Delayed Cerebrospinal Fluid Rhinorrhea After Gamma Knife Radiosurgery with or without Preceding Transsphenoidal Resection for Pituitary Pathology

Long-Term Outcomes After Cyberknife Radiosurgery for Nonfunctioning Pituitary Adenomas

BACKGROUND AND OBJECTIVES

Stereotactic radiosurgery (SRS) has been widely adopted as an important adjunctive treatment modality for managing nonfunctioning pituitary adenomas (NFPAs). However, current studies on the long-term effects of SRS on pituitary adenomas have been largely limited by small sample sizes and short follow-up periods. The aim of this study was to evaluate the long-term outcomes of SRS for NFPAs.

METHODS

We conducted a retrospective review of 178 patients with NFPAs who received Cyberknife radiosurgery at a single institution between February 2008 and July 2021. Long-term outcomes of tumor control, new-onset hypopituitarism, and new visual disorders were assessed.

RESULTS

During a median radiological follow-up of 49.7 months (range, 2.5-158.1 months), only 11 (7.0%) patients experienced tumor progression. The progression-free survival at 3, 5, and 10 years was 97.47%, 95.57%, and 93.04%, respectively. New-onset hypopituitarism was diagnosed in 27 (16.9%) patients with a median clinical follow-up duration of 71.2 months (range, 11.5-175.4 months). The median time from SRS to new-onset hypopituitarism was 28.3 months (range, 2.8-101.7 months). The cumulative incidence of new-onset hypopituitarism at 3, 5, and 10 years was 8.47%, 12.43%, and 15.25%, respectively. Biological effective dose >140 Gy and single fraction equivalent dose >16.0 Gy were significant risk factors for new-onset hypopituitarism (P = .046). Other adverse events were experienced by 15 (8.4%) patients, 9 (5.1%) of whom presented with new visual disorders. Development of new visual disorders was associated with a pretreatment tumor volume of >2.5 mL (P = .044).

CONCLUSION

SRS is an effective and relatively safe means of managing both primary and residual/recurrent NFPAs.

Severe pneumocranium after gamma knife stereotactic radiosurgery for brain metastasis: A case report and literature review

RATIONALE

Gamma knife stereotactic radiosurgery (GKRS) is a recognized safe and effective treatment for brain metastasis; however, some complications can present significant clinical challenges. This case report highlights a rare occurrence of cerebrospinal fluid (CSF) leakage and pneumocranium following GKRS, emphasizing the need for awareness and prompt management of these complications.

PATIENT CONCERNS

A 35-year-old male with a history of malignant neoplasm of the lip in 2015 and perineural spread of malignancy into the left cavernous sinus was treated with GKRS in 2017. The patient was admitted emergently 39 days after discharge due to persistent headache and dizziness.

DIAGNOSES

Brain computed tomography (CT) revealed diffuse bilateral pneumocranium alongside an observation of CSF leakage.

INTERVENTIONS

A surgical procedure involving a left frontal-temporal craniotomy was performed to excise a residual skull base tumor and repair the dura, guided by a navigator system. The conclusive pathological assessment revealed the presence of squamous cell carcinoma markers.

OUTCOMES

The patient exhibited excellent tolerance to the entire procedure and experienced a prompt and uneventful recovery process. After surgery, the symptoms alleviated and CSF leak stopped. The follow-up image showed the pneumocranium resolved.

LESSONS

Pneumocranium due to early-stage post-GKRS is uncommon. The rapid tumor shrinkage and timing of brain metastasis spreading through the dura can lead to CSF leak and pneumocranium. We reviewed current treatment options and presented a successful craniotomy-based dura repair case.

Case of Cerebrospinal Fluid Leakage Nine Years after Pituitary Gamma Knife Surgery for Poststroke Thalamic Pain Syndrome

Pituitary gamma knife surgery (GKS) is a treatment option for poststroke thalamic pain syndrome. Complications such as hypopituitarism, transient enuresis, and transient hyponatremia have been reported. However, cerebrospinal fluid (CSF) leakage has not yet been reported as a complication of pituitary GKS for poststroke thalamic pain syndrome. Herein, we report a case of delayed CSF rhinorrhea that developed 9 years after GKS for poststroke thalamic pain syndrome. A 64-year-old man presented to our hospital with bacterial meningitis and CSF rhinorrhea. Pituitary GKS for poststroke thalamic pain had been performed 9 years prior to his admission to our hospital. Computed tomography revealed pneumocephalus, fluid in the sphenoid and maxillary sinuses, and a partial bony defect of the sella turcica floor with communication between the paranasal and intracranial spaces. The CSF rhinorrhea resolved with bed rest and a lumbar CSF drain but recurred several days later. The patient underwent direct endoscopic surgical repair of the skull base. The sellar floor was covered with an autologous fascia graft harvested from the rectus sheath, and the sphenoid sinus was packed with abdominal fat grafts. The patient recovered, and the CSF rhinorrhea has not recurred for 2 years. Long-term follow-up is necessary after pituitary GKS, considering the complication of delayed CSF leakage.

[Analysis of risk factors for delayed iatrogenic cerebrospinal fluid otorrhinorrhea]

Objective:To explore the common causes of iatrogenic cerebrospinal fluid（CSF） otorrhinorrhea, and further analyze the risk factors for delayed iatrogenic CSF otorrhinorrhea. Methods:The clinical data of 35 iatrogenic CSF otorrhinorrhea patients in department of Otorhinolaryngology Head and Neck Surgery from January 2010 to January 2020 were retrospectively analyzed. Patients were divided into delayed and non-delayed iatrogenic CSF leak groups, according to the time intervals from medical intervention to CSF leak occurrence. The differences of baseline data, complications and success rate between the two groups were analyzed, and the risk factors of delayed iatrogenic cerebrospinal fluid otorrhinorrhea were further analyzed. Results:Endoscopic sinus surgery （n=11）, transsphenoidal pituitary surgery（n=8）, craniotomy（n=12）, and radiotherapy（n=4） all contribute to iatrogenic CSF otorrhinorrhea. Compared with the non-delayed group, the incidence of meningitis in the delayed group was significantly higher（20% vs 60%, P=0.041）. There were no significant differences in gender, radiation, hypertension, diabetes, and success rate between the two groups. Additionally, binary logistic regression analysis showed that sex, age, history of radiation, hypertension and diabetes, as well as causes of CSF otorrhinorrhea had no association with delayed iatrogenic CSF leakage. Conclusion:Patients with delayed iatrogenic CSF otorrhinorrhea have an increased risk of meningitis. Timely diagnose and intervention with appropriate surgical approach and reconstruction method ensures good clinical outcomes.

Treatment and Outcomes of Iatrogenic Cerebrospinal Fluid Leak Caused by Different Surgical Procedures

BACKGROUND

Iatrogenic cerebrospinal fluid (CSF) leaks are associated with serious sequelae. We analyzed the causes, complications, treatments, and outcomes of iatrogenic CSF leaks. Furthermore, the comorbidities and outcomes between timely and delayed repairs of iatrogenic CSF leaks were also compared.

METHODS

Medical records of patients with iatrogenic CSF leaks from January 2010 to January 2020 were reviewed.

RESULTS

Iatrogenic CSF leaks can be attributed to endoscopic sinus surgery (ESS), transsphenoidal pituitary surgery, open craniotomy, or postradiation necrosis. Twenty-nine patients diagnosed with iatrogenic CSF leak were recruited. The primary diagnoses included 12 (41.4%) nasal lesions, 7 (24.2%) pituitary tumors, 3 (10.3%) anterior cranial fossa lesions, 4 (13.8%) cerebellopontine angle lesions, and 3 (10.3%) clival lesions. The longest interval from symptom onset to presentation at our hospital was observed after craniotomy, followed by transsphenoidal surgery and ESS, increasing the risks of meningitis in these patients. The most common leakage sites after ESS and transsphenoidal surgery were the cribriform plate/ethmoid roof and sella turcica, respectively, whereas the defect sites related to open craniotomy varied. The grafts used for repair varied according to the defect location and prior surgical history. Additionally, patients in whom repair was delayed had a higher incidence of meningitis (P = 0.003), than those with timely repair.

CONCLUSIONS

Delayed intervention of CSF leak after transsphenoidal surgery and craniotomy was observed, increasing the risks of meningitis. Timely intervention with grafts based on the defect sites and patient prior surgical history is crucial for avoiding life-threatening comorbidities.

Pediatric pituitary adenomas

BACKGROUND

Pediatric pituitary adenomas are a rare medical entity that makes up a small portion of intracranial tumors in children and adolescents. Although benign, the majority of these lesions are secreting functional tumors with the potential for physiological sequela that can profoundly affect a child's development.

FOCUS OF REVIEW

In this review, we discuss the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to treat these tumors. The management of pituitary tumors requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver comprehensive care.

Late-Onset Intractable Cerebrospinal Fluid Leakage After Stereotactic Radiotherapy After Resection of Giant Nonfunctioning Pituitary Adenoma

Background

Late-onset skull base cerebrospinal fluid (CSF) leakage after stereotactic radiotherapy (SRT) is a very rare complication.

Case Description

A 54-year-old woman came to our department for convulsions and was admitted. Brain magnetic resonance imaging revealed a giant tumor in the skull base region, including the sphenoid sinus, pituitary fossa, right cavernous sinus, right middle fossa, and right basal ganglia. Mild left hemiparesis was noted. An ophthalmologic examination revealed left side homonymous hemianopsia. Using an endonasal endoscopic surgical approach, tumor removal was performed, with the residual tumor removed with a transcranial approach. Residual tumor tissue remained around the right cavernous sinus; therefore, SRT was performed 1 month after the second procedure, which resulted in good control of growth. Four years later, spontaneous CSF leakage occurred, for which endoscopic endonasal surgery was performed. One month later, CSF leakage recurred, and the same procedure was again used. A third episode of recurrent CSF leakage occurred 5 days later. A transcranial approach was finally used for repair, and the patient showed complete recovery.

Conclusions

Late-onset CSF leakage after SRT for a pituitary adenoma can be intractable, and several aggressive repair procedures may be needed, including a combination of endonasal and transcranial approaches.

Carotid Artery Injury during Transsphenoidal Pituitary Surgery: Lessons from a 15-Year Modern Microsurgery Cohort

Background  Internal carotid artery (ICA) injury is a rare but potentially catastrophic complication of transsphenoidal resection (TSR) of pituitary tumors, potentially resulting in a host of deficits due to the risk of hemorrhage, ischemia, or even death. The endoscopic endonasal approach (EEA) has gained considerable popularity in the modern era, with few busy neurosurgeons remaining committed to practicing transnasal pituitary microsurgery. Our objective was therefore to characterize the overall incidence of ICA injury in a large, longitudinal, single-surgeon microscopic TSR series conducted during the modern EEA era. Methods  Retrospective case series. Results  Overall TSR volume by the senior author (F.B.M.) was 817 pituitary tumors during the study period, 2002 to 2017. Within that cohort, two instances of ICA injury were identified (0.2%), including one each with Cushing's disease and acromegaly, both of whom ultimately recovered without residual neurologic deficit. No pediatric injuries were identified. Conclusion  Vascular injury is an exceedingly rare complication of transsphenoidal pituitary surgery. Adjuncts to prevent this complication include careful review of the coronal magnetic resonance imaging, identification of the midline, as needed use of the Doppler, and initial caudal opening of the sellar dura. Although potentially disastrous, good neurologic outcomes may be obtained, with immediate judicious packing followed by immediate digital subtraction angiography to assess vessel patency and secondary complications such as pseudoaneurysm.

Little Insights from Big Data: Cerebrospinal Fluid Leak After Skull Base Surgery and the Limitations of Database Research

BACKGROUND

Cerebrospinal fluid (CSF) leak is a frustrating complication of skull base surgery. Published methodologies using national surgical databases to assess CSF leak have not accounted for variability between skull base operations.

OBJECTIVE

Our goal was to attempt the development of a novel framework for adapting big data techniques to skull base surgery and assess the reliability of corresponding data manipulations.

METHODS

A retrospective nested case-control analysis was performed using patients from the National Surgical Quality Improvement Program (NSQIP) registry, 2012-2015. Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes identified possible skull base operations, which were systematically grouped by anatomic location. Meningioma, schwannoma, pituitary adenoma, and trigeminal neuralgia (TN) were included.

RESULTS

Of 2918 patients, 84 (2.9%) were readmitted/reoperated on within 30 days for CSF leak. Operations involving the anterior fossa, both middle/posterior fossas in 1 approach, or the orbitocranial zygomatic approach were significantly associated with CSF leak, as were schwannomas and meningiomas in any location (8.5%, 3.1%, 10.2%, 4.1%, and 3.0%; all P < 0.0001). Multivariate analysis of only middle/posterior fossa lesions identified schwannoma (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.3-5.6; P = 0.008), TN (OR, 5.4; 95% CI, 2-14.7; P = 0.008), chronic obstructive pulmonary disease (OR, 3.9; 95% CI, 1.1-14; P = 0.03), and increased operative time (OR, 4.0; 95% CI, 1.7-9.5; P = 0.009) as significant CSF leak risk factors.

CONCLUSIONS

Based on NSQIP data analyzed using a rational skull base/anatomic framework, risk factors for postoperative CSF leak include chronic obstructive pulmonary disease, operative time, anterior fossa meningioma, and middle/posterior fossa schwannoma or TN. Although databases such as NSQIP can be extensively manipulated to generate surrogate results that may provide limited insight, applications beyond their design should be approached carefully.

CSF Rhinorrhea Following Medical Treatment for Prolactinoma: Management and Challenges

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.

Delayed complications from expanded endonasal surgery for intracranial tumors

PURPOSE OF REVIEW

Delayed complications after endoscopic endonasal approaches to the skull base, defined as complications greater than 1 month postoperatively, are uncommon. These complications are divided into categories including sinonasal, neuroanatomic, endocrine and vascular. This review highlights the most up-to-date advancements and reviews the management of delayed complications for skull base patients.

RECENT FINDINGS

Over the last 10 years, the field of endoscopic endonasal skull base surgery has expanded with new data highlighting the long-term patient outcomes. The majority of patients experience increased quality of life (QOL) after these interventions. However, delayed complications including alterations to sinonasal function, delayed encephaloceles from the bony skull base defect and resulting endocrinopathies can significantly impact patient's QOL. Awareness of these complications and their current management is valuable for endoscopic surgeons.

SUMMARY

Endonasal approaches to the skull base are safe and well tolerated in properly selected patients. This article highlights the delayed complications that require recognition and management by skull base surgeons to ensure the best possible care for patients.

Just another case of bacterial meningitis… or… is it?

Non-traumatic cerebrospinal fluid (CSF) rhinorrhoea is a rare condition. We describe a case of a 62-year-old woman with pneumococcal bacterial meningitis who later was found to have CSF rhinorrhoea secondary to an eroding skull base tumour, which was proven to be pituitary macroadenoma on biopsy. She recovered well from meningitis without any neurological sequelae and underwent trans-sphenoidal surgery for tumour removal as well as dural repair.

Pediatric Pituitary Adenoma: Case Series, Review of the Literature, and a Skull Base Treatment Paradigm

Background  Pediatric pituitary adenoma is a rare skull base neoplasm, accounting for 3% of all intracranial neoplasms in children and 5% of pituitary adenomas. Compared with pituitary tumors in adults, secreting tumors predominate and longer disease trajectories are expected due to the patient age resulting in a natural history and treatment paradigm that is complex and controversial. Objectives  The aims of this study were to describe a large, single-institution series of pediatric pituitary adenomas with extensive long-term follow-up and to conduct a systematic review examining outcomes after pituitary adenoma surgery in the pediatric population. Methods  The study cohort was compiled by searching institutional pathology and operative reports using diagnosis and site codes for pituitary and sellar pathology, from 1956 to 2016. Systematic review of the English language literature since 1970 was conducted using PubMed, MEDLINE, Embase, and Google Scholar. Results  Thirty-nine surgically managed pediatric pituitary adenomas were identified, including 15 prolactinomas, 14 corticotrophs, 7 somatotrophs, and 4 non-secreting adenomas. All patients underwent transsphenoidal resection (TSR) as the initial surgical treatment. Surgical cure was achieved in 18 (46%); 21 experienced recurrent/persistent disease, with secondary treatments including repeat surgery in 10, radiation in 14, adjuvant pharmacotherapy in 11, and bilateral adrenalectomy in 3. At the last follow-up (median 87 months, range 3-581), nine remained with recurrent/persistent disease (23%). Thirty-seven publications reporting surgical series of pediatric pituitary adenomas were included, containing 1,284 patients. Adrenocorticotropic hormone (ACTH)-secreting tumors were most prevalent (43%), followed by prolactin (PRL)-secreting (37%), growth hormone (GH)-secreting (12%), and nonsecreting (7%). Surgical cure was reported in 65%. Complications included pituitary insufficiency (23%), permanent visual dysfunction (6%), chronic diabetes insipidus (DI) (3%), and postoperative cerebrospinal fluid (CSF) leak (4%). Mean follow-up was 63 months (range 0-240), with recurrent/persistent disease reported in 18% at the time of last follow-up. Conclusion  Pediatric pituitary adenomas are diverse and challenging tumors with complexities far beyond those encountered in the management of routine adult pituitary disease, including nuanced decision-making, a technically demanding operative environment, high propensity for recurrence, and the potentially serious consequences of hypopituitarism with respect to fertility and growth potential in a pediatric population. Optimal treatment requires a high degree of individualization, and patients are most likely to benefit from consolidated, multidisciplinary care in highly experienced centers.

Cerebrospinal Fluid Leak Rhinorrhea after Systemic Erlotinib Chemotherapy for Metastatic Lung Cancer: A Familiar Problem from an Unfamiliar Culprit

BACKGROUND

Cerebrospinal fluid (CSF) rhinorrhea after medical therapy for pituitary prolactinoma is a rare but well-described phenomenon. To our knowledge, no CSF leaks have been reported after targeted medical treatment of pituitary or anterior skull base metastases. We report this unusual case to raise awareness of spontaneous CSF leaks in the setting of skull base metastatic disease.

CASE PRESENTATION

A 66-year-old woman presented with epidermal growth factor receptor-mutant stage IV adenocarcinoma of the lung. Headache workup revealed a large sellar and clival lesion consistent with metastatic disease. Systemic erlotinib chemotherapy was initiated with a robust positive response. Approximately 1 week after chemotherapy initiation, the patient noted clear discharge from the right nostril. Her oncologist first diagnosed her with allergic rhinitis, but she presented with meningitis 4 days after diagnosis of CSF leak and was admitted for intravenous antibiotics and definitive repair of a CSF leak via an endoscopic endonasal approach. An erosion of bone and dura was found at the dorsum sellae where tumor had regressed due to the chemotherapy. A multilayer skull base repair was made uneventfully, and she recovered fully with no leakage seen at 2-month follow-up.

CONCLUSIONS

All members of the treatment team should be aware of this possibility of CSF leak after initiation of systemic chemotherapy and tumor regression and urgently refer patients for repair if a leak should develop before the development of meningitis.