Cabergoline-Induced Pneumocephalus Following Treatment for Giant Invasive Macroprolactinoma Presenting With Spontaneous Cerebrospinal Fluid Rhinorrhea

Prolactinoma: Navigating the Dual Challenge of Side Effects and Treatment Strategies - A Comprehensive Review

This narrative review provides a succinct exploration of prolactinoma, the most common pituitary adenoma, focusing on its epidemiology, clinical manifestations, and therapeutic interventions. Beginning with an overview of its prevalence and aetiology, the review delves into the gender distribution and familial associations of prolactinoma. Clinical presentations, including endocrine disruptions, reproductive health issues, and metabolic disturbances, are examined, emphasizing their impact on hormonal regulation and cardiovascular health. The narrative then navigates through pharmacological treatments, surgical interventions, and radiation therapy, highlighting their efficacy, side effects, and long-term management challenges. Strategies to mitigate side effects and optimize treatment outcomes are discussed, emphasizing the importance of multidisciplinary collaboration in prolactinoma management. This review is a concise yet comprehensive resource for healthcare professionals and researchers, providing insights into prolactinoma's clinical complexities and therapeutic nuances to guide optimal patient care strategies.

Treatment Strategy for Giant Invasive Macroprolactinoma with Spontaneous Cerebrospinal Fluid Rhinorrhea: A Case Report and Literature Review

BACKGROUND

Spontaneous cerebrospinal fluid (CSF) rhinorrhea associated with untreated prolactinomas is rare, which is in contrast to medical treatment-induced CSF rhinorrhea. Previous studies have suggested that cessation of drug administration should be the first line of treatment for prolactinoma with medically induced CSF rhinorrhea. On the other hand, there is no standard treatment strategy for prolactinoma with the development of spontaneous CSF rhinorrhea, because of its complicated pathology. Here, we report a case of giant invasive macroprolactinoma with spontaneous CSF rhinorrhea, and discuss the treatment strategy for this complicated condition with a review of the relevant literature.

CASE DESCRIPTION

A previously healthy 39-year-old man presented with 1-year history of intermittent clear fluid nasal discharge with headache and vomiting. Magnetic resonance imaging showed a large parasellar mass with destruction of the skull base. This tumor was diagnosed as prolactinoma with hypopituitarism based on the results of hormone examinations. Tumor resection with skull base reconstruction in the endoscopic endonasal approach was performed because CSF rhinorrhea was aggravated by bromocriptine loading test and administration of dopamine agonist. Life-threatening bacterial meningitis occurred after surgery, which was cured with antibiotics along with resolution the CSF rhinorrhea.

CONCLUSIONS

Careful consideration is necessary before applying standard first-line protocols with dopamine agonist administration in patients with prolactinoma, especially in cases with spontaneous CSF rhinorrhea. An appropriate treatment strategy should be planned according to the individual case, including factors such age, sex, pituitary function, tumor mass size, prolactin concentration, and condition of CSF leakage.

Spontaneous "pneumo-apoplexy" as a presentation of pituitary adenoma

Cases of spontaneous CSF leak associated with pituitary tumor apoplexy are uncommon in the literature with pneumocephalus or pneumosella being rare, especially spontaneous occurrence of pneumocephalus being extremely rare. We present a case of pituitary macroadenoma apoplexy resulting in spontaneous CSF leak and a large volume of intra-tumoral gas. A 65-year-old female presented with severe headache, profuse rhinorrhea and acute vision loss and was found to have a large sellar and suprasellar lesion with air and hemorrhage with mild peripheral enhancement. The patient underwent trans-sphenoidal tumor resection and repair of skull base for CSF leak with nasoseptal flap placement. Pathology demonstrated a pituitary adenoma exhibiting immunoreactivity for ACTH. To our best knowledge, our case is the first report of features of pituitary tumor apoplexy with hemorrhage and pneumosella, which could be summarized by the term "pneumo-apoplexy".