CSF Rhinorrhea Following Medical Treatment for Prolactinoma: Management and Challenges

Abstract

Objective Cerebrospinal fluid (CSF) rhinorrhea following medical management of prolactinoma is a rare complication. We evaluated the clinical background of this condition, identify potential risk factors, and discuss the management options and challenges involved.

Methodology We retrospectively reviewed clinical details of patients who were treated for CSF leaks among patients treated for prolactinoma between 2013 and 2017.

Results Seven patients were treated for CSF rhinorrhea in the context of prolactinoma, with the age range between 24 and 56 years. Six patients had CSF leak following initiation of cabergoline, while one patient presented with CSF rhinorrhea. The time of onset of leak following medical treatment ranged from 14 days to 5 years. The mean preoperative serum prolactin level was 12,638 ng/mL (range: 1,000–26,287 ng/mL). All patients underwent repair of skull base defect. (four endoscopic, two microscopic, and one bifrontal craniotomy). The site of defect in the majority of patients was the sellar floor. Two patients who were initially managed with acetazolamide alone, eventually required surgical repair. Three patients were cured of CSF leak with a single procedure. Three patients had to undergo re-exploration and endoscopic repair after their first surgery failed. Two patients required lumboperitoneal (LP) shunt after a failed endoscopic transsphenoidal repair.

Conclusion Surgical management for medically-induced CSF rhinorrhea is necessary; however, it can pose significant issues. Endoscopic repair of the defect should be considered at the earliest. Multiple surgical procedures are often required because of skull base erosion. LP shunt can be considered if CSF leak persists following multiple surgeries.

Keywords

CSF rhinorrhea - prolactinoma - medical management - cabergoline - surgical management - failure

• References

• 1 Shiley SG, Limonadi F, Delashaw JB. , et al. Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery. Laryngoscope 2003; 113 (08) 1283-1288
• 2 Yilmazlar S, Arslan E, Kocaeli H. , et al. Cerebrospinal fluid leakage complicating skull base fractures: analysis of 81 cases. Neurosurg Rev 2006; 29 (01) 64-71
• 3 Ziu M, Savage JG, Jimenez DF. Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures. Neurosurg Focus 2012; 32 (06) E3
• 4 Han ZL, He DS, Mao ZG, Wang HJ. Cerebrospinal fluid rhinorrhea following trans-sphenoidal pituitary macroadenoma surgery: experience from 592 patients. Clin Neurol Neurosurg 2008; 110 (06) 570-579
• 5 Perry A, Graffeo CS, Copeland III WR. , et al. Delayed cerebrospinal fluid rhinorrhea after gamma knife radiosurgery with or without preceding transsphenoidal resection for pituitary pathology. World Neurosurg 2017; 100: 201-207
• 6 Barazi SA, Pasquini E, D'Urso PI. , et al. Extended endoscopic transplanum-transtuberculum approach for pituitary adenomas. Br J Neurosurg 2013; 27 (03) 374-382
• 7 Sciarretta V, Mazzatenta D, Ciarpaglini R, Pasquini E, Farneti G, Frank G. Surgical repair of persisting CSF leaks following standard or extended endoscopic transsphenoidal surgery for pituitary tumor. Minim Invasive Neurosurg 2010; 53 (02) 55-59
• 8 Molitch ME. Diagnosis and treatment of pituitary adenomas: a review. JAMA 2017; 317 (05) 516-524
• 9 de Lacy P, Benjamin S, Dixon R, Stephens JW, Redfern R, Price DE. Is surgical intervention frequently required for medically managed macroprolactinomas? A study of spontaneous cerebrospinal fluid rhinorrhea. Surg Neurol 2009; 72 (05) 461-463 , discussion 463
• 10 Suliman SG, Gurlek A, Byrne JV. , et al. Nonsurgical cerebrospinal fluid rhinorrhea in invasive macroprolactinoma: incidence, radiological, and clinicopathological features. J Clin Endocrinol Metab 2007; 92 (10) 3829-3835
• 11 Lam G, Mehta V, Zada G. Spontaneous and medically induced cerebrospinal fluid leakage in the setting of pituitary adenomas: review of the literature. Neurosurg Focus 2012; 32 (06) E2
• 12 Leong KS, Foy PM, Swift AC, Atkin SL, Hadden DR, MacFarlane IA. CSF rhinorrhoea following treatment with dopamine agonists for massive invasive prolactinomas. Clin Endocrinol (Oxf) 2000; 52 (01) 43-49
• 13 Virk JS, Elmiyeh B, Saleh HA. Endoscopic management of cerebrospinal fluid rhinorrhea: the charing cross experience. J Neurol Surg B Skull Base 2013; 74 (02) 61-67
• 14 Daele JJ, Goffart Y, Machiels S. Traumatic, iatrogenic, and spontaneous cerebrospinal fluid (CSF) leak: endoscopic repair. B-ENT 2011; 7 (Suppl. 17) 47-60
• 15 Hadad G, Bassagasteguy L, Carrau RL. , et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
• 16 Thakur B, Jesurasa AR, Ross R, Carroll TA, Mirza S, Sinha S. Transnasal trans-sphenoidal endoscopic repair of CSF leak secondary to invasive pituitary tumours using a nasoseptal flap. Pituitary 2011; 14 (02) 163-167
• 17 Little AS. Repair of cerebrospinal fluid fistula from an invasive skull base prolactinoma using a septal mucosal vascularized flap: technical case report. J Neurol Surg A Cent Eur Neurosurg 2013; 74 (Suppl. 01) e50-e53
• 18 Greenblatt SH, Wilson DH. Persistent cerebrospinal fluid rhinorrhea treated by lumboperitoneal shunt. Technical note. J Neurosurg 1973; 38 (04) 524-526
• 19 Tang J, Zhu Y, Zhang B, Gu Q, Li Y. Ventriculoperitoneal shunt strategy for cerebrospinal fluid rhinorrhea repair: a case report and review of the literature. Pediatr Neurol 2012; 47 (05) 369-372
• 20 Bret P, Hor F, Huppert J, Lapras C, Fischer G. Treatment of cerebrospinal fluid rhinorrhea by percutaneous lumboperitoneal shunting: review of 15 cases. Neurosurgery 1985; 16 (01) 44-47
• 21 Muthukumar N, Palaniappan P, Gajendran R. Tension pneumocephalus complicating lumboperitoneal shunt. J Indian Med Assoc 1996; 94 (12) 457 , 459