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

2012 ◽  
Vol 32 (6) ◽  
pp. E2 ◽  
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.

scholarly journals Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients

2018 ◽  
Vol 129 (2) ◽  
pp. 425-429 ◽  
Author(s):  
Ben A. Strickland ◽  
Joshua Lucas ◽  
Brianna Harris ◽  
Edwin Kulubya ◽  
Joshua Bakhsheshian ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenomas ◽  
Transsphenoidal Approach ◽  
Csf Leak ◽  
Sellar Region ◽  
Inclusion Criteria ◽  
Csf Rhinorrhea ◽  
Sellar Lesions ◽  
Sellar Reconstruction ◽  
Csf Leaks

OBJECTIVECerebrospinal fluid (CSF) rhinorrhea is among the most common complications following transsphenoidal surgery for sellar region lesions. The aim of this study was to review the authors’ institutional experience in identifying, repairing, and treating CSF leaks associated with direct endonasal transsphenoidal operations.METHODSThe authors performed a retrospective review of cases involving surgical treatment of pituitary adenomas and other sellar lesions at the University of Southern California between December 1995 and March 2016. Inclusion criteria included all pathology of the sellar region approached via a direct microscopic or endoscopic endonasal transsphenoidal approach. Demographics, pathology, intraoperative and postoperative CSF leak rates, and other complications were recorded and analyzed. A literature review of the incidence of CSF leaks associated with the direct endonasal transsphenoidal approach to pituitary lesions was conducted.RESULTSA total of 1002 patients met the inclusion criteria and their cases were subsequently analyzed. Preoperative diagnoses included pituitary adenomas in 855 cases (85.4%), Rathke’s cleft cyst in 94 (9.4%), and other sellar lesions in 53 (5.2%). Lesions with a diameter ≥ 1 cm made up 49% of the series. Intraoperative repair of an identified CSF leak was performed in 375 cases (37.4%) using autologous fat, fascia, or both. An additional 92 patients (9.2%) underwent empirical sellar reconstruction without evidence of an intraoperative CSF leak. Postoperative CSF leaks developed in 26 patients (2.6%), including 13 (1.3% of the overall group) in whom no intraoperative leak was identified. Among the 26 patients who developed a postoperative CSF leak, 13 were noted to have intraoperative leak and underwent sellar repair while the remaining 13 did not have an intraoperative leak or sellar repair. No patients who underwent empirical sellar repair without an intraoperative leak developed a postoperative leak. Eight patients underwent additional surgery (0.8% reoperation rate) for CSF leak repair, and 18 were successfully treated with lumbar drainage or lumbar puncture alone. The incidence of postoperative CSF rhinorrhea in this series was compared with that in 11 other reported series that met inclusion criteria, with incidence rates ranging between 0.6% and 12.1%.CONCLUSIONSIn this large series, half of the patients who developed postoperative CSF rhinorrhea had no evidence of intraoperative CSF leakage. Unidentified intraoperative CSF leaks and/or delayed development of CSF fistulas are equally important sources of postoperative CSF rhinorrhea as the lack of employing effective CSF leak repair methods. Empirical sellar reconstruction in the absence of an intraoperative CSF leak may be of benefit following resection of large tumors, especially if the arachnoid is thinned out and herniates into the sella.

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.

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

2019 ◽  
Vol 17 (4) ◽  
pp. 382-388
Author(s):  
Eui Hyun Kim ◽  
Ju Hyung Moon ◽  
Sun Ho Kim
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenoma ◽  
Anterior Pituitary ◽  
Pituitary Function ◽  
Cerebrospinal Fluid Leakage ◽  
Arachnoid Membrane ◽  
Csf Rhinorrhea ◽  
Csf Leakage ◽  
Anterior Pituitary Function ◽  
Clipping Technique

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.

Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas

2012 ◽  
Vol 116 (6) ◽  
pp. 1299-1303 ◽  
Author(s):  
Gautam U. Mehta ◽  
Edward H. Oldfield
Keyword(s):  
Cerebrospinal Fluid ◽  
Transsphenoidal Surgery ◽  
Surgical Repair ◽  
Fat Graft ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Cerebrospinal Fluid Drainage ◽  
Csf Drainage ◽  
Csf Leakage ◽  
Csf Leaks

Object Cerebrospinal fluid leakage is a major complication of transsphenoidal surgery. An intraoperative CSF leak, which occurs in up to 50% of pituitary tumor cases, is the only modifiable risk factor for postoperative leaks. Although several techniques have been described for surgical repair when an intraoperative leak is noted, none has been proposed to prevent an intraoperative CSF leak. The authors postulated that intraoperative CSF drainage would diminish tension on the arachnoid, decrease the rate of intraoperative CSF leakage during surgery for larger tumors, and reduce the need for surgical repair of CSF leaks. Methods The results of 114 transsphenoidal operations for pituitary macroadenoma performed without intraoperative CSF drainage were compared with the findings from 44 cases in which a lumbar subarachnoid catheter was placed before surgery to drain CSF at the time of dural exposure and tumor removal. Results Cerebrospinal fluid drainage reduced the rate of intraoperative CSF leakage from 41% to 5% (p < 0.001). This reduction occurred in macroadenomas with (from 57% to 5%, p < 0.001) and those without suprasellar extension (from 29% to 0%, p = 0.31). The rate of postoperative CSF leakage was similar (5% vs 5%), despite the fact that intraoperative CSF drainage reduced the need for operative repair (from 32% to 5%, p < 0.001). There were no significant catheter-related complications. Conclusions Cerebrospinal fluid drainage during transsphenoidal surgery for macroadenomas reduces the rate of intraoperative CSF leaks. This preventative measure obviated the need for surgical repair of intraoperative CSF leaks using autologous fat graft placement, other operative techniques, postoperative lumbar drainage, and/or reoperation in most patients and is associated with minimal risks.

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

2015 ◽  
Vol 11 (1) ◽  
pp. 26-31 ◽  
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.

The Use of Methylene Blue Staining Test in Determining the CSF Leaks Location of the Anterior Skull Base

2018 ◽  
Vol 69 (6) ◽  
pp. 1376-1377
Author(s):  
Razvan Hainarosie ◽  
Teodora Ghindea ◽  
Irina Gabriela Ionita ◽  
Mura Hainarosie ◽  
Cristian Dragos Stefanescu ◽  
...  
Keyword(s):  
Methylene Blue ◽  
Cerebrospinal Fluid ◽  
Intrathecal Injection ◽  
Diagnostic Procedures ◽  
Blue Staining ◽  
Csf Leak ◽  
Glucose Content ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Csf Leakage

Cerebrospinal fluid rhinorrhea represents drainage of cerebrospinal fluid into the nasal cavity. The first steps in diagnosing CSF rhinorrhea are a thorough history and physical examination of the patient. Other diagnostic procedures are the double ring sign, glucose content of the nasal fluid, Beta-trace protein test or beta 2-transferrin. To establish the exact location of the defect imagistic examinations are necessary. However, the gold standard CSF leakage diagnostic method is an intrathecal injection of fluorescein with the endoscopic identification of the defect. In this paper we analyze a staining test, using Methylene Blue solution, to identify the CSF leak�s location.

scholarly journals Cerebrospinal fluid leakage after cranial surgery in the pediatric population—a systematic review and meta-analysis

2021 ◽  
Author(s):  
Emma M. H. Slot ◽  
Kirsten M. van Baarsen ◽  
Eelco W. Hoving ◽  
Nicolaas P. A. Zuithoff ◽  
Tristan P. C van Doormaal
Keyword(s):  
Risk Factors ◽  
Systematic Review ◽  
Cerebrospinal Fluid ◽  
Pediatric Population ◽  
Meta Analysis ◽  
Leakage Rate ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Cranial Surgery ◽  
Csf Leakage

Abstract Background Cerebrospinal fluid (CSF) leakage is a common complication after neurosurgical intervention. It is associated with substantial morbidity and increased healthcare costs. The current systematic review and meta-analysis aim to quantify the incidence of cerebrospinal fluid leakage in the pediatric population and identify its risk factors. Methods The authors followed the PRISMA guidelines. The Embase, PubMed, and Cochrane database were searched for studies reporting CSF leakage after intradural cranial surgery in patients up to 18 years old. Meta-analysis of incidences was performed using a generalized linear mixed model. Results Twenty-six articles were included in this systematic review. Data were retrieved of 2929 patients who underwent a total of 3034 intradural cranial surgeries. Surprisingly, only four of the included articles reported their definition of CSF leakage. The overall CSF leakage rate was 4.4% (95% CI 2.6 to 7.3%). The odds of CSF leakage were significantly greater for craniectomy as opposed to craniotomy (OR 4.7, 95% CI 1.7 to 13.4) and infratentorial as opposed to supratentorial surgery (OR 5.9, 95% CI 1.7 to 20.6). The odds of CSF leakage were significantly lower for duraplasty use versus no duraplasty (OR 0.41 95% CI 0.2 to 0.9). Conclusion The overall CSF leakage rate after intradural cranial surgery in the pediatric population is 4.4%. Risk factors are craniectomy and infratentorial surgery. Duraplasty use is negatively associated with CSF leak. We suggest defining a CSF leak as “leakage of CSF through the skin,” as an unambiguous definition is fundamental for future research.

A Single Layer Synthetic Dural Substitute Inlay is an Effective Sellar Reconstruction Technique in Endoscopic Transsphenoidal Pituitary Surgery

2020 ◽  
Author(s):  
Mark B. Chaskes ◽  
Tawfiq Khoury ◽  
Chandala Chitguppi ◽  
Pascal Lavergne ◽  
Gurston G. Nyquist ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Tertiary Care ◽  
Single Layer ◽  
Csf Leak ◽  
Reconstruction Technique ◽  
Potential Cost ◽  
Lumbar Drainage ◽  
Dural Substitute ◽  
Sellar Reconstruction ◽  
Csf Leaks

Abstract Objectives A variety of endonasal sellar repair techniques have been described; many are complex, multilayered, and carry potential morbidity. We propose an effective, technically simple single-layer repair for select sellar defects, including those with an intraoperative cerebrospinal fluid (CSF) leak. Our technique utilizes only a synthetic dural substitute inlay and dural sealant glue without packing or lumbar drainage. Design This is a retrospective review-based study. Setting This study was conducted at tertiary care center. Participants Patients who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with the aforementioned inlay technique. Patients were selected for this technique if they had an identified intraoperative CSF leak, a patulous diaphragm (expanded and thinned diaphragma sella), or a comorbidity excluding them from a simpler onlay only reconstruction. Outcome Measures Postoperative CSF leak and sinonasal morbidity included in the study Results A total of 409 subjects were identified; 368 were initial resections. Gross total resection of the pituitary adenoma was achieved in 356 (87.0%) cases. Average tumor size was 2.6 ± 1.1 cm. Average tumor volume was 10.8 ± 12.1 cm3. There were 135 intraoperative CSF leaks and 196 patulous diaphragms. There were five postoperative CSF leaks (1.2%), all of which occurred in the first half of our series. Pre- and postoperative sino-nasal outcomes test-22 scores were 19.2 ± 18.2 and 18.8 ± 21.3 (p = 0.492), respectively. Conclusion A synthetic dural substitute inlay and dural sealant glue is an excellent single-layer repair for sellar defects, even those with an intraoperative CSF leak. This technique is highly effective in preventing postoperative CSF leaks and does not utilize packing or lumbar drainage. It also avoids the potential cost and morbidity associated with more complex and multilayered closures.

Acquired Chiari I malformation secondary to spontaneous spinal cerebrospinal fluid leakage and chronic intracranial hypotension syndrome in seven cases

1998 ◽  
Vol 88 (2) ◽  
pp. 237-242 ◽  
Author(s):  
John L. D. Atkinson ◽  
Brian G. Weinshenker ◽  
Gary M. Miller ◽  
David G. Piepgras ◽  
Bahram Mokri
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Hypotension ◽  
Chiari I Malformation ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Content Type ◽  
Intracranial Hypotension Syndrome ◽  
Csf Leakage ◽  
Chiari I ◽  
Fine Print

Object. Spontaneous spinal cerebrospinal fluid (CSF) leakage with development of the intracranial hypotension syndrome and acquired Chiari I malformation due to lumbar spinal CSF diversion procedures have both been well described. However, concomitant presentation of both syndromes has rarely been reported. The object of this paper is to present data in seven cases in which both syndromes were present. Three illustrative cases are reported in detail. Methods. The authors describe seven symptomatic cases of spontaneous spinal CSF leakage with chronic intracranial hypotension syndrome in which magnetic resonance (MR) images depicted dural enhancement, brain sagging, loss of CSF cisterns, and acquired Chiari I malformation. Conclusions. This subtype of intracranial hypotension syndrome probably results from chronic spinal drainage of CSF or high-flow CSF shunting and subsequent loss of brain buoyancy that results in brain settling and herniation of hindbrain structures through the foramen magnum. Of 35 cases of spontaneous spinal CSF leakage identified in the authors' practice over the last decade, MR imaging evidence of acquired Chiari I malformation has been shown in seven. Not to be confused with idiopathic Chiari I malformation, ideal therapy requires recognition of the syndrome and treatment directed to the site of the spinal CSF leak.

scholarly journals Pediatric Pituitary Adenoma: Case Series, Review of the Literature, and a Skull Base Treatment Paradigm

2018 ◽  
Vol 79 (01) ◽  
pp. 091-114 ◽  
Author(s):  
Avital Perry ◽  
Christopher Graffeo ◽  
Christopher Marcellino ◽  
Bruce Pollock ◽  
Nicholas Wetjen ◽  
...  
Keyword(s):  
Systematic Review ◽  
Pituitary Adenoma ◽  
Skull Base ◽  
Pituitary Adenomas ◽  
Pediatric Population ◽  
Csf Leak ◽  
Persistent Disease ◽  
Treatment Paradigm ◽  
Surgical Cure

Background Pediatric pituitary adenoma is a rare skull base neoplasm, accounting for 3% of all intracranial neoplasms in children and 5% of pituitary adenomas. Compared with pituitary tumors in adults, secreting tumors predominate and longer disease trajectories are expected due to the patient age resulting in a natural history and treatment paradigm that is complex and controversial. Objectives The aims of this study were to describe a large, single-institution series of pediatric pituitary adenomas with extensive long-term follow-up and to conduct a systematic review examining outcomes after pituitary adenoma surgery in the pediatric population. Methods The study cohort was compiled by searching institutional pathology and operative reports using diagnosis and site codes for pituitary and sellar pathology, from 1956 to 2016. Systematic review of the English language literature since 1970 was conducted using PubMed, MEDLINE, Embase, and Google Scholar. Results Thirty-nine surgically managed pediatric pituitary adenomas were identified, including 15 prolactinomas, 14 corticotrophs, 7 somatotrophs, and 4 non-secreting adenomas. All patients underwent transsphenoidal resection (TSR) as the initial surgical treatment. Surgical cure was achieved in 18 (46%); 21 experienced recurrent/persistent disease, with secondary treatments including repeat surgery in 10, radiation in 14, adjuvant pharmacotherapy in 11, and bilateral adrenalectomy in 3. At the last follow-up (median 87 months, range 3–581), nine remained with recurrent/persistent disease (23%).Thirty-seven publications reporting surgical series of pediatric pituitary adenomas were included, containing 1,284 patients. Adrenocorticotropic hormone (ACTH)-secreting tumors were most prevalent (43%), followed by prolactin (PRL)-secreting (37%), growth hormone (GH)-secreting (12%), and nonsecreting (7%). Surgical cure was reported in 65%. Complications included pituitary insufficiency (23%), permanent visual dysfunction (6%), chronic diabetes insipidus (DI) (3%), and postoperative cerebrospinal fluid (CSF) leak (4%). Mean follow-up was 63 months (range 0–240), with recurrent/persistent disease reported in 18% at the time of last follow-up. Conclusion Pediatric pituitary adenomas are diverse and challenging tumors with complexities far beyond those encountered in the management of routine adult pituitary disease, including nuanced decision-making, a technically demanding operative environment, high propensity for recurrence, and the potentially serious consequences of hypopituitarism with respect to fertility and growth potential in a pediatric population. Optimal treatment requires a high degree of individualization, and patients are most likely to benefit from consolidated, multidisciplinary care in highly experienced centers.

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