Transsphenoidal management of 28 symptomatic Rathke's cleft cysts, with special reference to visual and hormonal recovery

Hyperprolactinaemia associated with a complex cystic pituitary mass: medical versus surgical therapy

A 39-year-old woman presented with visual loss and hyperprolactinaemia. Magnetic resonance imaging showed an intrasellar and suprasellar mass with a large cystic component that was hyperintense on T2-weighted imaging. Prolactin levels were up to 5400 mIU/L. Following trans-sphenoidal surgery, histology showed -elements of both a Rathke's cleft cyst and prolactinoma. We suggest primary surgical management of large cystic pituitary lesions with associated hyperprolactinaemia, particularly when there is hyperintensity on T2-weighted imaging.

Surgery for Rathke cleft cysts: technical considerations and outcomes

OBJECT

The aim of this study was to identify the optimal surgical goals and techniques for managing symptomatic Rathke cleft cysts (RCCs).

METHODS

The authors conducted a retrospective study of 62 consecutive patients who had undergone surgery for RCCs. Postoperative follow up was a mean of 28 months. Fifty-six patients underwent transsphenoidal cyst decompression and biopsy procedures, and six underwent cyst wall resection. Postoperatively, symptoms improved in 91% of patients with headaches and 92% of patients with visual deficits. Decompression and biopsy were associated with a 10% incidence of new anterior pituitary hormone deficiencies and a 6% incidence of new permanent diabetes insipidus; the incidence of new hormone deficiencies was significantly higher in the few patients who had undergone cyst wall resection. The incidence of relapse, defined as cyst regrowth with either recurrent symptoms or chiasmal compression, was 16%. Resection of the cyst wall was associated with a trend toward a decreased risk of relapse. Sellar packing, sellar floor reconstruction, and irrigation with absolute ethanol did not affect the likelihood of relapse. Squamous metaplasia and inflammation increased the risk of relapse. Residual cyst demonstrated on postoperative magnetic resonance imaging was associated with an increased risk of subsequent asymptomatic cyst regrowth. Seven patients (11%) underwent repeated operation with symptomatic improvement and minimal morbidity; only one patient relapsed following a second surgery.

CONCLUSIONS

Decompression and biopsy procedures in the treatment of RCCs lead to improvement in signs and symptoms, with low morbidity rates. Repeated operations will be required in as many as 16% of patients but are also associated with symptomatic improvement, low morbidity, and durable remission. Decompression and biopsy may represent the optimal surgical management of RCC.

Symptomatic Rathke's cleft cysts: a report of 24 cases

We review the clinical, hormonal and imaging features of 24 consecutive patients with symptomatic Rathke's cleft cysts (RCCs), and assess the long-term effectiveness and complications of transsphenoidal cyst removal. Out of 250 consecutive patients, 24 (10%) underwent endonasal transsphenoidal surgery for RCC; 19 (79%) were women. Symptoms at presentation included headaches (83%), hyperprolactinemia (38%), central hypothyroidism (21%), galactorrhea (13%), diabetes insipidus (13%), IGF-1 deficiency (13%), central adrenal insufficiency (8%) and visual loss (8%). In total, 37% of women had irregular menses and 60% of men sexual dysfunction and hypogonadism. Two girls presented with precocious puberty. Cyst size varied from 7 to 25 mm. Fifteen (60%) had a suprasellar component. Initial and 3-month post-operative imaging revealed complete cyst resection in 23 of 24 patients. Headaches resolved in 65% of subjects and visual loss resolved in both patients who presented with this symptom. Of those presenting with endocrinopathy, 56% had improvement of at least one anterior pituitary axis; two subjects (8%), both with suprasellar RCC, developed a new hormone deficiency post-operatively and two sujects young girls, (8%) had RCC recurrence, one at 36 months after surgery, requiring a second operation, and the other had a small asymptomatic recurrence 6 months after surgery. In conclusion, RCC accounts for 10 % of surgically treated sellar and suprasellar masses. Headache, hyperprolactinemia, menstrual irregularities and sexual dysfunction are common presenting symptoms. Simple cyst removal via a transsphenoidal approach offers a safe and effective treatment. Cyst recurrence may be more common in children.

Neuroendoscopic surgery of intracranial cysts in adults

OBJECTS

The purpose of this study was to describe the indications, surgical techniques and postoperative outcome of neuroendoscopic interventions in a heterogeneous group of intracranial cystic pathologies.

PATIENTS AND METHODS

Between 1992 and 2003, 127 patients with symptomatic intracranial cysts and cystic tumours underwent neuroendoscopic treatment in our department. In 22 patients indication for surgery was colloid cysts, in 9 patients pineal cysts and in 3 patients cavum vergae cysts. Twelve arachnoid cysts, 10 cystic craniopharyngiomas, 2 Rathke's cleft cysts and 69 malignant cystic tumours were operated on. The patients' mean age was 45 years and their clinical presentations varied from typical signs of increased intracranial pressure to focal neurological deficits.

RESULTS

One hundred and twenty-seven patients with intracerebral cystic space-occupying lesions were operated on using stereotactic frameless or frame-based endoscopic techniques. There was no operative mortality. The operative morbidity was 3.1% including 1 memory deficit due to fornix injury, 1 hemiparesis due to postoperative haematoma after lesion biopsy, 1 aseptic meningitis and 1 subdural fluid collection.

CONCLUSIONS

Endoscopic interventions enable neurosurgeons to manage intracranial cystic lesions. Via the same approach, the obstructed CSF pathways may be restored and consequently the increased intracranial pressure diminishes. With the aid of stereotactic guidance or a neuronavigation system, access to the lesion can be gained rapidly and with high accuracy.

Devastating complications from alcohol cauterization of recurrent Rathke cleft cyst

✓ Rathke cleft cysts are commonly found on autopsy but are seldom symptomatic. Conventional treatment of these lesions consists of transsphenoidal drainage with partial excision of the cyst, and recurrence is rare. Alternatively, the instillation of absolute alcohol into the cyst has been described in several reports, with no complications. The authors report on a woman with Rathke cleft cyst that recurred three times after the initial treatment; the lesion was treated with alcohol cauterization on the final recurrence with devastating complications.

This 51-year-old woman presented in 1992 with headaches and visual disturbances. Admission magnetic resonance imaging revealed a sellar/suprasellar lesion that was treated with conventional surgery and was subsequently confirmed to be a Rathke cleft cyst. The patient again presented with recurrence of the cyst at 22, 26, and 31 months after the initial presentation. On the final recurrence the cyst was treated with alcohol cauterization. Postoperatively, the patient awoke blind and suffered a seizure from leakage of the alcohol. The patient remains completely blind in both eyes and is also anosmic and has left lid ptosis and exotropia, which signify damage to the first through third cranial nerves.

Rathke cleft cysts have been known to recur after primary surgery; however, this is the first report of a single cyst recurring three times despite conventional surgical treatment. Additionally, this is the first report in which devastating complications from alcohol cauterization of the cyst have been described. The authors therefore advocate caution when attempting alcohol cauterization and advise that meticulous care be taken to ensure the patency of the cyst.

Rathke's cleft cyst in two girls with precocious puberty

Rathke's cleft cysts arise from remnants of Rathke's pouch and are usually found incidentally on MRI or autopsy. In childhood, the most common presenting symptoms of Rathke's cleft cysts are endocrine abnormalities, such as reduced growth hormone secretion, hyperprolactinemia, or diabetes insipidus. Non-specific symptoms, such as headache and visual disturbance, may also occur. Although precocious puberty has occasionally been described in association with suprasellar lesions, such as hamartomas, arachnoid cysts, and craniopharyngiomas, to our knowledge there have been no documented cases secondary to Rathke's cleft cysts. We report here two patients, both of whom presented with precocious puberty, and were found to have Rathke's cleft cysts.

Hemorrhagic Rathke’s Cleft Cyst Presenting as Diplopia

OBJECTIVE

To report a case of uncommon presentation of hemorrhagic Rathke's cleft cyst (RCC) extending into the cavernous sinus, causing diplopia.

METHOD

We present clinical, radiologic, and histologic findings on this patient, and review related medical literature.

RESULTS

A 34-year-old man presented with a 4-month duration of worsening left-sided headache with acute development of diplopia which worsened upon looking to the left. Magnetic resonance imaging identified a left pituitary mass with posterior extension and involvement of the cavernous sinus. Hormone level evaluation revealed a low free thyroxine index and elevated prolactin levels, and normal levels of thyroid stimulating hormone, growth hormone, insulin-like growth factor type 1, and cortisol. The patient underwent transsphenoidal resection of a yellow fibrous mass from the left side of the sella. Tumor tissue pathology was consistent with a RCC that may have undergone secondary hemorrhage and rupture. Postoperatively, this patient developed transient diabetes insipidus, and required levothyroxine therapy for hypothyroidism. The diplopia improved, though he continues to complain of episodic headaches.

CONCLUSION

RCCs are challenging to diagnose, as they can cause symptoms related to enlargement and hemorrhage. Imaging studies and other diagnostic measures may, therefore, describe heterogeneous features. The most common clinical presentation of this disorder is a manifestation of pituitary dysfunction, such as hyperprolactinemia, diabetes insipidus, and, occasionally, apoplexy. These symptoms may be accompanied by headache. Visual disturbances often appear, usually as visual field defects and decreased visual acuity. This case demonstrates that nonpituitary masses such as RCC can hemorrhage and extend into the cavernous sinus, causing acute ophthalmoplegia.

Surgical treatment of symptomatic Rathke cleft cysts: clinical features and results with special attention to recurrence

OBJECT

Rathke cleft cysts (RCCs) are rarely symptomatic. The purpose of this study was to clarify the clinical, neuroimaging, surgical, and pathological features of symptomatic RCCs with special attention to their recurrence.

METHODS

This retrospective study involved 53 patients with pathologically confirmed symptomatic RCCs. There were 28 female and 25 male patients, ranging in age from 11 to 68 years (mean 37 years). Common clinical presentations included headache, visual impairment, and endocrine disturbance. The most common endocrine disturbances were hyperprolactinemia and diabetes insipidus. Most of these improved or were resolved after surgery, with the exception of diabetes insipidus and panhypopituitarism. The cysts were intrasellar with suprasellar extension in 33 patients, and ranged in size from 5 to 40 mm (mean 17 mm). In the 50 magnetic resonance (MR) images that were reviewed, the signal intensities were quite variable. Fourteen MR images demonstrated enhancement after an injection of Gd. Intraoperatively, the cyst contents were found to be yellowish (18 patients [37%]) and mucoid (25 patients [51%]). Pathological examinations revealed a pseudostratified columnar epithelium in 26 patients (49%). Abundant squamous metaplasia and a stratified squamous epithelium were also found in 12 patients (23%). Follow-up MR images revealed cyst recurrences that required a repeated operation in six patients. Statistically significant risk factors for a recurrence included enhancement of the lesion on MR images (p = 0.017), the extent of cyst removal (p = 0.012), and the presence of squamous epithelium (p = 0.008).

CONCLUSIONS

Rathke cleft cysts are associated with a variety of clinical presentations and sometimes confusing intraoperative and pathological findings. Close postoperative observation with neuroimaging and neuroophthalmological assessment is necessary, especially after a partial removal, as in cases with squamous metaplasia.

Symptomatic Rathke's cleft cysts: a radiological, surgical and pathological review

Rathke's cleft cyst is a non neoplastic lesion remnant of the Rathke's poutch. Symptomatic cysts must be surgically treated. There are no specific neuroradiological features for this lesion. We present a series of 14 symptomatic Rathke's cleft cysts treated with transphenoidal endoscopic technique, and we correlate the MRI intensity images with the intraoperative findings, the pathological analysis, the growth pattern and the recurrence tendency, to understand wether there is a better way to recognize these lesions, especially the asyntomatic ones, that, despite other neoplastic cysts, colud only be observed with a MRI follow up.

Tension pneumocyst after transsphenoidal surgery for Rathke's cleft cyst: case report

OBJECTIVE AND IMPORTANCE

Tension pneumocephalus is a rare but well-described complication of transsphenoidal surgery. It is usually associated with postoperative cerebrospinal fluid fistulae causing lower intracranial pressure, with air located in the subdural, subarachnoid, or intraventricular space. We report a case of suprasellar tension pneumocyst that caused visual deterioration to develop after an operation for a Rathke's cleft cyst. Only one similar case has been reported previously.

CLINICAL PRESENTATION

A 54-year-old woman with a cystic sellar-suprasellar mass compressing the chiasm was operated on via a standard transsphenoidal approach. The intraoperative diagnosis was Rathke's cleft cyst, and the floor of sella was left open to avoid recurrence. The sphenoid sinus was filled with a fat graft, and the rostrum of the sphenoid was reconstructed with a bone fragment. The patient's postoperative course was uneventful, and her vision improved. Ten days after discharge, the patient was readmitted to the emergency service with headache and visual impairment. Emergent computed tomography confirmed a suprasellar tension pneumocyst.

INTERVENTION

The patient underwent immediate reoperation via an endonasal endoscopic approach. After the trapped air was evacuated, the sella was closed with fascia lata and muscle using fibrin glue. The patient's vision improved postoperatively.

CONCLUSION

Suprasellar tension pneumocyst is an extremely rare complication of transsphenoidal surgery. To avoid this complication, the sellar floor should be repaired in a watertight fashion, and patients should be instructed to avoid blowing the nose, sneezing, straining, and coughing postoperatively.

Endonasal transsphenoidal approach for pituitary adenomas and other sellar lesions: an assessment of efficacy, safety, and patient impressions

OBJECT

The direct endonasal approach performed with the aid of an operating microscope for removal of pituitary tumors has the potential advantage over the traditional sublabial route of minimizing postoperative rhinological complications, yet maintaining a high degree of efficacy and safety. To assess the effectiveness of this procedure, tumor remission rates and surgical complications were documented, and patients' postoperative complaints were recorded using a questionnaire.

METHODS

One hundred consecutive patients underwent 109 endonasal operations for tumor removal. At a median follow-up period of 16 months (range 3-45 months), surgical remission rates were as follows: in 40 patients with endocrine-inactive macroadenomas, 95% for noninvasive and 40% for invasive tumors; in the 20 patients with prolactinomas, 75% for prolactinomas with an initial prolactin (PRL) level lower than 200 ng/ml, 33% for those with a PRL level between 200 and 600 ng/ml, and 0% for those with a PRL level higher than 1400 ng/ml; in the 15 patients with Cushing disease, 73% for microadenomas and 25% for macroadenomas; in the 10 patients with acromegaly, 75% for microadenomas and 50% for macroadenomas; in the five patients with Rathke cleft cysts, 80%; and in the five patients with craniopharyngiomas, 40%. There were seven major surgical complications and no operative deaths. Among the 78 patients who completed questionnaires (response rate 89%), the most common complaints concerned nasal packing (39%), removal of packing (36%), and mouth breathing (35%). At 3 months or longer after surgery, patients quantified sinonasal problems as follows: for facial pain, no problem in 83% and severe difficulty in 4%; for nasal congestion, no problem in 74%, and severe difficulty in 3%; for decreased nasal airflow, no problem in 77% and severe difficulty in 4%; for decreased sense of smell, no problem in 73% and severe difficulty in 4%; and for upper-lip numbness, no problem in 87% and severe difficulty in 1%. Twelve (86%) of 14 patients who had undergone sublabial surgery previously preferred the endonasal approach in terms of pain and ease of recovery.

CONCLUSIONS

The direct endonasal route for pituitary tumor removal has efficacy and complication rates comparable to those of the sublabial route. Patients generally recover rapidly from this minimally invasive procedure and have no or minimal sinonasal complaints. For patients requiring a repeated operation, the endonasal route appears to be less painful and easier to recover from than the sublabial route. Given the minimal nasal mucosal dissection required and the frequent patient complaints related to nasal packing, use of packing is no longer used for this procedure.

Characteristics of Rathke's Cleft in MR Imaging

PURPOSE

Symptoms, macroscopic appearances and microscopic findings of Rathke's cleft cysts with magnetic resonance (MR) imaging.

PATIENTS AND METHODS

We analyzed the data from 31 patients with pathologically confirmed Rathke's cleft cysts. MR appearances were evaluated on T1WI, T2WI and contrast T1WI. Symptoms, macroscopic appearances and pathological findings were obtained from available medical records. We analyzed the images according to the following criteria: 1. findings on the location and shape of the lesions and form of the lesional wall; 2. the relationship between the maximum diameter of the lesions and symptoms; 3. the relationship between MR and macroscopic appearance; 4. the sites of adjacent contrast enhancement.

RESULTS

The lesions were located mostly in both the intrasellar and suprasellar regions for a total of 87%. All lesions revealed either an oval or dumbbell shape with a smooth lesional wall. When correlated with physical symptoms, asymptomatic cases were associated with smaller lesions, while visual disturbances and dizziness were associated with relatively larger lesions. MR lesion signal intensity was related to the content of macroscopic appearance to some degree: the selected lesions showed shortening of T1 and T2 relaxation times in relation to the increase in protein concentration. This should have been macroscopically reflected in the color and turbidity of the liquid within the cyst. Adjacent contrast enhancement around the lesion was found at various sites, but anterior enhancement was most frequent. Circumferential enhancement was revealed to be derived from inflammatory changes.

CONCLUSION

Rathke's cleft cyst exhibits a varied MR signal. It may be difficult to differentiate from craniopharyngioma from the intensity alone.

Multiple endocrine disorders and Rathke's cleft cyst with Klinefelter's syndrome: a case report

A 46-year-old Japanese male was admitted for the evaluation of severe hypertension. He was obese and had a eunuchoidal body habitus. Chromosomal analysis revealed a 46, XY/47, XXY karyotype. Serum LH, FSH and testosterone levels were low, indicating hypogonadotropic hypogonadism. Endocrinological dynamic tests disclosed presence of hypothalamic panhypopituitarism, partial diabetes insipidus, type 2 diabetes mellitus and low renin essential hypertension. Brain computed tomography and magnetic resonance imaging revealed intra- and extrasellar masses. Histological examination of the tissue obtained at transsphenoidal surgery showed a Rathke's cleft cyst (RCC). To the best of our knowledge, this is the first case report of mosaic Klinefelter's syndrome accompanied by symptomatic RCC, type 2 diabetes mellitus and low renin essential hypertension.

Rathke's cleft cyst presenting as pituitary apoplexy

Sellar lesions mainly constitute pituitary adenomas, craniopharyngiomas and benign cysts. Rathke's pouch cyst is a developmental sellar and/or suprasellar cystic lesion lined by a single layer of ciliated cuboidal or columnar epithelium, which rarely be comes symptomatic. The authors present an interesting case of intrasellar Rathke's pouch cyst, with a presenting feature of acute pituitary apoplexy. This was a 19 year old healthy male who had developed sudden headache and visual disturbance. Neuro-radiological imaging revealed a mass in the sella. Via transsphenoidal approach a haemorrhagic intrasellar cystic lesion was removed and was confirmed as a haemorrhagic Rathke's cleft cyst by histopathological examination. Interesting clinical presentations and the neuroimaging findings are described and discussed.

An entirely suprasellar Rathke's cleft cyst: case report and review of the literature

Rathke's cleft cysts usually present with an intrasellar or a combined intrasellar and suprasellar localization. In this report we present a 58-year-old man with a Rathke's cleft cysts in an entirely suprasellar location with intact diaphragm and intact sella. Although this presentation of a Rathke's cleft cyst is extremely rare, it belongs in the differential diagnosis of entirely suprasellar lesions. The relevant literature is discussed.

Clinical features of symptomatic Rathke's cleft cyst

To investigate the clinical features of Rathke's cleft cysts (RCCs), we retrospectively analyzed 15 cases with histologically confirmed RCCs. All patients underwent formal testing of visual field, endocrinological evaluation and magnetic resonance imagings. As overall presenting symptoms, endocrine disturbance was the most common symptoms, followed by visual disturbance and headache. Among the endocrine disturbances based on adenohypophysial dysfunction, hyperprolactinemia was most common. Considering the size of RCCs, RCCs could induce hyperprolactinemia only when the cysts became large enough to compress the infundibular system. Our series showed relative high incidence of pituitary dwarfism and diabetes insipidus (DI). These facts indicated that RCCs could evoke hyposecretion of growth hormone in young patients and DI in aged patients by direct compression of the pituitary gland in the early stage of progression. All cases who had headache had no other symptoms. We could not prove the evidence that RCCs could induce headaches in these cases. This might be suggested that headache could not be a sole symptom in cases of RCCs.

A case of Rathke's Cleft Cyst inflammation presenting with diabetes insipidus

Rathke's Cleft Cyst (RCC), which is located at the intrasellar region, is considered to be the distended remnants of Rathke's pouch, an invagination of the stomodeum. Lined with columnar or cuboidal epithelium of ectodermal origin, RCC usually contains mucoid material and it is found in 13-22% of normal pituitary glands. The cyst rarely leads to the development of symptoms but, when it does, the most common presenting symptoms are headache, visual impairment, hypopituitarism and hypothalamic dysfunction. However, in some cases it presents symptoms of diabetes insipidus, decreased libido and impotence. Recently we experienced a case of RCC inflammation presenting with diabetes insipidus and treated with transsphenoidal surgery. To our knowledge, this is the first report of RCC presenting with symptoms of diabetes insipidus in Korea.

[Rathke's pouch cysts: diagnosis and treatment]

We studied retrospectively a series of four patients with Rathke pouch cysts and pointed out to their clinical presentation and treatment. They all occurred with female patients. Predominant symptoms were amenorrhea, headache and visual disorders. We present a revision of the literature concerning various series of Rathke's pouch cysts. We conclude that surgery is the best therapeutical procedure and transsphenoidal approach is the best surgical technique.

Rathke's cleft cyst presenting as sphenoid sinusitis

Rathke's cleft cysts are developmental abnormalities of the craniopharyngeal duct composed of retained stratified ciliated cuboidal cells of the respiratory type. Incidentally found in the pars intermedia in 13% to 33% of routine autopsies, they are discovered in growing numbers on CT and MRI scans. From 1991 to 1999, 9 cases of Rathke's cleft cysts were encountered by the senior authors, 4 of which were treated surgically (3 by using a transsphenoidal approach and one by using a transcranial subfrontal approach). Of the 3 patients treated with a transsphenoidal approach, 2 presented with symptoms mimicking sphenoid sinusitis and were initially referred for otolaryngologic evaluation. The clinical, pathologic, and radiologic features, as well as management and follow-up of those 2 patients, are reviewed. There has been only one previous case report of Rathke's cleft cysts presenting as sinusitis. Nevertheless, the otolaryngologist should be aware of this condition because it may present with other significant symptomatic extracranial extensions.

Rathke's cleft cyst with large frontal extension: unusual shape and pathomechanism of its formation

The patient was a 62 year old woman who presented with a visual field defect. Magnetic resonance images showed an intra-and supra-sellar low intensity mass on T1 weighted images. The preoperative diagnosis was craniopharyngioma, Rathke's cleft cyst (RCC) or arachnoid cyst. The patient underwent transsphenoidal surgery & the pathological diagnosis was RCC. We conclude that although RCC has a round, ovoid or dumb-bell shaped configuration, it may present a unusual shape in cases with preconditions, as were seen in our patient.

Resection of suprasellar tumors by using a modified transsphenoidal approach. Report of four cases

Generally accepted contraindications to using a transsphenoidal approach for resection of tumors that arise in or extend into the suprasellar region include a normal-sized sella turcica, normal pituitary function, and adherence of tumor to vital intracranial structures. Thus, the transsphenoidal approach has traditionally been restricted to the removal of tumors involving the pituitary fossa and, occasionally, to suprasellar extensions of such tumors if the sella is enlarged. However, conventional transcranial approaches to the suprasellar region require significant brain retraction and offer limited visualization of contralateral tumor extension and the interface between the tumor and adjacent structures, such as the hypothalamus, third ventricle, optic apparatus, and major arteries. In this paper the authors describe successful removal of suprasellar tumors by using a modified transsphenoidal approach that circumvents some of the traditional contraindications to transsphenoidal surgery, while avoiding some of the disadvantages of transcranial surgery. Four patients harbored tumors (two craniopharyngiomas and two hemangioblastomas) that arose in the suprasellar region and were located either entirely (three patients) or primarily (one patient) within the suprasellar space. All patients had a normal-sized sella turcica. Preoperatively, three of the four patients had significant endocrinological deficits signifying involvement of the hypothalamus, pituitary stalk, or pituitary gland. Two patients exhibited preoperative visual field defects. For tumor excision, a recently described modification of the traditional transsphenoidal approach was used. Using this modification, one removes the posterior portion of the planum sphenoidale, allowing access to the suprasellar region. Total resection of tumor was achieved (including absence of residual tumor on follow-up imaging) in three of the four patients. In the remaining patient, total removal was not possible because of adherence of tumor to the hypothalamus and midbrain. One postoperative cerebrospinal fluid leak occurred. Postoperative endocrinological function was worse than preoperative function in one patient. No other new postoperative endocrinological or neurological deficits were encountered. This study demonstrates the feasibility of using a modified transsphenoidal approach for resection of certain suprasellar, nonpituitary tumors.

Cystic lesions of the pituitary: clinicopathological features distinguishing craniopharyngioma, Rathke's cleft cyst, and arachnoid cyst

The distinction among craniopharyngioma (CR), Rathke's cleft cyst (RCC), and intrasellar arachnoid cyst (AC) remains a difficult preoperative problem. Accurate diagnosis of these rare pituitary lesions is important to determine the type of treatment and predict prognostic outcome. The majority of the literature describes the clinical manifestations and management of only one of CR, RCC, or AC, rendering comparisons difficult. We conducted a study to 1) investigate distinguishing preoperative clinical, biochemical, and radiographic features of patients with CR, RCC, and AC; and 2) identify clinicopathological features that independently predict recurrence in CR and RCC in adults. Fifty-two adult patients included 21 patients with CR (mean age at initial surgery, 35 +/- 14 yr), 26 patients with RCC (mean age, 37 +/- 14 yr), and 5 patients with AC (mean age, 53 +/- 12 yr). Mean follow-up duration was 70 +/- 13 months. Patients with CR presented with hypopituitarism in 95% of cases and hyperprolactinemia in 38%. These patients also had more preoperative neurological deficits (67%), ophthalmological complaints (67%), and significantly higher psychiatric manifestations (33%; P = 0.003) than those with RCC or AC. Patients with AC presented with headaches (60%), visual field deficits (60%), or impotence (50%) in the absence of other specific endocrine dysfunction symptoms. Using biochemical criteria, the percentage of patients with two or more pituitary hormonal axes impaired preoperatively was 67% for CR and 62% for RCC, significantly greater (P = 0.03) than that for the AC patients who had pituitary dysfunction of only one axis. The composition of CR lesions was cystic (38%), solid (10%), or mixed solid and cystic (43%). Patients with RCC or AC groups had a significantly greater proportion (P = 0.006) of purely cystic lesions (88% and 100%, respectively). Calcification detectable on computed tomographic scanning was present in 87% of patients with CR, a significantly greater proportion (P < 0.001) compared to those with RCC (13%) or AC (0%). No significant differences were found between the groups based on computed tomography density, the presence of postcontrast enhancement, or magnetic resonance imaging. Recurrence rate was 62% for CR, 19% for RCC, and 20% for AC. Surgical intervention statistically improved most neurological, ophthalmological, and psychiatric manifestations; in contrast, galactorrhea, menstrual dysfunction, and diabetes insipidus (52% CR; 31% RCC) did not improve or became worse postoperatively. A significantly higher percentage of patients with CR required postoperative hormone replacement. Similarly, there was a biochemical trend suggesting that a smaller proportion of patients with CR improved in at least one pituitary axis after surgery (P = 0.08) compared to those with RCC or AC. There was a positive correlation between cyst size and recurrence rate (r = 0.689; P < 0.01) and between cyst size and time to recurrence (r = 0.582; P = 0.037) for all three groups. We describe the largest clinical, biochemical, radiographic, and histological series of adult patients with cystic disease of the sella turcica. Patients with AC tended to be older at initial diagnosis than CR or RCC patients. Mass effects, such as visual problems and headaches, are common symptoms of all three cystic lesions, but psychiatric deficits favor a diagnosis of CR. Calcification or solid components on neuroimaging characterize CR. Endocrinological deficits, especially diabetes insipidus, had the worst prognosis after surgery. Low recurrence rates can be expected for RCC and AC. These data have direct implications for the management and monitoring of patients with cystic lesions of the sella turcica.

Differential diagnosis of sellar masses

The differential diagnosis of nonpituitary sellar masses is broad; differentiating among potential etiologies may not always be straightforward because many of these lesions, tumorous and nontumorous, may mimic the clinical, endocrinologic, and radiologic presentations of pituitary adenomas. This article provides an overview of the clinical and radiographic characteristics of both pituitary tumors and the nonpituitary lesions found in the sellar/parasellar region and discusses, in detail, the specific nonpituitary origins of the sellar masses.