Clipping Technique for the Repair of the Intraoperative Cerebrospinal Fluid Leakage during Transsphenoidal Pituitary Tumor Surgery

Abstract BACKGROUND During transsphenoidal surgery (TSS) for a pituitary adenoma with a large suprasellar extension, cerebrospinal fluid (CSF) leakage commonly develops from a defect in the arachnoid recess or the arachnoid membrane. OBJECTIVE To evaluate the usefulness of a newly developed clipping technique for the repair of intraoperative CSF leakage. METHODS Between September 2012 and November 2016, 698 patients with pituitary adenoma were operated on with TSS. Intraoperative CSF leakage was encountered in 301 patients (43.1%). The clipping technique was used to repair CSF leakage in 144 patients: from the arachnoid recess in 100 patients and from the arachnoid membrane in 44 patients. The clipping technique used titanium clips and a newly designed clip applier. We evaluated anterior pituitary function of the patients whose CSF leakage was closed by clipping, and compared this with function in another patient group treated with different repair techniques. RESULTS We successfully applied clip technique in 140 out of 144 patients. This clipping technique was faster and easier for repairing CSF leakage than our previously published suture technique. In our early series, 4 patients developed unexpected CSF rhinorrhea after TSS. We found no difference in anterior pituitary function between a clipping group and others. Although titanium clip was identified on postoperative MRI, its metallic scattered artifact was very minimal and did not hinder the detection of possible remnant and recurrent tumors. CONCLUSION This clipping technique is a very simple and reliable method for repairing intraoperative CSF leakage when properly applied with caution.

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Spontaneous and medically induced cerebrospinal fluid leakage in the setting of pituitary adenomas: review of the literature

Neurosurgical FOCUS ◽

10.3171/2012.4.focus1268 ◽

2012 ◽

Vol 32 (6) ◽

pp. E2 ◽

Cited By ~ 37

Author(s):

Grace Lam ◽

Vivek Mehta ◽

Gabriel Zada

Keyword(s):

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Somatostatin Analogs ◽

Csf Leak ◽

Cerebrospinal Fluid Leakage ◽

Review Of The Literature ◽

Csf Rhinorrhea ◽

Clinical Scenarios ◽

Csf Leakage ◽

Csf Leaks

Object Spontaneous and medically induced CSF leaks are uncommonly associated with pituitary adenomas. The aim of this study was to further characterize the clinical scenarios most closely associated with this phenomenon. Methods A review of the literature was conducted to identify all cases of nonsurgical CSF leaks associated with pituitary adenomas. The authors aimed to identify associated risk factors and management strategies used to treat these tumors and repair the CSF leak site. Results Fifty-two patients with spontaneous or medically induced CSF leaks in the setting of a pituitary adenoma were identified from 29 articles published from 1980 through 2011. In 38 patients (73%), CSF rhinorrhea developed following initiation of medical therapy, whereas spontaneous CSF leakage developed as the presenting symptom in 14 patients (27%). The patients' mean age was 42.8 years (range 23–68 years). There were 35 males and 17 females. Forty-two patients (81%) had a prolactinoma, with the remaining patients having the following tumors: nonfunctioning pituitary adenoma (6 patients), growth hormone–secreting adenoma (2 patients), mammosomatotroph cell adenoma (1 patient), and ACTH-secreting adenoma (1 patient). Infrasellar tumor invasion into the paranasal sinuses was specifically reported in 56% of patients. The medical agents associated with CSF leakage were dopamine agonists (97%) and somatostatin analogs (3%). The average time from initialization of medical treatment to onset of rhinorrhea was 3.3 months (range 3 days–17 months). Nonsurgical management was successful in 4 patients, including 1 who had successful resolution with a temporary lumbar drain. Forty-six patients (88%) underwent surgical intervention to treat the CSF leak and/or resect the tumor. In 2 patients, surgery was not performed due to medical contraindications or patient preference. Conclusions Nonsurgical development of CSF rhinorrhea may occur in the setting of pituitary adenomas, especially following favorable response of invasive prolactinomas to initiation of dopamine agonist therapy. Additional cases have been reported as the presenting symptom of a pituitary adenoma and are likely to be related to decreased tumor volume due to intrinsic infarction or hemorrhage, ongoing invasion, and/or increases in intracranial pressure. Surgical repair, preferentially via a transsphenoidal approach, is the recommended initial treatment for definitive repair of the CSF leak and achievement of maximal tumor resection.

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Risk Factors For Postoperative Cerebrospinal Fluid Leakage After Transsphenoidal Surgery For Pituitary Adenoma: A Meta-Analysis And Systematic Review

10.21203/rs.3.rs-601428/v1 ◽

2021 ◽

Author(s):

Zhihuan Zhou ◽

Feifei Zuo ◽

Xiaoqun Chen ◽

Qinqin Zhao ◽

Mengna Luo ◽

...

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Cerebrospinal Fluid ◽

Pituitary Adenoma ◽

Cohort Studies ◽

Transsphenoidal Surgery ◽

Case Control ◽

Cochrane Library ◽

Cerebrospinal Fluid Leakage ◽

Csf Leakage

Abstract Objective: Postoperative cerebrospinal fluid (CSF) leakage represents a challenge even for experienced pituitary surgeons. We aimed to quantitatively synthesize data from studies regarding the risk factors for postoperative CSF leakage after transsphenoidal surgery (TSS) for pituitary adenoma (PA).Methods: PubMed, Web of Science, The Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), Wanfang database, and VIP database were searched for case–control and cohort studies, focusing on the risk factors associated with postoperative CSF leakage after TSS for PA. Pooled odds ratios (ORs) and 95% confidence intervals were calculated to determine the risk factors.Results: A total of 34 case–control and cohort studies involving a total of 9,144 patients with PA were included in this systematic review. The overall rate of postoperative CSF leakage after TSS for PA was 5.6%. Tumor size, adenoma consistency, revision surgery, and intraoperative CSF leakage were independent risk factors for postoperative CSF leakage (ORs, 3.18–6.33). By contrast, the endoscopic approach showed a slight protective benefit compared with the microscopic approach in TSS (OR, 0.69).Conclusions: This review provides a comprehensive overview of the quality of the evidence base, informing clinical staff of the importance of screening risk factors for postoperative CSF leakage after TSS for PA. More attention should be paid to PA patients at high risk for CSF leakage after TSS to reduce complications and improve prognosis.

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Cerebrospinal fluid fistula as the presenting manifestation of pituitary adenoma: case report with a 4-year follow-up

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2001000200023 ◽

2001 ◽

Vol 59 (2A) ◽

pp. 263-265 ◽

Cited By ~ 17

Author(s):

Ricardo Alexandre Hanel ◽

Daniel Monte Serrat Prevedello ◽

Alceu Correa ◽

Affonso Antoniuk ◽

João Cândido Araújo

Keyword(s):

Cerebrospinal Fluid ◽

Pituitary Adenoma ◽

Sella Turcica ◽

Rare Condition ◽

Normal Serum ◽

Cerebrospinal Fluid Fistula ◽

Csf Rhinorrhea ◽

Csf Leakage ◽

Bony Erosion

We report the case of a young woman who presented with cerebrospinal fluid (CSF) rhinorrhea due to an undiagnosed and untreated pituitary adenoma. The tumor had extended well beyond sella turcica and caused bony erosion. The patient initially refused surgery and was treated with bromocriptine and a radiation therapy. CSF leakage did not improved and she was submitted to surgery by the transsphenoidal approach with removal of a tumor mass located in sphenoid sinus and sellar region. Origin of the leak was localized and repaired with fascia lata and a lumbar subarachnoid drain was left in place for 5 days. After 4 years she has normal serum PRL levels and no rhinorrhea. The management, complications and mechanisms involved in this rare condition are discussed.

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Untreated Non-Functioning Pituitary Adenoma Causing Spontaneous Cerebrospinal Fluid Rhinorrhea: A Case Report

Journal of the Medical Association of Thailand ◽

10.35755/jmedassocthai.2020.09.11543 ◽

2020 ◽

Vol 103 (9) ◽

pp. 960-963

Keyword(s):

Cerebrospinal Fluid ◽

Pituitary Adenoma ◽

Transsphenoidal Surgery ◽

Case Reports ◽

Medical Attention ◽

Nasal Discharge ◽

Csf Rhinorrhea ◽

Cerebrospinal Fluid Rhinorrhea ◽

Presenting Symptoms ◽

Csf Leakage

Cerebrospinal fluid (CSF) leakage is common with traumatic brain injury or after transsphenoidal surgery (TSS). In contrast, spontaneous rhinorrhea caused by pituitary adenoma (PA) without prior treatment is rather unusual. Moreover, cases of non-functioning PA (NFPA) who seek medical attention without visual or hormonal symptoms but with watery nasal discharge, mistaken for rhinitis, and misled to delayed diagnosis, are extremely rare. The authors presented a case of spontaneous CSF rhinorrhea, confirmed by clinical, laboratory, and radiographic studies, caused by NFPA. Endoscopic TSS came across a typical PA, and subsequently, the sellar defect was successfully repaired. Pathological diagnosis of NFPA was established. The patient had an uncomplicated postoperative course and complete resolution of her presenting symptoms. A short review of prior case reports is also provided. Keywords: Spontaneous cerebrospinal fluid rhinorrhea, Pituitary adenoma, Non-functioning, Endoscopic transsphenoidal surgery

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Anterior Pituitary Function in Patients with Nonfunctioning Pituitary Adenoma: Results of Longitudinal Follow-up.

Endocrine Journal ◽

10.1507/endocrj.42.421 ◽

1995 ◽

Vol 42 (3) ◽

pp. 421-427 ◽

Cited By ~ 24

Author(s):

ATSUSHI TOMINAGA ◽

TOHRU UOZUMI ◽

KAZUNORI ARITA ◽

KAORU KURISU ◽

TAKASHI YANO ◽

...

Keyword(s):

Pituitary Adenoma ◽

Anterior Pituitary ◽

Pituitary Function ◽

Nonfunctioning Pituitary Adenoma ◽

Anterior Pituitary Function

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Sexual precocity in a boy due to hypersecretion of LH and prolactin by a pituitary adenoma

Acta Endocrinologica ◽

10.1530/acta.0.1020167 ◽

1983 ◽

Vol 102 (2) ◽

pp. 167-172 ◽

Cited By ~ 29

Author(s):

M. Faggiano ◽

T. Criscuolo ◽

L. Perrone ◽

C. Quarto ◽

A. A. Sinisi

Keyword(s):

Pituitary Adenoma ◽

Precocious Puberty ◽

Anterior Pituitary ◽

Pituitary Function ◽

Sexual Precocity ◽

Anterior Pituitary Function ◽

Suprasellar Extension

Abstract. The paper reports on precocious puberty and galactorrhoea in a 4 8/12 year old boy. Roentgenograms of the skull showed slight lateral bulging of sella floor and pneumoencephalography indicated a pituitary adenoma with a suprasellar extension. Pre-operative study of anterior pituitary function was normal except for increased values of LH (900 mIU/ml), testosterone (2000 ng/ml) and prolactin (215 ng/ml). After removal of a chromophobe pituitary adenoma by transfrontal surgery the galactorrhoea disappeared within 10 days. Post-operative endocrine evaluation showed immediate normalization of LH, testosterone and prolactin values.

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Apoplexy accompanying pituitary adenoma as a complication of preoperative anterior pituitary function tests

Acta Neurochirurgica ◽

10.1007/s00701-007-1155-8 ◽

2007 ◽

Vol 149 (6) ◽

pp. 557-565 ◽

Cited By ~ 13

Author(s):

A. Yoshino ◽

Y. Katayama ◽

T. Watanabe ◽

A. Ogino ◽

T. Ohta ◽

...

Keyword(s):

Pituitary Adenoma ◽

Anterior Pituitary ◽

Pituitary Function ◽

Function Tests ◽

Anterior Pituitary Function

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Risk factors for postoperative cerebrospinal fluid leakage after transsphenoidal surgery for pituitary adenoma: a meta-analysis and systematic review

BMC Neurology ◽

10.1186/s12883-021-02440-0 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Zhihuan Zhou ◽

Feifei Zuo ◽

Xiaoqun Chen ◽

Qinqin Zhao ◽

Mengna Luo ◽

...

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Cerebrospinal Fluid ◽

Pituitary Adenoma ◽

Cohort Studies ◽

Transsphenoidal Surgery ◽

Case Control ◽

Cochrane Library ◽

Cerebrospinal Fluid Leakage ◽

Csf Leakage

Abstract Objective Postoperative cerebrospinal fluid (CSF) leakage represents a challenge even for experienced pituitary surgeons. We aimed to quantitatively synthesize data from studies regarding the risk factors for postoperative CSF leakage after transsphenoidal surgery (TSS) for pituitary adenoma (PA). Methods PubMed, Web of Science, The Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), Wanfang database, and VIP database were searched for case–control and cohort studies, focusing on the risk factors associated with postoperative CSF leakage after TSS for PA. Pooled odds ratios (ORs) and 95% confidence intervals were calculated to determine the risk factors. Results A total of 34 case–control and cohort studies involving a total of 9,144 patients with PA were included in this systematic review. The overall rate of postoperative CSF leakage after TSS for PA was 5.6%. Tumor size, adenoma consistency, revision surgery, and intraoperative CSF leakage were independent risk factors for postoperative CSF leakage (ORs, 3.18–6.33). By contrast, the endoscopic approach showed a slight protective benefit compared with the microscopic approach in TSS (OR, 0.69). Conclusions This review provides a comprehensive overview of the quality of the evidence base, informing clinical staff of the importance of screening risk factors for postoperative CSF leakage after TSS for PA. More attention should be paid to PA patients at high risk for CSF leakage after TSS to reduce complications and improve prognosis.

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Direct Suture Technique of Normal Gland Edge on the Incised Dura Margin to Repair the Intraoperative Cerebrospinal Fluid Leakage From the Arachnoid Recess During Transsphenoidal Pituitary Tumor Surgery

Operative Neurosurgery ◽

10.1227/neu.0000000000000612 ◽

2015 ◽

Vol 11 (1) ◽

pp. 26-31 ◽

Cited By ~ 1

Author(s):

Eui Hyun Kim ◽

Tae Hoon Roh ◽

Hun Ho Park ◽

Ju Hyung Moon ◽

Je Beom Hong ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Fibrin Glue ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Suture Technique ◽

Cerebrospinal Fluid Leakage ◽

Csf Rhinorrhea ◽

Normal Gland ◽

Csf Leakage

Abstract BACKGROUND During transsphenoidal surgery for pituitary adenomas with large suprasellar extension, cerebrospinal fluid (CSF) leakage commonly develops from a defect at the arachnoid recess between the resected dura margin and the anterior edge of a normal pituitary gland (type 1 CSF leakage). OBJECTIVE To evaluate the usefulness of a direct suture technique of the normal gland edge on the incised dural margin to repair intraoperative CSF leakage from the arachnoid recess. METHODS Between November 2005 and December 2012, 861 patients with pituitary adenomas were operated on with transsphenoidal surgery, and intraoperative CSF leakage was encountered in 432 patients. Type 1 CSF leakage developed in a total of 122 patients, and their defects were repaired with the direct suture technique in 51 patients, whereas a fleece-coated fibrin glue patch alone was applied onto the defect in the other 71 patients. This direct suture technique required an additional 5 to 20 minutes in most cases. RESULTS We experienced no case of postoperative CSF rhinorrhea in the 51 patients whose defects were repaired by the direct suture technique and only 1 case of CSF rhinorrhea in 71 patients whose defects were repaired with a fleece-coated fibrin glue patch alone. There was no statistical difference in the outcome between 2 groups. Postoperative lumbar CSF drainage was not performed in any case. CONCLUSION Our 2 different repair techniques for arachnoid recess tears are very reliable methods for managing this type of CSF leakage. The direct suture technique may be more appropriate for type 1 CSF leakage with a wider gap and more prominent CSF leakage.

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