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

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.

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Universal Sellar Anatomical Reconstruction Using the Sellar Floor Flap after Endoscopic Pituitary Adenoma Surgery

Otolaryngology ◽

10.1177/0194599818756861 ◽

2018 ◽

Vol 158 (4) ◽

pp. 774-776 ◽

Cited By ~ 2

Author(s):

Zixiang Cong ◽

Kaidong Liu ◽

Guodao Wen ◽

Liang Qiao ◽

Handong Wang ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Pituitary Adenoma ◽

Csf Leak ◽

Anatomical Reconstruction ◽

Endoscopic Endonasal ◽

Reconstructive Technique ◽

Sellar Reconstruction ◽

Sellar Floor ◽

Csf Leaks

Postoperative cerebrospinal fluid (CSF) leaks still occur in patients without intraoperative CSF leaks after endoscopic endonasal pituitary adenoma surgery. We propose a reconstructive technique, the sellar floor flap (SFF), for universal sellar anatomical reconstruction. A total of 113 patients without intraoperative CSF leaks after endoscopic endonasal pituitary adenoma surgery from July 2013 to June 2016 were reviewed: 43 underwent sellar reconstruction with the SFF (the SFF group) and 70 underwent sellar packing only (the nonreconstruction group). No case of postoperative CSF leak was reported in the SFF group, whereas 7 cases were reported in the nonreconstruction group ( P < .05). The SFF is suitable for universal reconstruction after endoscopic endonasal pituitary adenoma surgery and may decrease postoperative CSF leak.

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

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/a-1722-4433 ◽

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.

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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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SPONTANEOUS CEREBROSPINAL FLUID LEAK AFTER INITIATION OF DOPAMINE AGONIST THERAPY IN MACROPROLACTINOMAS: TWO CASE REPORTS AND A LITERATURE REVIEW

AACE Clinical Case Reports ◽

10.4158/aacr-2019-0372 ◽

2020 ◽

Vol 6 (2) ◽

pp. e90-e93

Author(s):

Jonea Lim ◽

Mitali Talsania ◽

Madona Azar

Keyword(s):

Magnetic Resonance Imaging ◽

Cerebrospinal Fluid ◽

Magnetic Resonance ◽

Dopamine Agonist ◽

Csf Leak ◽

Resonance Imaging ◽

Csf Rhinorrhea ◽

History Of ◽

Beta 2 ◽

Csf Leaks

Objective: To describe 2 spontaneous cerebrospinal fluid (CSF) leaks complicating treatment of macroprolactinoma (MPRL) with dopamine agonist (DA) therapy. Methods: We present the 2 cases of spontaneous, DA-related CSF leaks. Prolactin levels were used to assess hyperprolactinemia. Beta-2 transferrin was tested in rhinorrhea fluid, and magnetic resonance imaging was used to assess the sella. Results: Case 1 was a 45-year-old woman with a history of MPRL, recently started on bromocriptine at 15 mg/day, presented with clear rhinorrhea, headache, and nuchal rigidity. Magnetic resonance imaging showed a large sellar lesion extending into the cavernous sinuses, posterior sphenoid sinuses, and suprasellar cistern. Computed tomography revealed areas concerning for bony erosion, likely representing leak sites, and the rhinorrhea fluid was positive for beta-2 transferrin, confirming the CSF source. Empiric antibiotics for meningitis were given and she underwent urgent neuroendoscopic, transsphenoidal CSF leak repair and debulking of the pituitary mass. Case 2 was a 55-year-old man with a 10-year history of untreated MPRL who was started on bromocriptine at 5 mg/day 2 weeks prior to admission. He presented with clear rhinorrhea and a metallic taste in his mouth, worse with the Valsalva maneuver. Imaging confirmed clinical suspicion and he was taken for surgery. A high-flow CSF leak was encountered once the tumor was debulked. This was repaired with an abdominal fat pad graft. Both patients developed diabetes insipidus and required postoperative adjuvant DA therapy. Conclusion: Spontaneous CSF leaks can complicate medical therapy of large MPRL with underlying skull defects, typically within weeks of initiation of DA. This should prompt clinicians to educate patients about the symptoms of potential CSF rhinorrhea and encourage them to promptly report them.

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Transnasal Endoscopic Cerebrospinal Fluid Rhinorrhea Repair: Our Experience of 35 Cases

Clinical Rhinology An International Journal ◽

10.5005/jp-journals-10013-1193 ◽

2014 ◽

Vol 7 (2) ◽

pp. 47-51 ◽

Cited By ~ 1

Author(s):

Mohnish Grover ◽

Pawan Singhal ◽

Shashank Nath Singh ◽

Man Prakash Sharma ◽

Avani Jain

Keyword(s):

Cerebrospinal Fluid ◽

Success Rate ◽

Csf Leak ◽

Endoscopic Repair ◽

Csf Rhinorrhea ◽

Cerebrospinal Fluid Rhinorrhea ◽

Endoscopic Techniques ◽

The Past ◽

Intracranial Complications ◽

Csf Leaks

ABSTRACT Cerebrospinal fluid rhinorrhea results from a breakdown of barriers between the subarachnoid space and aerodigestive tract. Because of the risk of potential intracranial complications, all persistent cerebrospinal fluid (CSF) leaks should be repaired. Over the past few decades, with the advances in endoscopic techniques, the surgical management of CSF rhinorrhea has changed significantly. CSF leak repair has advanced from the conventional open intracranial approaches by neurosurgeons to the transnasal endoscopic ones by otorhinolaryngologists. In this study, 35 patients with CSF leaks underwent endoscopic repair with a 94.3% first attempt success rate, and 100% overall success rate. There were no major intraoperative or postoperative complications. To conclude, the endoscopic approach has a high success rate with minimal morbidity and has therefore, become the preferred method. How to cite this article Jain A, Singhal P, Sharma MP, Singh SN, Grover M. Transnasal Endoscopic Cerebrospinal Fluid Rhinorrhea Repair: Our Experience of 35 Cases. Clin Rhinol An Int J 2014;7(2):47-51.

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A Simple Onlay Sellar Reconstruction Does not Increase the Risk of Postoperative Cerebrospinal Fluid Leak in Well-Selected Patients

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-3402000 ◽

2020 ◽

Cited By ~ 1

Author(s):

Mark B. Chaskes ◽

Judd H. Fastenberg ◽

Swar Vimawala ◽

Gurston F. Nyquist ◽

Mindy R. Rabinowitz ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Pituitary Adenoma ◽

Care Center ◽

Tertiary Care ◽

Cerebrospinal Fluid Leak ◽

Csf Leak ◽

Oxidized Cellulose ◽

Repair Technique ◽

Sellar Reconstruction ◽

Csf Leaks

Abstract Objectives A variety of endonasal sellar repair techniques have been described; many of which are complex, expensive, and carry potential morbidity but are felt to be necessary to prevent postoperative cerebrospinal fluid (CSF) leaks. We propose an effective, technically simple repair for select sellar defects utilizing an onlay of regenerated oxidized cellulose. Design Retrospective review of patients from a single neurosurgeon who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with only an onlay of regenerated oxidized cellulose. Patients were selected for this repair technique based on the absence of: (1) intraoperative identification of a CSF leak, (2) patulous diaphragm (expanded diaphragm sella herniating to or through sellar floor defect), and (3) other prohibiting comorbidities. Setting The present study was conducted at a tertiary care center. Participants In this study, pituitary adenoma patients were the participants. Outcome Measures Main outcome measure of the study is postoperative CSF leak. Results A total of 172 patients were identified. Of these, 153 were initial resections of pituitary adenomas. Gross total resection was achieved in 142 (82.6%) cases. Average tumor size was 2.2 ± 1.1 cm. Average tumor volume was 10.4 ± 19.8 cm3. No patients had intraoperative CSF leaks. All cases were repaired with only an onlay of regenerated oxidized cellulose. There were two postoperative CSF leaks (1.16%). Pre and postoperative SNOT-22 scores were 12.9 ± 11.9 and 14.3 ± 14.9 (p = 0.796), respectively. Conclusion The use of an onlay of regenerated oxidized cellulose alone is an effective repair technique for select sellar defects. This technique does not result in increased postoperative CSF leak rates and avoids the higher relative cost and potential morbidity associated with more complex, multilayered closures.

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Use of the Hadad-Bassagasteguy Flap for Repair of Recurrent Cerebrospinal Fluid Leak after Prior Transsphenoidal Surgery

Allergy & Rhinology ◽

10.2500/ar.2013.4.0072 ◽

2013 ◽

Vol 4 (3) ◽

pp. ar.2013.4.0072 ◽

Cited By ~ 10

Author(s):

Joseph Brunworth ◽

Tina Lin ◽

David B. Keschner ◽

Rohit Garg ◽

Jivianne T. Lee

Keyword(s):

Cerebrospinal Fluid ◽

Transsphenoidal Surgery ◽

Retrospective Chart Review ◽

Pedicled Flap ◽

Csf Leak ◽

Csf Rhinorrhea ◽

Csf Drainage ◽

Advanced Planning ◽

Csf Leaks

The Hadad-Bassagasteguy vascularized nasoseptal pedicled flap (HBF) is an effective technique for reconstruction of skull base defects with low incidence of postoperative cerebrospinal fluid (CSF) leak. Advanced planning is required as posterior septectomy during transsphenoidal surgery can preclude its use due to destruction of the vascular pedicle. We present four cases in which the HBF was successfully used to repair recurrent CSF leaks despite prior posterior septectomy and transsphenoidal surgery. A retrospective chart review was performed on all patients who developed recurrent CSF leak after transsphenoidal surgery over a 7-year period (2006–2013). Data were collected regarding demographics, clinical presentation, intraoperative findings, and surgical outcomes. Four patients who developed recurrent CSF drainage after transsphenoidal surgery were managed with HBF reconstruction during the study period. Two were men and two were women with a mean age of 37 years (range, 24–48 years). All had previously undergone resection of a pituitary macroadenoma via a transsphenoidal approach, with intraoperative CSF leaks repaired using multilayered free grafts. Recurrent CSF rhinorrhea arose 0.37–12 months (mean, 2.98 months) after the initial pituitary surgery. Active CSF drainage could be visualized intraoperatively with posterior septal perforations present. The HBF was successfully used in all cases, with no evidence of recurrent CSF leak after a mean follow-up of 2.35 years. The HBF may be salvaged for repair of recurrent CSF leaks even in the context of prior posterior septectomy and transsphenoidal surgery. However, longer follow-up is necessary to determine the long-term efficacy of this procedure in such revision cases.

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Management and Implications of Intraoperative Cerebrospinal Fluid Leak in Transnasoseptal Transsphenoidal Microsurgery

Operative Neurosurgery ◽

10.1227/neu.0b013e318207b3fc ◽

2011 ◽

Vol 68 (suppl_1) ◽

pp. ons144-ons151 ◽

Cited By ~ 5

Author(s):

George J. Kaptain ◽

Adam S. Kanter ◽

David K. Hamilton ◽

Edward R. Laws

Keyword(s):

Cerebrospinal Fluid ◽

Visual Function ◽

Transsphenoidal Surgery ◽

Visual Loss ◽

Fat Graft ◽

Csf Leak ◽

Csf Rhinorrhea ◽

Graft Harvest ◽

Additional Surgery ◽

Sellar Reconstruction

Abstract BACKGROUND: Nonvascularized autologous grafts used for sellar reconstruction in transseptal transsphenoidal surgery are commonly applied in the setting of intraoperative cerebrospinal fluid (CSF) leak and have been shown to be effective in preventing postoperative complications. OBJECTIVE: To assess the clinical implications of intraoperative CSF leak, to evaluate the efficacy of repair techniques using autologous nonvascularized materials, and to analyze the nature and timing of failures. These data may serve as a basis for assessing the utility of innovations in techniques and implant technologies. METHODS: A review was conducted of 257 consecutive patients who underwent transsphenoidal surgery that was complicated by intraoperative CSF leak from 1995 to 2001. Sellar reconstruction was performed with autologous materials except in reoperations in which septal materials were not available; lumbar drain catheters were used selectively. RESULTS: Six of the 257 patients (2.3%) developed postoperative CSF rhinorrhea occurring an average of 6.6 days after surgery. All 6 underwent reoperation, with 5 of 6 managed with operative lumbar drainage. Bacterial meningitis developed in 3 of 257 (1.2%). Worsening in visual function occurred in 8 of 257 (3.1%), with 1 of 257 (0.3%) suffering from permanent worsening of visual function. Additional surgery was performed in 2 of these patients, resulting in successful reversal of visual loss. Ten of 257 patients (3.9%) developed a subcutaneous hematoma at the fat graft harvest site, with 1 patient requiring surgical re-exploration. CONCLUSIONS: Watertight closure of the sella with autologous materials is effective in preventing postoperative rhinorrhea. Complications specific to the technique include graft site hematoma (4%) and rare instances of visual loss caused by optic nerve compression.

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Management of Spontaneous Cerebrospinal Fluid Leaks in the Middle Cranial Fossa and Bone Tegmen Tympani Defect in Patients with Meningitis and Rhinorrhea

Surgical Case Reports ◽

10.31487/j.scr.2020.02.09 ◽

2020 ◽

pp. 1-5

Author(s):

Francesco Paglia ◽

Altamura C.F ◽

D'Angelo L ◽

Francesco Paglia ◽

Marzetti F ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Middle Cranial Fossa ◽

Occurrence Rate ◽

Csf Leak ◽

Surgical Approaches ◽

Csf Rhinorrhea ◽

Tegmen Tympani ◽

Cranial Fossa ◽

Dural Defects ◽

Csf Leaks

The pathogenetic process of spontaneous CerebroSpinal Fluid (CSF) leaks in the middle cranial fossa has not been clearly identified yet. It is related to a tegmen defect associated to the presence of a simultaneous encephalocele or meningoencephalocele. The main complication of a CSF leak is meningitis, whose occurrence rate ranges from 4% to 50% according to different causes and conditions of the leak [1]. Surgical approaches to temporal bone reconstruction include middle cranial fossa (MCF) craniotomy, transmastoid (TM), or a combined (MCF/TM) approach. In our experience, we describe 2 cases of patients who presented with CSF rhinorrhea and meningoencephaloceles correlated with conductive hearing loss and meningitis. The MCF approach is a considerable way to successful repair CSF leaks and encephaloceles due to tegmen tympani and dural defects.

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Efficacy of Perioperative Lumbar Drainage following Endonasal Endoscopic Cerebrospinal Fluid Leak Repair: A Meta-analysis

Otolaryngology ◽

10.1177/0194599816670370 ◽

2016 ◽

Vol 156 (1) ◽

pp. 52-60 ◽

Cited By ~ 18

Author(s):

Omar H. Ahmed ◽

Sonya Marcus ◽

Jenna R. Tauber ◽

Binhuan Wang ◽

Yixin Fang ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Confidence Interval ◽

Odds Ratio ◽

Meta Analysis ◽

Anterior Skull Base ◽

Csf Leak ◽

Endoscopic Repair ◽

Csf Rhinorrhea ◽

Lumbar Drainage ◽

Csf Leaks

Objective Perioperative lumbar drain (LD) use in the setting of endoscopic cerebrospinal fluid (CSF) leak repair is a well-established practice. However, recent data suggest that LDs may not provide significant benefit and may thus confer unnecessary risk. To examine this, we conducted a meta-analysis to investigate the effect of LDs on postoperative CSF leak recurrence following endoscopic repair of CSF rhinorrhea. Data Sources A comprehensive search was performed with the following databases: Ovid MEDLINE (1947 to November 2015), EMBASE (1974 to November 2015), Cochrane Review, and PubMed (1990 to November 2015). Review Method A meta-analysis was performed according to PRISMA guidelines. Results A total of 1314 nonduplicate studies were identified in our search. Twelve articles comprising 508 cases met inclusion criteria. Overall, use of LDs was not associated with significantly lower postoperative CSF leak recurrence rates following endoscopic repair of CSF rhinorrhea (odds ratio: 0.89, 95% confidence interval: 0.40-1.95) as compared with cases performed without LDs. Subgroup analysis of only CSF leaks associated with anterior skull base resections (6 studies, 153 cases) also demonstrated that lumbar drainage did not significantly affect rates of successful repair (odds ratio: 2.67, 95% confidence interval: 0.64-11.10). Conclusions There is insufficient evidence to support that adjunctive lumbar drainage significantly reduces postoperative CSF leak recurrence in patients undergoing endoscopic CSF leak repair. Subgroup analysis examining only those patients whose CSF leaks were associated with anterior skull base resections demonstrated similar results. More level 1 and 2 studies are needed to further investigate the efficacy of LDs, particularly in the setting of patients at high risk for CSF leak recurrence.

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