2025 Poster Presentations
P275: DELAYED POSTOPERATIVE CEREBROSPINAL FLUID RHINORRHEA IN PATIENTS ON BEVACIZUMAB
Somtochi Okafor, MD; Eseosa Odigie, MD; Anthony Ghanem, MD; Patrick Codd, MD; Ralph Abi Hachem, MD, MSc; David W Jang; Duke University Hospital
Objective: Bevacizumab, a vascular endothelial growth factor (VEGF) inhibitor, is commonly used as an adjunct chemotherapy agent for a variety of cancers. However, bevacizumab has been associated with delayed wound healing as well as spontaneous formation of pseudomeningocele. In the nasal cavity, is has been associated with spontaneous septal perforations. However, delayed cerebrospinal fluid (CSF) rhinorrhea after skull base surgery has not been described. The purpose of this study is to describe two cases of delayed CSF leak in patients who underwent endoscopic skull base surgery.
Methods: Retrospective case review of two patients
Results: The first patient is a 48 year old woman with atypical anterior parafalcine meningioma who underwent resection with bifrontal craniotomy three years earlier followed by adjuvant radiation and bevacizumab every three weeks for progressive multifocal disease. She presented with CSF rhinorrhea of the left cribriform plate. This was repaired with a free mucosal graft, but following resumption of bevacizumab therapy, the graft became necrotic and her repair failed two months after surgery. Cessation of bevacizumab led to spontaneous closure of the leak within three months.
The second patient is a 67 year old man with multiple recurrent ACTH-secreting pituitary adenoma treated with multiple surgeries, adjuvant radiation, and bevacizumab. Most recent surgery was eight years prior and patient was currently on bevacizumab. He presented with pneumocephalus and CSF rhinorrhea. Nasal endoscopy revealed fibrinous tissue and thinning of the diaphragm with CSF microleak. This was repaired with an abdominal fat graft.
Conclusion: Bevacizumab is an adjuvant treatment option for intracranial tumors following surgery. Due to its anti-angiogenic properties, it can cause complications related to tissue ischemia and necrosis. Our cases demonstrate the possibility of delayed CSF leak in patients who underwent skull base resection due to bevacizumab, presumably due to necrosis of the anterior skull base. One case demonstrates the possibility that defects can heal spontaneously with cessation of bevacizumab. Additional studies are needed to elucidate the role of bevacizumab in delayed CSF rhinorrhea after skull base surgery.