Lumbar Puncture for the Injection of Intrathecal Fluorescein: Should It Be Avoided in a Subset of Patients Undergoing Endoscopic Endonasal Resection of Sellar and Parasellar Lesions?

Abstract

Objectives The use of intrathecal fluorescein (ITF) has become an increasingly adopted practice for the identification of cerebrospinal fluid (CSF) leaks during endoscopic skull base surgery for pituitary adenomas. Administration through lumbar puncture can result in postoperative positional headaches, increasing morbidity, cost, and length of stay. We sought to identify the incidence of and variables associated with postoperative headaches to determine if there was a subgroup of patients in whom this procedure should be avoided. Methods We conducted a retrospective single-institution review of 148 patients who underwent endoscopic resection with ITF for pituitary adenoma between December 2003 and February 2016. We excluded patients who had lumbar drains and with intraoperative CSF leak, as these patients may have other headache etiologies. Patient demographics, comorbidities, tumor features, surgical approach, surgical closure, and histology were recorded. Primary outcomes included the presence of postoperative and positional headaches. Results We identified 62 patients with postoperative headaches (41.9%) and 10 with positional headaches (6.8%), of whom 6 underwent blood patch with complete resolution. Following univariate analysis, there was a significant positive association with prolactin-secreting tumors (p = 0.008). There was a negative association with a history of hypertension (p = 0.0001) and age (p = 0.01). Following multivariate modeling, the significance for hypertension (p = 0.01) was preserved. Conclusions Positional headaches in patients who receive ITF are uncommon and should not limit its use in the preparations for endoscopic resection of pituitary adenomas. Avoiding ITF in younger patients without hypertension with prolactinomas might decrease the risk of post-ITF positional headaches.

Surgical Experience in Prevention of Postoperative CSF Leaks Using Abdominal Fat Grafts in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas

“…9,22 When CSF leaks are not evident or identified using the Valsalva maneuver during surgery, 10,23 the use of intrathecal fluorescein (ITF) to detect CSF leaks and/or perform sellar floor repair procedures for the purpose of prevention may be helpful. 24,25 In a recent study including 419 patients who underwent endonasal endoscopic skull base surgery, the sensitivity and specificity of ITF use via lumbar puncture or lumbar drain were 92.9 and 100%, respectively. 25 This technique may be beneficial when intraoperative CSF leaks are hard to identify during endoscopic endonasal skull base surgery for various diseases, for example, pituitary adenoma.…”