Cabergoline-induced cerebrospinal fluid fistulae in macroprolactinomas

Cerebrospinal fluid (CSF) rhinorrhea is a rare complication after dopamine agonist treatment of macroprolactinomas. Up to 90% need surgical repair, however, there are controversial opinions on the necessity of tumor resection upon this occasion. Here we present our long-term follow-up experience in patients who underwent surgical repair of the CSF leak or observation.

We report a series of three patients who presented with cabergoline-induced CSF rhinorrhea with long-term follow-up up to 170 months. Two patients underwent endoscopic transnasal-transsphenoidal surgical repair of CSF rhinorrhea by fat graft and fibrin glue without tumor removal. In another patient, CSF rhinorrhea resolved spontaneously after two weeks without recurrence.

All three patients had no recurrence of CSF rhinorrhea during long-term follow-up up to 170 months. One patient with surgical CSF leak repair was asymptomatic with continued medication at long-term follow-up of 116 months. Tumor progression occurred 21 months after CSF leakage repair in another patient after cessation of dopamine agonist treatment and necessitated tumor debulking. The patient with continued medication without surgery had no recurrence of CSF rhinorrhea on long-term follow-up of 170 months.

The optimal management of CSF fistulae due to tumor shrinkage of macroprolactinomas after dopamine agonist therapy remains to be defined. Exceptionally, medication-induced CSF fistulae in response to tumor shrinkage may close spontaneously without recurrence. If persistent, transnasal-transsphenoidal closure of CSF fistulae represents an efficient treatment and dopamine agonist treatment may be continued. Thus, we recommend early surgical repair.