Prolactinoma extension as a contributing factor in dopamine agonist-induced CSF rhinorrhea: a systematic review of the literature

BACKGROUND

Dopamine agonist-induced cerebrospinal fluid (CSF) rhinorrhea is an uncommon treatment-related complication arising in 6.1% of prolactinoma patients treated with dopamine agonists. Locally invasive prolactinomas may create CSF fistulae through formation of dural and osseous skull base defects. Tumor shrinkage secondary to dopamine agonist therapy unmasks skull base defects, thus inducing CSF rhinorrhea. In these cases, repair of the leak may be achieved through collaborative surgical intervention by rhinologists and neurosurgeons. Multiple variables have been investigated as potential contributors to the risk of CSF rhinorrhea development in medically treated prolactinoma patients, with little consensus.

OBJECTIVE

The primary aim of our study was the characterization of risk factors for CSF rhinorrhea development following dopamine agonist treatment.

METHODS

A systematic review of the literature was conducted to identify cases of CSF rhinorrhea following dopamine agonist treatment of prolactinoma. The clinical history, radiographic findings and treatment outcomes are discussed.

RESULTS

Fifty-four patients with dopamine agonist-induced CSF rhinorrhea were identified across 23 articles published from 1979 to 2019. Description of diagnostic imaging [computed tomography (CT)/magnetic resonance imaging (MRI)] was not provided for 18/54 subjects. For the 36 cases that described prolactinoma appearance on CT or MRI, invasion of the cavernous sinuses was reported in 13 (36.1%) and invasion of the sphenoid sinus was reported in 18 (50%).

CONCLUSION

Based on our systematic review, we propose that CT findings of osseous erosion of the sella or the anterior skull base may predict dopamine agonist-induced CSF rhinorrhea. We recommend obtaining a thin-slice CT of the sinuses in cases with MRI evidence of sphenoid involvement.

Treatment of unusually located traumatic intracranial aneurysms and severe vasospasm following a gunshot wound to the head: A case report

Background:

Traumatic intracranial aneurysms (TICAs) represent up to 1% of all intracranial aneurysms. They can be the result of non-penetrating and penetrating brain injury (PBI). Approximately 20% of TICA are caused by PBI. Endovascular treatments as well as surgical clipping are reported in the literature. Other vascular complications of PBI include vasospasm although the literature is lacking on this topic.

Case Description:

The authors present a unique case of multiple TICAs after a PBI in a 15-year-old patient who sustained a gunshot wound to the head. The patient sustained injury through the middle cranial fossa and was taken emergently for a right-sided decompressive hemicraniectomy. Diagnostic cerebral angiogram (DCA) identified multiple TICAs along the right internal carotid artery (ICA) terminus and right middle cerebral artery as well as severe vasospasm. The patient was taken for clipping of those aneurysms and intraoperative treatment of vasospasm. Intraoperative blood flow measurements were taken before and after administration of intracisternal papaverine and arterial soft tissue dissection showing a significant increase in blood flow and improvement of vasospasm.

Conclusion:

While the literature has shifted towards endovascular treatment for TICAs, surgery still offers a safe and efficacious treatment strategy especially when TICAs present at large vessel bifurcation points where parent vessel sacrifice and stent assisted coiling are less favorable strategies. Severe flow limiting vasospasm can be seen in post-traumatic setting specifically PBI. Vasospasm can be treated during open surgery with intracisternal papaverine and arterial soft dissection as confirmed in this case report with intraoperative micro-flow probe measurements.

Restrictive cerebral cortical venopathy: A new clinicopathological entity

We present a case of a novel restrictive cerebral venopathy in a child, consisting of a bilateral network of small to medium cortical veins without evidence of arteriovenous shunting, absence of the deep venous system, venous ischemia, elevated intracranial pressure, and intracranial calcifications. The condition is unlike other diseases characterized by networks of small veins, including cerebral proliferative angiopathy, Sturge-Weber syndrome, or developmental venous anomaly. While this case may be the result of an anatomic variation leading to the congenital absence of or early occlusion of the deep venous system, the insidious nature over many years argues against this. The absence of large cortical veins suggests a congenital abnormality of the venous structure. The child's presentation with a seizure-like event followed by protracted hemiparesis is consistent with venous ischemia. We propose that this is likely to represent a new clinicopathological entity.

Enterocutaneous fistula in the setting of ventriculoperitoneal shunt extrusion through the skin and perforation through the small bowel

The authors report a case of a 2-year-old boy with postinfectious hydrocephalus, managed with a ventriculoperitoneal (VP) shunt and complicated by shunt extrusion through the cranial skin. The shunt was removed due to concern for infection, and the child was found to have an enterocutaneous fistula (ECF) communicating along the shunt track between the small bowel and a clavicular sinus. Self-closure of the ECF was anticipated. Thus, the fistula was managed expectantly with dressing changes of the clavicular sinus, while the patient's malnutrition was managed in accordance with World Health Organization protocols. The presentation, prognosis and management of ECFs, including the likelihood of self-resolution and the role of expectant management, are discussed. Additionally, proposed mechanisms of ECF formation in the setting of a VP shunt are discussed, with an emphasis on the roles of infection and malnutrition.

Addicted to constructs: science in reverse?

Advancement in science requires clarity of constructs.Like other fields in behavioral science, addiction research is being held back by researchers' use of different terms to mean similar things (synonymy) and the same term to mean different things (polysemy). Journals can help researchers to stay focused on novel and significant research questions by challenging new terms introduced without adequate justification and requiring authors to be parsimonious in their use of terms. To support construct lucidity, new modes of thinking about research integration are needed to keep up with the aggregate of relevant research.