scholarly journals CSF Rhinorrhea Following Medical Treatment for Prolactinoma: Management and Challenges

2019 ◽  
Vol 80 (06) ◽  
pp. 620-625
Author(s):  
Arivazhagan Arimappamagan ◽  
Nishanth Sadashiva ◽  
Sandeep Kandregula ◽  
Dhaval Shukla ◽  
Sampath Somanna
Keyword(s):  
Medical Treatment ◽  
Skull Base ◽  
Rare Complication ◽  
Csf Leak ◽  
Serum Prolactin ◽  
Management Options ◽  
Endoscopic Repair ◽  
Csf Rhinorrhea ◽  
Preoperative Serum ◽  
Potential Risk Factors

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.

scholarly journals A retrospective study to analyze treatment of post traumatic cerebro spinal fluid rhinorrhea and role of trans cranial pedicled pericranial repair in present day context

2022 ◽  
Vol 7 (4) ◽  
pp. 111-118
Author(s):  
Shashivadhanan ◽  
Abhishek Mishra
Keyword(s):  
Retrospective Study ◽  
Skull Base ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Spinal Fluid ◽  
Csf Leak ◽  
Care Hospital ◽  
Endoscopic Repair ◽  
Csf Rhinorrhea ◽  
Post Traumatic

: Skull base fractures are a major cause of morbidity and mortality in head injury. Anterior cranial Fossa (ACF) skull base fracture, leading to Cerebro Spinal Fluid (CSF) Rhinorrhea is one of the most commonly encountered presentation in ACF base fractures. The key to successful management of such cases lies in early diagnosis and surgical management before it leads to meningitis and avoidable mortality.To evaluate the cases of post traumatic CSF rhinorrhea and analyze the parameters utilized to guide the management strategies. An attempt was made to come up with guidelines for its management in a tertiary care hospital.This was a retrospective study in which all cases of traumatic CSF Rhinorrhea admitted to Tertiary care hospital were included. Patients were divided into three groups. First group was conservatively managed in which the rhinorrhea and serial imaging findings showed favourable response.In thesecond group patients were subjected to endoscopic repair by the ENT surgeon based on anatomical considerations. The third group included patients who were had failed the trial of conservative management and the site of leak did not favor endoscopic repair.The outcomes in all these groups were analyzed and conclusions drawn.A total of 54 patients were included in the study which was conducted between Jan 2014 to 2020. 24 were successfully managed conservatively,10 were managed with endoscopic repair and 20 were managed by bifrontal craniotomy and pedicled pericranial ACF Base repair. There was one case from the first group who developed CSF leak after one month necessitating ACF base repair. There was no recurrence reportedin the cases managed endoscopically, whereas one case subjected to craniotomy had recurrence requiring lumbar drain placement. With each transcranial surgery there was a refinement in the technique further minimizing complications. We have elaborated on the surgical nuances to ensurebetter outcomes. : Pedicledpericranial flap ACF base repair is an elegant approach which requires an understanding of the mechanism of CSF leak from skull base fractures. This procedure can easily be mastered and when performed correctly provides best results for cases where there are multiple ACF defects, those not accessible by endoscope and also in those cases where imaging is not able to localize the exact site of defect leading to CSF rhinorrhea. Anosmia is an in evitable complication of this procedure. However, the trade off between mortality resulting from meningitis versus anosmia makes it a viable and attractive treatment option.

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

2018 ◽  
Vol 11 ◽  
pp. 117955141875864 ◽  
Author(s):  
Souha S Elabd ◽  
Maswood M Ahmad ◽  
Sameer Q Qetab ◽  
Mussa Hussain Almalki
Keyword(s):  
Cerebrospinal Fluid ◽  
Medical Treatment ◽  
Case Reports ◽  
Rare Complication ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Surgical Interventions ◽  
Tension Pneumocephalus ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Uncommon Presentation

Cerebrospinal fluid (CSF) rhinorrhea is rarely reported as the first presenting feature of giant invasive macroprolactinomas. Cerebrospinal fluid rhinorrhea is usually reported as a complication of trauma, neurosurgical, and skull-based procedures (such as pituitary surgery or radiations), and less frequently after medical treatment with dopamine agonists (DAs) for macroprolactinomas. This phenomenon results from fistula creation that communicates between the subarachnoid space and the nasal cavity. Meanwhile, pneumocephalus is another well-recognized complication after transsphenoidal surgery for pituitary macroadenomas. This entity may present with nausea, vomiting, headache, dizziness, and more seriously with seizures and/or a decreased level of consciousness if tension pneumocephalus develops. Case reports about the occurrence of spontaneous pneumocephalus after medical treatment with DAs without prior surgical interventions are scarce in the literature. Our index case is a young man who was recently diagnosed with a giant invasive prolactin-secreting pituitary macroadenoma with skull base destruction. A few months before this diagnosis, he presented with spontaneous CSF rhinorrhea with no history of previous medical or surgical treatment. In this case report, we report an uncommon presentation for giant invasive macroprolactinoma with a CSF leak treated with cabergoline that was subsequently complicated by meningitis and pneumocephalus. This is a very rare complication of cabergoline therapy, which occurred approximately 1 month after treatment initiation.

Pneumocephalus and CSF leak secondary to skull base fracture by pyrotechnical object: case report

2021 ◽  
Vol 3 (3) ◽  
Author(s):  
Marcos Vilca ◽  
◽  
Carlos Palacios ◽  
Sofía Rosas ◽  
Ermitaño Bautista ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Pressure ◽  
Skull Base ◽  
Rare Complication ◽  
Cerebrospinal Fluid Leak ◽  
Standing Position ◽  
Csf Leak ◽  
Skull Base Fracture ◽  
Timely Diagnosis ◽  
The Right

Introduction: Pneumocephalus is mainly associated with traumatic injuries, being a rare complication but with high mortality rates; it behaves like a space-occupying lesion and increases intracranial pressure. The symptoms are not specific, but in the event of trauma it is necessary to suspect this entity to carry out a timely diagnosis and treatment, since being the product of the skull base fracture it can cause communication with the outside, and the appearance of cerebrospinal fluid (CSF) leak. Clinical Case: a 38-year-old male patient who suffers trauma from a pyrotechnic explosion near his right ear, when handling a pyrotechnic object (whistle) during the New Year, presenting severe pain, slight bleeding in the right ear, feeling faint and holocranial headache that increased in a standing position; likewise, he presents high-flow aqueous secretion (CSF) from the right ear. Brain and skull base tomography (CT) showed air in the intracranial cavity, fracture of the skull base, and the ossicles of the right middle ear. Conservative management was performed using rest and lumbar drainage, presenting a satisfactory evolution. Conclusion: Pneumocephalus is a frequent and expected complication of trauma with a skull base fracture. Its early and timely diagnosis using skull base CT is essential to define therapeutic measures. Accidents due to the misuse of pyrotechnics continue to be a relevant problem in our country. Knowing and disseminating its consequences can help raise awareness in the population. Keywords: Pneumocephalus, Skull Base, Intracranial Pressure, Cerebrospinal Fluid Leak. (Source: MeSH NLM)

Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea: Learning from Our Failures

2001 ◽  
Vol 15 (5) ◽  
pp. 333-342 ◽  
Author(s):  
Paolo Castelnuovo ◽  
Silvia Mauri ◽  
Davide Locatelli ◽  
Enzo Emanuelli ◽  
Giovanni Delù ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Success Rate ◽  
Csf Leak ◽  
Graft Material ◽  
Literature Analysis ◽  
Endoscopic Repair ◽  
Common Procedure ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea

Endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea is becoming a common procedure. The purpose of this study was to perform a literature analysis centering cases of treatment failure and to review our 31 cases with a 1-year minimum follow-up. An extensive search of the literature was conducted, which focused on success rate, follow-up, diagnostic techniques, graft material used, failure rate, and comments on failures. A retrospective analysis of our 31 patients was carried out, and all cases were treated with the endoscopic approach with a 1-year minimum follow-up. From the literature analysis, the median success rate at the first endoscopic attempt is 90%. Our success rate was 87.1%. Failures were analyzed. A unique protocol for CSF leak diagnosis does not exist; we suggest our diagnostic algorithm. Graft material used depends on the authors’ experience, and based on this review of cases to date, did not significantly influence the success rate. The analysis of cases of failure shows that the majority of authors omit details. More research is needed to improve prevention of failures.

Detection of Cerebrospinal Fluid Leaks Using the Endoscopic Fluorescein Test in the Post-Operative Period Following Pituitary and Ventral Skull Base Surgery

2021 ◽  
Author(s):  
Peter A. Benedict ◽  
Joseph R. Connors ◽  
Micah R. Timen ◽  
Nupur Bhatt ◽  
Richard Lebowitz ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Postoperative Period ◽  
Skull Base Surgery ◽  
Tertiary Care ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Predictive Values ◽  
Ventral Skull Base ◽  
Csf Leaks

Objective: Diagnosis of cerebrospinal fluid (CSF) leaks is sometimes challenging in the postoperative period following pituitary and ventral skull base surgery. Intrathecal fluorescein (ITF) may be useful in this setting. Design: Retrospective chart review Setting: Tertiary care center Methods and Participants: All patients who underwent pituitary and ventral skull base surgery performed by a single rhinologist between January 2017–March 2020 were included. There were 103 patients identified. Eighteen patients received 20 ITF injections due to clinical suspicion for CSF leak during the postoperative period without florid CSF rhinorrhea on clinical exam. Computed tomography scans with new or increasing intracranial air and intra-operative findings were used to confirm CSF leaks. Clinical courses were reviewed for at least 6 months after initial concern for leak as the final determinate of CSF leak. Main Outcome Measures: Specificity and safety of ITF Results: Eleven (61%) ITF patients were female and 7 (39%) were male. Average patient age was 52.50±11.89. There were 6 patients with confirmed postoperative CSF leaks, 3 of whom had evaluations with ITF. ITF use resulted in 2 true positives, 1 false negative, 17 true negatives and 0 false positives. ITF sensitivity was 67%, specificity was 100%, and positive and negative predictive values were 100% and 94.4%, respectively. There were no adverse effects from ITF use. Conclusions: Existing modalities for detecting postoperative CSF leaks suffer from suboptimal sensitivity and specificity, delayed result reporting, or limited availability. Intrathecal fluorescein represents a specific and safe test with potential utility in the postoperative setting.

scholarly journals Surgically repaired posttraumatic CSF rhinorrhea: An institutional experience and review of literature

2012 ◽  
Vol 01 (01) ◽  
pp. 023-027
Author(s):  
Brijesh Kumar ◽  
Rabinarayan Sahu ◽  
A.K. Srivastava ◽  
Anup Nair ◽  
Anant Mehrotra ◽  
...  
Keyword(s):  
Skull Base ◽  
Early Onset ◽  
Review Of Literature ◽  
Endoscopic Repair ◽  
Csf Rhinorrhea ◽  
Skull Base Fracture ◽  
Institutional Experience ◽  
History Of ◽  
Extradural Approach ◽  
Better Than

AbstractPosttraumatic cerebrospinal fluid (CSF) rhinorrhea frequently complicates anterior skull base fracture. Although skull base fracture is present in only about 7% cases of head injury, CSF rhinorrhea develops in 30% of cases with basal fracture.A total of 43 cases admitted in our Institute (SGPGI Lucknow) from January 2000 to June 2011with history of head trauma followed by CSF rhinorrhea. Forty one cases were included in this study as two patients refused surgery.Out of forty one cases, 26 cases (63%) were admitted with history of recurrent meningitis, 21 cases (51%) with loss of smell, 26 cases (63%) with delayed onset CSF rhinorrhea, 3 cases (7%) with early onset rhinorrhea which did not improve after trauma, 12 cases (30%) with early onset rhinorrhea which improved but reappeared after some time. Twenty cases (48.8%) were repaired by extradural approach, 10 cases (24.4%) were repaired by intradural approach and 11 cases (26.8%) were repaired by endoscopic approach. 12 cases (29.0%) required re-surgery for persistent or recurrence of CSF rhinorrhea.Although posttraumatic CSF rhinorrhea usually resolves with conservative management, its persistence makes an individual prone for further complications like meningitis, brain abscess and septicaemia. Timely surgical intervention usually gives promising results. Endoscopic repair was better than transcranial repair.

Lack of causal association between spontaneous intracranial hypotension and cranial cerebrospinal fluid leaks

2012 ◽  
Vol 116 (4) ◽  
pp. 749-754 ◽  
Author(s):  
Wouter I. Schievink ◽  
Marc S. Schwartz ◽  
M. Marcel Maya ◽  
Franklin G. Moser ◽  
Todd D. Rozen
Keyword(s):  
Skull Base ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Spinal Imaging ◽  
Radiological Data ◽  
Single Instance ◽  
Csf Leakage ◽  
Csf Leaks

Object Spontaneous intracranial hypotension is an important cause of headaches and an underlying spinal CSF leak can be demonstrated in most patients. Whether CSF leaks at the level of the skull base can cause spontaneous intracranial hypotension remains a matter of controversy. The authors' aim was to examine the frequency of skull base CSF leaks as the cause of spontaneous intracranial hypotension. Methods Demographic, clinical, and radiological data were collected from a consecutive group of patients evaluated for spontaneous intracranial hypotension during a 9-year period. Results Among 273 patients who met the diagnostic criteria for spontaneous intracranial hypotension and 42 who did not, not a single instance of CSF leak at the skull base was encountered. Clear nasal drainage was reported by 41 patients, but a diagnosis of CSF rhinorrhea could not be established. Four patients underwent exploratory surgery for presumed CSF rhinorrhea. In addition, the authors treated 3 patients who had a postoperative CSF leak at the skull base following the resection of a cerebellopontine angle tumor and developed orthostatic headaches; spinal imaging, however, demonstrated the presence of a spinal source of CSF leakage in all 3 patients. Conclusions There is no evidence for an association between spontaneous intracranial hypotension and CSF leaks at the level of the skull base. Moreover, the authors' study suggests that a spinal source for CSF leakage should even be suspected in patients with orthostatic headaches who have a documented skull base CSF leak.

S269 – Anterior Cerebral Artery Syndrome: A Silent Killer in ESS

2008 ◽  
Vol 139 (2_suppl) ◽  
pp. P165-P165
Author(s):  
Nicolas Charbonneau ◽  
Shaun Kilty ◽  
Robert Moumdjian ◽  
Khalil Al-Macki ◽  
Mohammad Maleki ◽  
...  
Keyword(s):  
Skull Base ◽  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Rare Complication ◽  
Case Series ◽  
Operative Management ◽  
Csf Leak ◽  
Endonasal Surgery ◽  
Pseudoaneurysm Formation ◽  
Neurovascular Imaging

Objectives This presentation will help the physician optimize their management of this rare complication. Methods Presentation of a case series from our experience with the management of 3 endonasal surgery complications of intracranial hemorrhage due to anterior cerebral artery trauma. We present a review of the literature and propose an algorithm for the prompt and appropriate management of this complication. Results The recognition of actual or potential intracranial vascular injury following trauma to the skull base during endonasal surgery requires prompt identification and management that extends beyond that of simple CSF leak repair. During the immediate post-operative period, identification of the extent of injury with neurovascular imaging studies and early neurosurgical consultation is essential. Intermediate peri-operative management focuses on the prevention of the additional complications of intracranial infection, an intracranial hematoma, and pseudoaneurysm formation by using staged angiography. Long-term management focuses on optimizing a patient's functional outcome with selective use of MRI to evaluate brain healing while assessing the risk for developing a convulsive disorder. Conclusions Awareness of the potential for trauma to the anterior cerebral artery complex following skull base penetration during endonasal surgery will allow a surgeon to better anticipate and manage its potential sequelae, thereby reducing the risk of an unfavorable outcome.

Excavating Meningoencephaloceles: A Newly Recognized Entity

2017 ◽  
Vol 31 (2) ◽  
pp. 127-134 ◽  
Author(s):  
Patricia A. Loftus ◽  
Sarah K. Wise ◽  
Pedram Daraei ◽  
Kristen Baugnon ◽  
John M. DelGaudio
Keyword(s):  
Ct Scan ◽  
Skull Base ◽  
Operating Room ◽  
Tertiary Care ◽  
Distinct Type ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Skull Base Defect ◽  
Skull Base Defects ◽  
Csf Leaks

Background Spontaneous cerebrospinal fluid (CSF) leaks are largely attributed to idiopathic intracranial hypertension and typically present as skull base defects with or without prolapse of intracranial contents. However, in our practice, we have encountered a distinct type of spontaneous CSF leak that presents in a different manner. Objective To discuss a newly-classified, difficult to treat, subset of spontaneous CSF leaks that present as excavation of the bone of the skull base in a tunnel- or canal-like fashion by a meningocele or meningoencephalocele instead of as a localized area of bony dehiscence. Methods A retrospective review was performed at a tertiary care rhinology practice to identify a subset of CSF leak patients with an excavating/canal-like skull base defect visualized radiographically on computed tomography (CT) scan or magnetic resonance imaging and/or endoscopically in the operating room. Results The cohort of patients consisted of 7 females and 1 male with an average age of 53.6 years and a self-reported race of 4:3:1 African-American: Caucasian-Indian. All patients presented with CSF rhinorrhea. The most common leak site was the cribriform and upper septum. Six of the 8 patients had multiple defects and/or progression of their skull base defects, and 5 patients required multiple and/or repeat repairs in the operating room. Seven of the 8 patients underwent a cisternogram because the excavating nature of the leaks made it difficult to identify the specific leak site on high-resolution CT scan alone. Conclusion In spontaneous CSF leaks that are difficult to identify or recur soon after a proper repair, an excavating pattern should be considered. Failure to recognize this type of leak and all of its tributaries, to fully unroof the excavated bone to completely resect the meningocele, and to visualize and close the site of origin will likely result in failure and recurrence of CSF leak.

Endonasal Endoscopic Management of Frontal Sinus Cerebrospinal Fluid Leak

2017 ◽  
Vol 31 (6) ◽  
pp. 406-411 ◽  
Author(s):  
Javaneh Jahanshahi ◽  
Mehdi Zeinalizadeh ◽  
Hasan Reza Mohammadi ◽  
Seyed Mousa Sadrehosseini
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Frontal Sinus ◽  
Surgical Approaches ◽  
Endoscopic Management ◽  
Graft Material ◽  
Endoscopic Repair ◽  
Skull Base Reconstruction ◽  
Csf Rhinorrhea

Background A frontal sinus leak is uncommon and is seen in ∼15% of cases of patients with cerebrospinal fluid (CSF) rhinorrhea. Now, endonasal endoscopic techniques have been reported to reconstruct skull base defects in the frontal sinus with a favorable outcome. Objective To review our experience in the repair of frontal sinus CSF leaks through an endonasal endoscopic approach. Methods Twenty-four patients with a frontal sinus leak who underwent endonasal endoscopic repair entered the study. Clinical presentation, location, frontal sinusotomy, graft material, follow-up, and frontal sinus status were evaluated. Results Among >100 cases of surgically repaired CST rhinorrhea, the frontal sinus was the site of the leak in 24 patients (mean age, 28.9 years; mean follow-up, 22 months). The etiology consisted of spontaneous leak and traumatic leak; whereas patients with skull base reconstruction after removal of tumor were excluded. Surgical approaches included Draf IIb, Draf III, Draf IIa in 20, 3, and 1 patients, respectively. Tree autografts as two-layer inlay fat–muscle and onlay fascia lata were used in the majority of patients. A success rate was achieved in 95.83% of the patients. Conclusion Endonasal endoscopic repair of a frontal sinus leak was a successful procedure, with a low failure rate and minimal morbidity.

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