Endoscopic Repair of Delayed Cerebrospinal Fluid Leakage 10 Years after Gamma Knife Radiosurgery for Pituitary Adenoma: A Case Report

Case Report

Austin J Endocrinol Diabetes. 2014;1(3): 1001.

Endoscopic Repair of Delayed Cerebrospinal Fluid Leakage 10 Years after Gamma Knife Radiosurgery for Pituitary Adenoma: A Case Report

Masayuki Iwato1, Yasuhiko Hayashi1*, Daisuke Kita1, Issei Fukui1, Tadao Miyamori2 and Junichiro Hamada1

1Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan

2Division of Neurosurgery, Toyama Municipal Hospital, Toyama, Japan

*Corresponding author: Yasuhiko Hayashi, Department of Neurosurgery, Graduated School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8640, Japan

Received: February 28, 2014; Accepted: April 06, 2014; Published: April 08, 2014


Cerebrospinal fluid (CSF) leakage is a major complication during and after transsphenoidal surgery (TSS) for pituitary tumors. To prevent postoperative CSF leakage causing meningitis, sellar floor reconstruction with artificial or autologous materialsis recommended. Mucosa in the sphenoid sinus can cover the CSF fistula or materials used for the sellar floor reconstruction in the perioperative period, resulting in the disappearance of CSF leakage. In this case, a 60-year-old woman presented with CSF leakage. She had undergone TSS for a large pituitary macroadenoma 21 years prior and gamma knife radiosurgery was delivered for a residual tumor 11 years after the TSS. Endoscopic surgical repair of the CSF leakage was successfully performed. Although delayed CSF leakage is very rare in patients who did not experience CSF leakage in the perioperative period after TSS, it can occur if the residual pituitary adenoma was treated with irradiation. This mucosal atrophy due to irradiation was considered the possible cause for the delayed CSF leakage in our case. Thus, endoscopic surgery is useful for the detection and repair of the CSF fistulas.

Keywords: Transsphenoidal surgery, Cerebrospinal fluid leakage, Endoscope, Radiosurgery.


CSF: Cerebrospinal Fluid; GKS; Gamma Knife Radiosurgery; MRI; Magnetic Resonance Imaging; TSS; Transsphenoidal Surgery.


Advances in endoscopic procedures have increased the surgical indications for the various intracranial lesions, mainly because they provide a wide–angled view and decreased surgical trauma [1,2]. Endoscopic surgery is also increasingly used for transsphenoidal surgery (TSS) on pituitary tumors. However, a major complication of TSS is cerebrospinal fluid (CSF) leakage, which is reported to occur in 0.4–9.6% of cases regardless of the introduction of the endoscope [3–5]. It tends to occur within a week after TSS, and in most of the patients, it rarely occurs if CSF leakage has previously disappeared spontaneously or with the aid of surgical procedures [3,6]. Many materials available for sellar floor reconstruction have been reported, including autologous fat, muscle and fascia, vascularized mucosal flaps, or artificial buttress materials and titanium mesh [7–11].

Here, We present the case of a patient with extremely delayed CSF leakage, occurring 21 years after her initial TSS for a pituitary macroadenoma and 10 years after gamma knife radiosurgery (GKS) for its local recurrence. We discuss the mechanisms underlying the development of delayed CSF leakage and the endoscopic procedures applied for fistula repair.

Case Report

When the patient was 33 years old, she manifested amenorrhea and galactorrhea. Six years later, she noticed a disturbance in her visual acuity and bilateral temporal hemianopsia. Magnetic resonance imaging (MRI) showed a tumor measuring 30 mm in diameter in the sella turcica and extending into the bilateral cavernous sinus and the suprasellar region. TSS for the pituitary adenoma was performed in a local hospital, and it resulted in the partial removalof the tumor. Postoperatively, there was no CSF leakage, and her visual symptoms disappeared. When she was 44 years old, MRI showed regrowth of the residual tumor into the sphenoid sinus and clivus. She underwent GKS (20Gy; prescription isodose 50%) 11 years after the first operation (Figure 1A, B). Follow–up MRI revealed significant shrinkage of, and multiple cystic changes inside, the tumor at the base of the sellar floor (Figure 1C).