Considerations

• Ensure proper patient restraint and positioning to minimize movement during the procedure 1
• Consider appropriate sedation if the ballistic movements are severe enough to interfere with procedural safety 1
• Focus on standard pre-procedural assessment for bleeding risk factors (coagulation parameters, medication history) rather than the movement disorder itself 1
• Experienced operators should perform the procedure to minimize technical complications 1