Anatomical Risk Factors for Intraoperative Cerebrospinal Fluid Leaks During Transsphenoidal Surgery for Pituitary Adenomas

BACKGROUND: Cerebrospinal fluid (CSF) fistulas are among the most clinically important and frequent complications of transsphenoidal surgery for pituitary adenomas. Between the adenoma and the CSF, a "barrier" exists that consists of <= 3 elements. These, from cephalad to caudad, are the arachnoid, dura mater (sellar diaphragm), and pituitary glandular tissue. The objective of the present study was to determine whether the presence or absence of any of these 3 anatomical elements would be associated with the development of an intraoperative CSF fistula. METHODS: From November 2016 to June 2018, 40 patients with pituitary adenomas underwent surgery, by transsphenoidal endonasal access, under a microscope. All procedures were filmed in 3 dimensions. The intraoperative findings and preoperative magnetic resonance images were analyzed and compared. The patients who had developed a fistula were compared against those who had not. RESULTS: In 20 patients, glandular tissue was identified between the tumor and subarachnoid space. In 13, dura mater was evident, and in 7, only the arachnoid was noted. An intraoperative CSF fistula occurred in 6 patients, all of whom had the arachnoid as the only barrier. The presence of a fistula was significantly more likely statistically for patients with an arachnoid-only barrier than for those with any other barrier composition (P < 0.001). CONCLUSIONS: The anatomical architecture forming the roof of the pituitary fossa is an important determinant of intraoperative CSF fistula risk. When the barrier consists of only the arachnoid, the risk will be significantly greater than when the barrier contains additional elements. Preoperative magnetic resonance imaging would be useful to determine the type of the existing barrier.