Risk factors and outcomes of cerebrospinal fluid leak related to endoscopic pituitary adenoma surgery

Objective: The incidence of and risk factors for intra- and postoperative cerebrospinal fluid (poCSF) leak in patients who underwent endoscopic surgery for pituitary adenoma were investigated in this retrospective study. Methods: A total of 216 consecutive patients operated on by a single neurosurgical team were included. Logistic regression was applied to identify risk factors for intraoperative CSF (ioCSF) and poCSF leaks, and the outcome and management of ioCSF and poCSF leaks were analyzed. Results: Sixty-five patients (30.1%) experienced ioCSF leak, of whom 10 developed poCSF leak. Three of 151 patients developed poCSF leak without obvious ioCSF leak. Multiple regression analysis revealed that tumor with lobular or irregular contour and gonadotrophic-positive staining increased the risk of ioCSF leak; additionally, nonfunctional tumor (p = 0.058) and preoperative gonadotrophic hormone abnormalities (p = 0.08) tended to increase this risk. The presence of ioCSF leak and preoperative visual impairment were predictors for poCSF leak. Tumor with Knosp grades 3-4 and a higher grade of ioCSF leak could increase the risk of poCSF leak. Tailored pedicled vascularized nasoseptal flaps (NSFs) preparation before tumor removal greatly decreased the rate of poCSF leak with ioCSF leak and the overall leak rate. Three prophylactic lumbar drains (LDs) were performed in patients with grade 3 ioCSF leak, none of whom developed poCSF leak. Conclusions: Lobular or irregular tumor contour and gonadotrophic-positive staining were associated with a high risk of ioCSF leak, while ioCSF leak and preoperative visual impairment were associated with poCSF leak. NSF preparation, preventive sellar reconstruction and LD use could likely decrease the rate of poCSF leak.