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

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.