Cerebrospinal fluid rhinorrhea caused by bromocriptine therapy of prolactinoma

Prolactinoma extension as a contributing factor in dopamine agonist-induced CSF rhinorrhea: a systematic review of the literature

BACKGROUND

Dopamine agonist-induced cerebrospinal fluid (CSF) rhinorrhea is an uncommon treatment-related complication arising in 6.1% of prolactinoma patients treated with dopamine agonists. Locally invasive prolactinomas may create CSF fistulae through formation of dural and osseous skull base defects. Tumor shrinkage secondary to dopamine agonist therapy unmasks skull base defects, thus inducing CSF rhinorrhea. In these cases, repair of the leak may be achieved through collaborative surgical intervention by rhinologists and neurosurgeons. Multiple variables have been investigated as potential contributors to the risk of CSF rhinorrhea development in medically treated prolactinoma patients, with little consensus.

OBJECTIVE

The primary aim of our study was the characterization of risk factors for CSF rhinorrhea development following dopamine agonist treatment.

METHODS

A systematic review of the literature was conducted to identify cases of CSF rhinorrhea following dopamine agonist treatment of prolactinoma. The clinical history, radiographic findings and treatment outcomes are discussed.

RESULTS

Fifty-four patients with dopamine agonist-induced CSF rhinorrhea were identified across 23 articles published from 1979 to 2019. Description of diagnostic imaging [computed tomography (CT)/magnetic resonance imaging (MRI)] was not provided for 18/54 subjects. For the 36 cases that described prolactinoma appearance on CT or MRI, invasion of the cavernous sinuses was reported in 13 (36.1%) and invasion of the sphenoid sinus was reported in 18 (50%).

CONCLUSION

Based on our systematic review, we propose that CT findings of osseous erosion of the sella or the anterior skull base may predict dopamine agonist-induced CSF rhinorrhea. We recommend obtaining a thin-slice CT of the sinuses in cases with MRI evidence of sphenoid involvement.

Medically induced CSF rhinorrhea following treatment of macroprolactinoma: case series and literature review

PURPOSE

Although several reports have addressed cerebrospinal fluid (CSF) rhinorrhea following dopamine agonist (DA) therapy of macroprolactinomas, further study is warranted for this relatively uncommon entity. Toward this aim, our retrospective series and review of literature further clarifies recommendations in treatment of this rare problem.

METHODS

We retrospectively reviewed all macroprolactinoma cases in our hospital for a 15-year period. Our systematic search of PubMed identified original articles and reviews of all macroprolactinoma cases with an associated medication-induced CSF leak.

RESULTS

Five patients with drug-induced CSF leak were identified; four of these patients received cabergoline therapy an average of 6 weeks before the onset of rhinorrhea and then underwent surgical repair of the CSF leak. Of 35 published studies included, we identified 60 patients with medication-induced CSF leak. Medical therapy included bromocriptine in 34 patients, cabergoline in 21 patients, and use of both DAs in two patients. Three cases did include complete diagnostic and treatment data. Median time from initiation of the DA treatment to occurrence of rhinorrhea was 6 weeks. For CSF rhinorrhea, 49 patients underwent surgical repair (38 by the transnasal approach) and seven patients were treated nonoperatively.

CONCLUSION

Baseline skull base erosion in macroprolactinomas in combination with subsequent tumor shrinkage induced by DA therapy may result in spontaneous CSF rhinorrhea. Therefore, such patients should be advised about and monitored for this potential setback. Once CSF leak is diagnosed, prompt treatment must be carried out to avoid infectious complications. Transnasal surgery appears the most effective therapeutic approach.

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

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.

Medically treated prolactin-secreting pituitary adenomas: when should we operate?

BACKGROUND

The incidence of medical failure for prolactin (PRL)-secreting pituitary tumours is not well known. Object. The purpose of this study is to report clinical, radiographic and laboratory findings of PRL-secreting tumours that predict failed medical management.

METHODS

An analysis of 92 consecutive patients was performed that met the inclusion criteria. Decision for surgery was made based on failure of dopamine agonists to either control clinical symptoms and normalise hormonal level or diminish mass effect on follow-up evaluation.

RESULTS

Of the 92 patients treated, 14 patients (15%) required trans-nasal, trans-sphenoidal pituitary surgery (TSS). One patient underwent surgery for repair of a skull defect and 13 patients (14%) required surgery after failed medical management. Higher initial PRL was statistically significant regarding the need for surgical intervention, but a persistently abnormal level after initiation of treatment was a more significant predictor (Fisher exact test, p = 0.005 vs. p < 0.001). Size was also a statistically significant factor (p = 0.014); macroadenomas had a relative risk of 9.27 (95% CI: 1.15-74.86) for needing surgery compared to microadenomas. In addition, macroadenomas with cavernous sinus (CS) extension and pre-operative visual field deficit demonstrated a strong tendency for surgical intervention.

CONCLUSION

Medical management remains the most effective treatment option for prolactinomas. A partial hormonal response to medical management seems to be the most significant predictive factor but adenomas > 20 mm, visual field deficit and invasion of the CS may help predict the need for surgery. We suggest a minimum trial period (at least 8 weeks) of medical treatment prior to the consideration of surgery.

Is surgical intervention frequently required for medically managed macroprolactinomas? A study of spontaneous cerebrospinal fluid rhinorrhea

BACKGROUND

The frequency of spontaneous CSF rhinorrhea in macroprolactinoma patients is poorly documented and was previously thought to be a very rare occurrence.

METHODS

Thirty patients with macroprolactinomas (>1.0 cm diameter) identified from the Swansea neuroendocrine database were studied retrospectively.

RESULTS

At presentation, the median serum prolactin was 28,354 (range, 1844 to >6,000,000) mU/L; radiologically, 4 adenomas were invading the cavernous sinus, one the sphenoid sinus and 5 both the cavernous and sphenoid sinus. After commencement of medical therapy, 4 subjects developed CSF rhinorrhea requiring surgical correction; all 4 had tumors invading both the cavernous and sphenoid sinus and an initial serum prolactin more than 75,000 mU/L. One subject developed an acute psychosis, and a man who presented with delayed puberty committed a serious sexual offense.

CONCLUSIONS

Serious adverse effects are not uncommon in medically treated macroprolactinoma patients. Subjects with adenomas invading the sphenoid sinus have a high risk of developing CSF rhinorrhea that requires neurosurgical intervention.

Brain & chiasmal herniations into sella after medical treatment of prolactinoma

BACKGROUND

Dopamine agonists are widely used in the treatment of pituitary prolactinomas. We report a case of inferior mesial frontal lobe (gyrus rectus) and chiasmal herniations into an enlarged sella following successful medical treatment of a pituitary macroadenoma.

METHOD

A 71-year-old healthy man presented to medical attention with visual complaints. On examination, he was found to have bitemporal hemianopsia. Endocrine evaluation revealed an elevated prolactin level. He was treated medically with a dopamine agonist (bromocriptine).

RESULTS

Evaluation after one year of medical treatment revealed stabilization of the patient's vision, with a significant bitemporal field loss. Serum prolactin levels normalized (5.16 ng/ml). The MRI of the sella showed almost complete disappearance of the tumor, resulting in right mesial frontal lobe herniation inferiorly into an enlarged sella with associated chiasmal deformation.

CONCLUSIONS

We report a case where successful medical treatment of a large pituitary prolactinoma has resulted in inferior frontal lobe and chiasmal herniatons into an enlarged sella.

Treatment of empty sella syndrome with ventriculoperitoneal shunt

A symptomatic empty sella developed in a female patient undergoing bromocriptine therapy for microprolactinoma. Placement of a ventriculoperitoneal shunt dramatically improved the symptoms of headache and blurred vision. The post-operative imaging showed resolution of the empty sella. She was able to resume bromocriptine therapy without recurrence of her previous symptoms and give birth to a baby 20 months later. An MRI 44 months after surgery and on bromocriptine therapy showed no recurrence of the empty sella. We conclude that ventriculoperitoneal shunt may be a simple, and durable treatment for drug induced empty sella and allows resumption of bromocriptine therapy for preexisting microprolactinoma.

Current management of prolactinomas

Prolactinomas constitute the largest group of pituitary adenomas in autopsy series. However, their relative incidence in recent surgical series is much less impressive since medical treatment with dopamine agonists is routinely employed, which in many cases leads to tumor shrinkage and normalization of prolactin levels. The clinical symptoms of hyperprolactinemia are menstrual dysfunction and galactorrhea in women and loss of libido and potency in men. Prolactinomas may present also as space occupying sellar mass lesions impinging on the adjacent structures like the pituitary gland, cavernous sinus and optic nerves. The standard primary treatment is medical by dopamine agonists. Prolactinomas are the prototype of tumors, the growth of which can be reliably and safely inhibited by specific drugs other than cytostatic chemotherapy. These unfortunately have side effects, like orthostatic hypotension, nausea and vomiting. The effects induced by dopamine agonists are suppressive but not tumoricidal. Thus, the therapeutic effect is only maintained as long as the drug is administered. Consequently. in most cases, treatment has to be continued life-long with a few exceptions, in whom normoprolactinemia persists even after discontinuation of dopamine agonists. Main indications of surgery in prolactinomas are intolerance of the medication, and tumors not responding to dopamine agonists. Occasionally, these may ultimately require radiation therapy. Remission rates in large series of surgically treated prolactinomas vary between 54% and 86%. In our consecutive series of 540 surgically treated prolactinomas, the normalization rate after transsphenoidal surgery basically depended on the preoperative prolactin levels, tumor size and extension. The remission rate of 82% in microprolactinomas with initial prolactin levels <200 ng/ml would even in small adenomas make one consider surgical treatment as an interesting alternative to long-term medical treatment.

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

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.

Cabergoline-induced CSF rhinorrhea in patients with macroprolactinoma. Report of three cases

induces the macroprolactinoma shrinkage. Endoscopic transsphenoidal surgery offers a safe, minimally invasive and efficient management of this complication, which allows to regularly perform the following steps of the therapeutical strategy against the prolactinoma.

A giant prolactinoma presenting with unilateral exophthalmos: effect of cabergoline and review of the literature

We report the case of a 45-year-old male presenting with unilateral exophthalmos due to a large tumoral mass invading the skull base. Ophthalmologic examination did not show any visual field defects. Imaging techniques demonstrated extension of a huge tumor (approx. 8x8x8 cm) into the right orbit and nasopharynx. Endocrine work-up revealed grossly elevated serum prolactin (PRL) levels (26,466 microg/l, nl. < 12), pointing to a large, invasive macroprolactinoma. Stimulation tests indicated associated partial adrenal and growth hormone deficiencies. Planned surgery was abandoned, and the patient was instead treated with the long-acting dopamine agonist, cabergoline. Over a period of one year, serum PRL dropped to 131 microg/l, while the tumor mass shrank to less than 50% of its original volume (with 3.5 mg/week of cabergoline). The exophthalmos disappeared, and the patient did not develop rhinorrhea or any other side effects from treatment with cabergoline. The efficacy was maintained throughout the second year (ultimate serum PRL 74 microg/l, and final size less than 10% of the original). With reference to this case, we review other macroprolactinomas reported in the recent literature for associated exophthalmos, grossly elevated serum PRL levels (> or = 15,000 microg/l), and/or "giant" size (> or = 4 cm in maximum diameter). We highlight the use of dopamine agonists in the treatment of prolactinomas with such unusual characteristics.

CSF rhinorrhoea following treatment with dopamine agonists for massive invasive prolactinomas

OBJECTIVE

The management of CSF rhinorrhoea following dopamine agonist (DA) treatment for invasive prolactinomas is difficult and there is no clear consensus for its treatment. Our objective was therefore to investigate the different treatments for this condition.

DESIGN AND PATIENTS

We examined the case notes of five patients with invasive prolactinomas and CSF rhinorrhoea following DA treatment. The different ways in which this complication had been managed is detailed along with a review of the literature.

RESULTS

Five patients aged 24-67 years (3 male) with massive invasive prolactinomas (serum prolactin 95000-500000 mU/l) eroding the skull base were treated with dopamine agonists (3 bromocriptine, 1 cabergoline and 1 both). CSF rhinorrhoea developed in all patients between 1 week and 4 months after commencing dopamine agonist treatment. In two patients (cases 1 and 4), CSF rhinorrhoea ceased within a few days of stopping bromocriptine but restarted when treatment was resumed. One of these (case 4), a 67-year-old woman had no further treatment and CSF leakage stopped completely. She died of unrelated medical problems 3 years later. In one patient staphylococcus aureus meningitis and pneumocephalus developed as a complication of CSF rhinorrhoea. Three patients had endoscopic nasal surgery to repair the fistula using muscle grafts, and to decompress the pituitary tumour, with success in two. One patient had intracranial surgery and dural repair, which was successful in sealing the leak.

CONCLUSIONS

We suggest that surgery as soon as is feasible is the treatment of choice for the repair of a CSF leak following dopamine agonist treatment. An additional strategy is the withdrawal of dopamine agonist to allow tumour re-growth to stop the leak.

Bromocriptine-induced cerebrospinal fluid fistula in patients with macroprolactinomas: report of three cases and a review of the literature

Bromocriptine therapy for macroprolactinoma induced cerebrospinal fluid (CSF) rhinorrhea in three patients. The tumor had extended well beyond the sella turcica and caused bony erosion in all the cases. All three patients responded to bromocriptine therapy rapidly. CSF fistula occurred concomitantly with the reduction of tumor size and caused meningitis in two of the patients. Withdrawal of bromocriptine resulted in cessation of the leakage. One of the patients underwent transsphenoidal repair. Two patients refused surgery. This potentially lethal complication encountered in these three cases demonstrates the need for close supervision of macroprolactinoma patients with skull base erosion placed under bromocriptine therapy.

Cerebrospinal fluid rhinorrhea in patients with untreated pituitary adenoma: report of two cases

We report the cases of two patients with untreated pituitary adenoma who presented with cerebrospinal fluid rhinorrhea. The surgical treatment and mechanisms involved in this rare condition are discussed.

Cerebrospinal fluid rhinorrhea occurring in long-term bromocriptine treatment for macroprolactinomas

Two patients harboring invasive macroprolactinomas, on treatment with bromocriptine, developed cerebrospinal fluid rhinorrhea 16 and 17 months after the beginning of the medical therapy. Neither patient had previously been submitted to surgery or radiotherapy. The fistulae were surgically corrected. Cerebrospinal fluid leakage is a well-documented complication of pituitary tumors, mainly after surgery and/or radiotherapy, but the reports of its occurrence after primary treatment with bromocriptine are rare. Therefore, the possibility of this complication must be considered, especially in patients with invasive macroprolactinomas.

Rhinorrhea following dopamine agonist therapy of invasive macroprolactinoma

We report on the occurrence of CSF rhinorrhea in a group of 17 patients harbouring macroprolactinomas who were treated with a dopamine agonist (DA, bromocriptine) alone or the combination of DA and transcranial operation. In 2 out of 17 cases shrinkage of tumour remnants during therapy with the oral or injectable form of bromocriptine was responsible for delayed occurrence of rhinorrhea. Operative procedures for successful closure of the fistulae were mandatory in both cases.

Oligoclonal "fingerprint" of CSF IgG in multiple sclerosis patients is not modified following intrathecal administration of natural beta-interferon

The IgG pattern in CSF was studied in 11 patients with multiple sclerosis who exhibited an oligoclonal banding upon thin-layer polyacrylamide gel isoelectric focusing followed by silver stain of unconcentrated CSF. Each patient received beta-interferon intrathecally during a 2 month period. No modification was observed over a 6 month period. In addition, the oligoclonal pattern was remarkably unique for each individual representing a typical "fingerprint" which allowed the identification of any single CSF.

Transient intrasellar collection of air during bromocriptine treatment of a prolactinoma

A patient is described with a large prolactinoma with expansion into the sphenoid sinus. During bromocriptine treatment an intrasellar area of gas developed, continuous with the air in the sinus. No operation was performed, bromocriptine was continued. During the regression of the tumor, the area of air disappeared.

Visual function in prolactinoma patients treated with bromocriptine

Ten patients with prolactin-secreting pituitary adenomas (prolactinoma) and visual dysfunction were treated primarily with bromocriptine. Nine patients had improvement of visual field or acuity associated with computed tomography (CT) evidence of a decrease in tumor size and reduction of serum prolactin level (SPL). Visual improvement usually began within days of commencing bromocriptine therapy. One patient with initial improvement had a worsening of visual fields at 11 months despite a normal SPL and a stable CT appearance of tumor size. This patient and the single patient without visual improvement underwent trans-sphenoidal hypophysectomy (TSH), but neither patient had postoperative visual improvement. Two other patients underwent TSH for nonvisual reasons. The remaining six patients have maintained excellent visual function at last follow-up (average of 18 months on bromocriptine therapy). This study shows that bromocriptine is an effective short- and long-term therapy for most patients with visual dysfunction due to prolactinoma.