Delayed Cerebrospinal Fluid Rhinorrhea After Gamma Knife Radiosurgery with or without Preceding Transsphenoidal Resection for Pituitary Pathology

Avital Perry, Christopher S. Graffeo, William R. Copeland, Kathryn M. Van Abel, Matthew L. Carlson, Bruce E. Pollock, Michael J. Link

Research output: Contribution to journalArticle

10 Citations (Scopus)

Abstract

Background Skull base cerebrospinal fluid (CSF) leak after gamma knife radiosurgery (GKRS) is a very rare complication. In patients who were treated with both GKRS and transsphenoidal resection (TSR) for pituitary lesions, early CSF leak occurs at a comparable rate with the general TSR population (4%). Delayed CSF leak occurring more than a year after TSR, GKRS, or dual therapy is exceedingly rare. Methods Retrospective chart review and review of the literature. Results We present 2 cases of delayed CSF leak after GKRS to treat pituitary adenoma. One patient developed CSF rhinorrhea 16 years after GKRS for growth hormone–producing pituitary adenoma. The patient had previously undergone TSR surgery 7 years prior to GKRS without complication. Additionally, a second patient developed high-flow CSF rhinorrhea 2 years after GKRS for a prolactinoma that failed dopamine agonist therapy. Both patients underwent a complicated clinical course after presentation, requiring multiple revisions for definitive CSF leak repair. Conclusions Delayed CSF leak is a rare but serious complication after GKRS independent of TSR status; urgent repair is the treatment of choice. Based on our experience, these leaks have the potential to be refractory, and we recommend aggressive reconstruction, preferably with a vascularized flap, and potentially supplemented by placement of a lumbar drain and acetazolamide. Current evidence is scant and provides little insight regarding an underlying mechanism, which may include bony destruction by the tumor, delayed radiation necrosis, or a secondary empty sella syndrome.

Original languageEnglish (US)
Pages (from-to)201-207
Number of pages7
JournalWorld Neurosurgery
Volume100
DOIs
StatePublished - Apr 1 2017

Fingerprint

Cerebrospinal Fluid Rhinorrhea
Radiosurgery
Pathology
Pituitary Neoplasms
Empty Sella Syndrome
Prolactinoma
Acetazolamide
Dopamine Agonists
Skull Base
Cerebrospinal Fluid Leak
Necrosis
Therapeutics
Radiation

Keywords

  • Acromegaly
  • Cerebrospinal fluid leak
  • Gamma knife
  • Late outcomes
  • Transsphenoidal surgery

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Delayed Cerebrospinal Fluid Rhinorrhea After Gamma Knife Radiosurgery with or without Preceding Transsphenoidal Resection for Pituitary Pathology. / Perry, Avital; Graffeo, Christopher S.; Copeland, William R.; Van Abel, Kathryn M.; Carlson, Matthew L.; Pollock, Bruce E.; Link, Michael J.

In: World Neurosurgery, Vol. 100, 01.04.2017, p. 201-207.

Research output: Contribution to journalArticle

Perry, Avital ; Graffeo, Christopher S. ; Copeland, William R. ; Van Abel, Kathryn M. ; Carlson, Matthew L. ; Pollock, Bruce E. ; Link, Michael J. / Delayed Cerebrospinal Fluid Rhinorrhea After Gamma Knife Radiosurgery with or without Preceding Transsphenoidal Resection for Pituitary Pathology. In: World Neurosurgery. 2017 ; Vol. 100. pp. 201-207.
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abstract = "Background Skull base cerebrospinal fluid (CSF) leak after gamma knife radiosurgery (GKRS) is a very rare complication. In patients who were treated with both GKRS and transsphenoidal resection (TSR) for pituitary lesions, early CSF leak occurs at a comparable rate with the general TSR population (4{\%}). Delayed CSF leak occurring more than a year after TSR, GKRS, or dual therapy is exceedingly rare. Methods Retrospective chart review and review of the literature. Results We present 2 cases of delayed CSF leak after GKRS to treat pituitary adenoma. One patient developed CSF rhinorrhea 16 years after GKRS for growth hormone–producing pituitary adenoma. The patient had previously undergone TSR surgery 7 years prior to GKRS without complication. Additionally, a second patient developed high-flow CSF rhinorrhea 2 years after GKRS for a prolactinoma that failed dopamine agonist therapy. Both patients underwent a complicated clinical course after presentation, requiring multiple revisions for definitive CSF leak repair. Conclusions Delayed CSF leak is a rare but serious complication after GKRS independent of TSR status; urgent repair is the treatment of choice. Based on our experience, these leaks have the potential to be refractory, and we recommend aggressive reconstruction, preferably with a vascularized flap, and potentially supplemented by placement of a lumbar drain and acetazolamide. Current evidence is scant and provides little insight regarding an underlying mechanism, which may include bony destruction by the tumor, delayed radiation necrosis, or a secondary empty sella syndrome.",
keywords = "Acromegaly, Cerebrospinal fluid leak, Gamma knife, Late outcomes, Transsphenoidal surgery",
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AU - Perry, Avital

AU - Graffeo, Christopher S.

AU - Copeland, William R.

AU - Van Abel, Kathryn M.

AU - Carlson, Matthew L.

AU - Pollock, Bruce E.

AU - Link, Michael J.

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N2 - Background Skull base cerebrospinal fluid (CSF) leak after gamma knife radiosurgery (GKRS) is a very rare complication. In patients who were treated with both GKRS and transsphenoidal resection (TSR) for pituitary lesions, early CSF leak occurs at a comparable rate with the general TSR population (4%). Delayed CSF leak occurring more than a year after TSR, GKRS, or dual therapy is exceedingly rare. Methods Retrospective chart review and review of the literature. Results We present 2 cases of delayed CSF leak after GKRS to treat pituitary adenoma. One patient developed CSF rhinorrhea 16 years after GKRS for growth hormone–producing pituitary adenoma. The patient had previously undergone TSR surgery 7 years prior to GKRS without complication. Additionally, a second patient developed high-flow CSF rhinorrhea 2 years after GKRS for a prolactinoma that failed dopamine agonist therapy. Both patients underwent a complicated clinical course after presentation, requiring multiple revisions for definitive CSF leak repair. Conclusions Delayed CSF leak is a rare but serious complication after GKRS independent of TSR status; urgent repair is the treatment of choice. Based on our experience, these leaks have the potential to be refractory, and we recommend aggressive reconstruction, preferably with a vascularized flap, and potentially supplemented by placement of a lumbar drain and acetazolamide. Current evidence is scant and provides little insight regarding an underlying mechanism, which may include bony destruction by the tumor, delayed radiation necrosis, or a secondary empty sella syndrome.

AB - Background Skull base cerebrospinal fluid (CSF) leak after gamma knife radiosurgery (GKRS) is a very rare complication. In patients who were treated with both GKRS and transsphenoidal resection (TSR) for pituitary lesions, early CSF leak occurs at a comparable rate with the general TSR population (4%). Delayed CSF leak occurring more than a year after TSR, GKRS, or dual therapy is exceedingly rare. Methods Retrospective chart review and review of the literature. Results We present 2 cases of delayed CSF leak after GKRS to treat pituitary adenoma. One patient developed CSF rhinorrhea 16 years after GKRS for growth hormone–producing pituitary adenoma. The patient had previously undergone TSR surgery 7 years prior to GKRS without complication. Additionally, a second patient developed high-flow CSF rhinorrhea 2 years after GKRS for a prolactinoma that failed dopamine agonist therapy. Both patients underwent a complicated clinical course after presentation, requiring multiple revisions for definitive CSF leak repair. Conclusions Delayed CSF leak is a rare but serious complication after GKRS independent of TSR status; urgent repair is the treatment of choice. Based on our experience, these leaks have the potential to be refractory, and we recommend aggressive reconstruction, preferably with a vascularized flap, and potentially supplemented by placement of a lumbar drain and acetazolamide. Current evidence is scant and provides little insight regarding an underlying mechanism, which may include bony destruction by the tumor, delayed radiation necrosis, or a secondary empty sella syndrome.

KW - Acromegaly

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KW - Late outcomes

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