Surg Neurol 1992;38:321
321
Letter to the Editor
To the Editor: W e read with great interest the paper entitled "Cerebrospinal fluid rhinorrhea occurring in long-term bromocriptine treatment for macroprolactinomas" by Bronstein et al (Surgical Neurology 1989;32:346-9). We recently encountered such a complication in a 52-year-old woman who presented with seizures, secondary amenorrhea, and intermittent galactorrhea. Clinical examination showed normal fundi and normal visual fields. Computed tomography (CT) revealed a large pituitary lesion extending into the sphenoid and the right middle fossa. Magnetic resonance imaging confirmed the CT appearances and delineated the extent of the lesion. The serum prolactin level was 438,000 mU/L, the cortisol response was normal, and the growth hormone was poor. She was treated with bromocriptine, 5 mg twice daily. The tumor shrunk in size, and the prolactin level dropped to 246 mU/L. However, 4 weeks later, she complained of clear fluid leakage through the nose. Further investigations showed that this was cerebrospinal fluid (CSF) rhinorrhea via the sphenoid sinus. She underwent transethmoidal repair of the CSF fistula, and the CSF leak stopped. Unfortunately, 2 weeks later she developed recurrent CSF rhinorrhea. Cisternography failed to localize the site of CSF leakage, so a lumboperitoneal shunt was inserted. The rhinorrhea gradually stopped.
© 1992 by ElsevierSciencePublishingCo., Inc.
We agree with the authors that the CSF fistula was the result of invasion of the dura and sellar floor by the prolactinoma, and we also agree that the treatment of choice should be direct surgery to remove the tumor and repair the dura. However, if direct surgery does not succeed in stopping the CSF leakage, CSF diversion procedures may be of value [2]. CSF diversion alone may also stop the CSF leakage [1], but the patient remains at the risk of intracranial infection until the CSF fistula is healed. Stopping the bromocriptine may succeed in stopping the CSF leakage, but at the risk of losing tumor control. We feel that an attempt to surgically seal the CSF fistula is the treatment of choice, followed by CSF diversion procedure if the CSF rhinorrhea recurs. M.S. Eljamel P.M. Foy A.C. Swift I.A. MacFarlane, M.D.
Liverpool, UnitedKingdom References 1. ClaytonRN, WebbJ, Heath DA, et al. Dramaticand rapid shrinkage of a massiveinvasiveprolactinomawith bromocriptine,a case report. Clin Endocrino11985;22:573-81. 2. SpetzlerRF, WilsonCB. Managementof recurrent CSF rhinorrhoea.J Neurosurg 1978;49:393-7.
0090-3019/92/$5.00
321
Letter to the Editor
To the Editor: W e read with great interest the paper entitled "Cerebrospinal fluid rhinorrhea occurring in long-term bromocriptine treatment for macroprolactinomas" by Bronstein et al (Surgical Neurology 1989;32:346-9). We recently encountered such a complication in a 52-year-old woman who presented with seizures, secondary amenorrhea, and intermittent galactorrhea. Clinical examination showed normal fundi and normal visual fields. Computed tomography (CT) revealed a large pituitary lesion extending into the sphenoid and the right middle fossa. Magnetic resonance imaging confirmed the CT appearances and delineated the extent of the lesion. The serum prolactin level was 438,000 mU/L, the cortisol response was normal, and the growth hormone was poor. She was treated with bromocriptine, 5 mg twice daily. The tumor shrunk in size, and the prolactin level dropped to 246 mU/L. However, 4 weeks later, she complained of clear fluid leakage through the nose. Further investigations showed that this was cerebrospinal fluid (CSF) rhinorrhea via the sphenoid sinus. She underwent transethmoidal repair of the CSF fistula, and the CSF leak stopped. Unfortunately, 2 weeks later she developed recurrent CSF rhinorrhea. Cisternography failed to localize the site of CSF leakage, so a lumboperitoneal shunt was inserted. The rhinorrhea gradually stopped.
© 1992 by ElsevierSciencePublishingCo., Inc.
We agree with the authors that the CSF fistula was the result of invasion of the dura and sellar floor by the prolactinoma, and we also agree that the treatment of choice should be direct surgery to remove the tumor and repair the dura. However, if direct surgery does not succeed in stopping the CSF leakage, CSF diversion procedures may be of value [2]. CSF diversion alone may also stop the CSF leakage [1], but the patient remains at the risk of intracranial infection until the CSF fistula is healed. Stopping the bromocriptine may succeed in stopping the CSF leakage, but at the risk of losing tumor control. We feel that an attempt to surgically seal the CSF fistula is the treatment of choice, followed by CSF diversion procedure if the CSF rhinorrhea recurs. M.S. Eljamel P.M. Foy A.C. Swift I.A. MacFarlane, M.D.
Liverpool, UnitedKingdom References 1. ClaytonRN, WebbJ, Heath DA, et al. Dramaticand rapid shrinkage of a massiveinvasiveprolactinomawith bromocriptine,a case report. Clin Endocrino11985;22:573-81. 2. SpetzlerRF, WilsonCB. Managementof recurrent CSF rhinorrhoea.J Neurosurg 1978;49:393-7.
0090-3019/92/$5.00
