发生脑脊液鼻漏的垂体腺瘤经蝶手术治疗

Pituitary adenomas associated with cerebrospinal fluid rhinorrhea and its transsphenoidal surgical treatment

目的 介绍发生脑脊液鼻漏的垂体腺瘤的临床特征和经蝶手术治疗方法。方法 分析１９９１ 年至１９９７ 年北京协和医院经蝶手术治疗的５ 例发生脑脊液鼻漏的垂体腺瘤， 并结合文献加以讨论。结果 ５ 例中４ 例为巨大型泌乳素腺瘤， １ 例为部分空泡蝶鞍合并垂体无功能腺瘤， ２ 例以脑脊液鼻漏为首发症状。术后随访半年至６ 年， ３ 例肿瘤全切除， ２ 例次全切除， 脑脊液鼻漏均消失。结论垂体腺瘤自发性脑脊液鼻漏可见于巨大型垂体腺瘤； 也可见于合并部分空泡蝶鞍的垂体腺瘤； 放疗、服溴隐亭治疗可促进垂体腺瘤脑脊液鼻漏的发生。经蝶入路是最适手术入路； 肿瘤切除后严密填塞蝶窦是补漏的主要措施； 术后去枕平卧和腰蛛网膜下腔引流有助于所修补漏口的愈合。

Objective To introduce the clinical features and surgical management of pituitary adenomas associated with cerebrospinal fluid rhinorrhea. Methods To describe the cases of five patients with pituitary adenomas who presented with CSF rhinorrhea,all of whom were treated by transsphenoidal surgical procedure between 1991 and 1997 in our department,and with reviewing the literature to discuss the surgical treatment and mechanisms involved in this rare condition.Results ln five patients,there were four giant prolactinomas and one nonfunctioning pituitary adenoma coexisting with a partially empty sella,and two patients presented CSF rhinorrhea as initial and only presenting symptom.The length of postoperative follow up ranged from 6 months to 6 years,total tumor removal were achieved in three cases,subtotal removal were effected in two cases,the CSF rhinorrhea disappeared in all of these patients. Conclusion CSF rhinorrhea can occur spontaneously in patients with giant pituitary adenomas,or less frequently,in patients with pituitary adenomas coexisting with partially empty sellas,and treatment of pituitary adenomas with radiation or bromocriptine may precipitate rhinorrhea.Surgical treatment using transsphenoidal approach is the most suitable for these patients;Packing sphenoid sinus hermetically after tumor removal is an effective method to obliterate the cerebrospinal fluid rhinorrhea;Resting in bed with supine position without pillows and draining CSF continuously via a lumbar subarachnoid catheter after operation are helpful in healing the repairs.