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 co nsensus for its treatment. Our objective was therefore to investigate the d ifferent treatments for this condition. DESIGN AND PATIENTS We examined the case notes of five patients with invasi ve prolactinomas and CSF rhinorrhoea following DA treatment. The different ways in which this complication had been managed is detailed along with a r eview of the literature. RESULTS Five patients aged 24-67 years (3 male) with massive invasive prola ctinomas (serum prolactin 95000-500000 mU/l) eroding the skull base were tr eated with dopamine agonists (3 bromocriptine, 1 cabergoline and 1 both). C SF 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 restart ed when treatment was resumed. One of these (case 4), a 67-year-old woman h ad no further treatment and CSF leakage stopped completely. She died of unr elated medical problems 3 years later. In one patient staphylococcus aureus meningitis and pneumocephalus developed as a complication of CSF rhinorrho ea. 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 successf ul 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 treatmen t. An additional strategy is the withdrawal of dopamine agonist to allow tu mour re-growth to stop the leak.