Cerebrospinal fluid rhinorrhea associated with untreated prolactinoma--case report

Treatment of pituitary adenoma with spontaneous cerebrospinal rhinorrhea using nasoseptal flap, two case reports

Background:

Postoperative cerebrospinal fluid (CSF) leakages are well documented, but pituitary adenoma with spontaneous CSF rhinorrhea as the initial symptoms are extremely rare. The objective of this study is to report two rare cases of pituitary adenoma with spontaneous CSF rhinorrhea successfully operated by endoscopic transsphenoidal approach with vascularized nasoseptal flap (NSF).

Case Description:

A 70-year-old woman presented with a 6-month history of watery rhinorrhea and posterior nasal drip that worsened when her head leaning forward. Sella magnetic resonance image (MRI) demonstrated pituitary macroadenoma (3.4 × 2.7 cm) invading cavernous sinus, clivus, and sphenoid sinus. A 47-year-old woman presented with a 10-month history of watery rhinorrhea and posterior nasal drip. Sella MRI demonstrated pituitary macroadenoma (6.3 × 4.6 cm) invading cavernous sinus, clivus, sphenoid sinus, and middle fossa. Both patients underwent endoscopic endonasal transsphenoidal operation and skull base reconstruction with vascularized NSF. The postoperative clinical course was uneventful and CSF rhinorrhea disappeared completely.

Conclusion:

Pituitary adenoma should be suspected if there is a watery CSF rhinorrhea that occurs without a history of trauma or nasal disease. In addition, effective treatment can be performed using NSF, a technique for endoscopic skull base reconstruction.

Spontaneous Cerebrospinal Fluid Rhinorrhea from a Prolactin-Secreting Pituitary Macroadenoma

Cerebrospinal fluid (CSF) rhinorrhea is a rare complication of macroprolactinomas that, in the vast majority of cases, is subsequent to either medical or surgical intervention. Here, we present the successful management of a rare case of spontaneous, noniatrogenic CSF rhinorrhea in a patient with an untreated macroprolactinoma. A 27-year-old man with no significant medical history presented with six months of persistent CSF rhinorrhea, which was confirmed by testing for beta-2-transferrin. He had had decreased libido since adolescence and impaired growth of secondary sexual characteristics. Workup revealed an elevated prolactin level, and imaging demonstrated erosion of the anterior sellar floor and soft tissue within the sphenoid sinus, concerning for tumor. The patient underwent surgical repair of the CSF leak via a transnasal transsphenoidal approach, with resection and biopsy of tumor material within the sinus. No tumor was noted within the sella itself. The patient tolerated the procedure well and had subsequent normalization of his prolactin level with no further CSF egress. Spontaneous noniatrogenic CSF rhinorrhea, although rare, should be considered in the differential diagnosis of invasive pituitary macroadenomas, especially prolactinomas. The mechanism of CSF leak from a prolactinoma is not completely understood, but the CSF leak should be urgently repaired through a transnasal transsphenoidal approach. Concurrently, tumor resection should be performed and a postoperative lumbar puncture or lumbar drain should be considered to reinforce the skull base reconstruction.

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 cerebrospinal fluid rhinorrhea associated with an incidental pituitary adenoma

Spontaneous cerebrospinal fluid (CSF) rhinorrhea presenting as the sole symptom of untreated pituitary adenoma is rare, with only 15 cases having been reported in the English literature. All these untreated pituitary adenoma contributing to spontaneous CSF rhinorrhea were diagnosed by the preoperative neuroimaging. Herein, we described an extraordinary rare patient with a pituitary microadenoma, presenting with spontaneous CSF rhinorrhea as the sole symptom. However, this pituitary microadenoma was only found incidentally at surgery, not preoperatively. To the best knowledge of us, this is the first reported case of spontaneous CSF rhinorrhea associated with an untreated pituitary adenoma diagnosed at surgery.

Fulminant Meningoencephalitis as the First Clinical Sign of an Invasive Pituitary Macroadenoma

We report the case of a young woman who presented with an acute fulminant meningoencephalitis as the first sign of an invasive pituitary macroadenoma. This rare and dramatic complication is described in detail, and the different management steps, from the lumbar puncture to the bifrontal craniectomy, are discussed. In conclusion, this clinical presentation highlights the importance of early diagnosis and urgent management of this uncommon complication.

[Management of cerebrospinal fluid fistulae: physiopathology, imaging and treatment]

Cerebrospinal fluid (CSF) fistulae can produce leakage through a defect in the bony skull and meninges into the contiguous air-filled cavities at the base of the skull. The major risk is central nervous system infection. When abundant clear rhinorrhea or otorrhea is present, the diagnosis is obvious and imaging is used to localize the fistula. Computed tomography (CT) with millimetric slices and magnetic resonance imaging (MRI) are the most effective diagnostic tools. CT cisternography, an invasive procedure, should only be used when the diagnosis remains uncertain following CT scan and MRI. When CSF leakage is sparse or intermittent, the diagnosis can be made by measuring beta-2 transferrine in the escaping fluid. CT scan followed by MRI are also useful for making the diagnosis and locating the fistula when exterior leakage is absent. CT scan alone is effective for assessing isolated otorrhea. If the diagnosis remains uncertain after all these studies have been used, the patient should be closely followed clinically and isotopic study or surgery should be considered.