Recurrence of Rathke's cleft cysts based on gross total resection of cyst wall: a meta-analysis

Surgical Strategies Regarding the Extended Endoscopic Transnasal Approach for Isolated Suprasellar Rathke's Cleft Cysts

OBJECTIVE

This study aims to evaluate the clinical and surgical outcomes with suprasellar Rathke's cleft cysts (RCCs) treated using the extended endoscopic transnasal approach. It emphasizes surgical strategies, nuances of the technique, and the importance of cyst wall resection in optimizing outcomes while preserving postoperative pituitary function.

METHODS

This retrospective study analyzed 35 patients with suprasellar RCC who underwent extended endoscopic transnasal surgery between 1997 and 2024. Data included demographics, symptoms, imaging findings, surgical details, and follow-up outcomes. The suprasellar cyst was classified as preinfundibular, retroinfundibular, and transinfundibular. Hormonal evaluations were performed, and surgical outcomes were classified as gross total resection or subtotal resection based on imaging and intraoperative findings.

RESULTS

The mean age of the patients was 36.37 ± 14.23 years and female/male ratio was 29:6. Headache is the most common symptom (77.1%). Twenty patients had hormonal deficiencies in at least one hypothalamic-pituitary axis. Preinfundibular group is in 21 patients and gross total resection was achieved in 28 (80%). One patient had permanent cortisol and another thyroid deficiency. One patient had persistent postoperative diabetes insipidus. Three patients developed late postoperative syndrome of inappropriate antidiuretic hormone.

CONCLUSIONS

Surgical intervention is essential for suprasellar RCCs due to their proximity to vital structures. Tailored strategies and gentle resection with minimal stalk manipulation are key to effective treatment and preserving endocrine function.

Rathke's cleft cyst: From history to molecular genetics

A Rathke's cleft cyst (RCC) is a remnant of the embryologic Rathke's pouch and a common pituitary lesion. A true RCC is lined with ciliated cuboidal or columnar epithelia with occasional goblet cells and squamous metaplasia. A RCC is frequently diagnosed incidentally through magnetic resonance imaging and computed tomography of the brain or pituitary gland. Presentation can range from an asymptomatic clinical picture to a rapidly progressive disease. RCC are located most often in the sellar and suprasellar regions and a careful differential diagnosis is crucial, especially to exclude craniophryngioma. Recent studies illuminate novel molecular mechanisms and markers for understanding the pathogenesis of RCC. PROP-1, a paired-like homeodomain transcription factor, controls pituitary ontogeny and its high expression induces RCCs. Both transgenic mouse models and immunohistochemical analysis of human RCCs indicate that the leukemia inhibitory factor is involved in pathogenesis. The expression of cytokeratins 8 and 2 in RCCs, but not in craniopharyngiomas, and the presence of beta-catenin mutations in many craniopharyngiomas, but not in RCCs, help with the differential diagnosis. For asymptomatic and small RCCs, observation is appropriate, with serial magnetic resonance imaging and hormonal investigation depending on the patient's clinical status. Surgical resection may be required for symptomatic RCC and recurrence rates are generally low. For patients with a recurrence, stereotactic radiosurgery is an effective approach with low risk.

Surgical management of symptomatic recurrent Rathke's cleft cysts: A systematic review and individual-participant data meta-analysis

The optimal management of symptomatic recurrent Rathke's cleft cysts (RCCs) is unclear. Here, we compared the outcomes of various surgical approaches for symptomatic recurrent RCCs. PubMed and Embase were systematically reviewed for studies that reported individual-participant data on outcomes after surgical treatment for symptomatic recurrent RCCs presenting with headache and/or visual field defect. The primary outcome was symptomatic recurrence, and the secondary outcome was postoperative complications. Subgroup analyses were performed based on the number of recurrences, duration since initial surgery, previous treatment, and symptoms of recurrence. Of the 713 studies screened, 14 studies (30 recurrences in 24 patients) were included in the meta-analysis. Cyst wall resection was the most common treatment (n = 17, 56.7 %), followed by drainage with intrasellar stent insertion (n = 7, 23.3 %) and resection with intracystic bleomycin (n = 6, 20.0 %). Most of the cases were first recurrences (56.7 %, n = 17). The mean (SD) duration between the initial treatment and onset of symptomatic recurrence was 3.0 (3.6) years. Over a median [IQR] follow-up period of 1.2 [0.4, 2.5] years, patients who underwent cyst wall resection had a significantly higher incidence of symptomatic recurrence at 58.8 %, compared to a 0 % symptomatic recurrence rate in patients treated with drainage and intrasellar stent insertion or resection with intracystic bleomycin (p = 0.014). Patients who underwent cyst wall resection also had the highest risk of symptomatic recurrence on subgroup analysis, though this was statistically significant only among patients who underwent cyst wall resection as their preceding treatment (p = 0.021). There were no significant differences in postoperative complication rates between the treatment arms. In conclusion, for patients with symptomatic recurrent RCCs presenting with headache and/or visual field defects, drainage with intrasellar stent insertion and intracystic bleomycin may be superior to cyst wall resection alone. This approach may reduce the risk of another symptomatic recurrence within one year.

Endonasal endoscopic or endoscopic-assisted transcranial surgery of Rathke's cleft cysts: does the approach and surgical technique influence the radicality and recurrence rate?

OBJECTIVE

Resections of symptomatic Rathke's cleft cysts (RCCs) are mainly performed via an endonasal transsphenoidal approach. However, there is a lack of equivalent data in current literature concerning transcranial keyhole approach in the treatment of RCCs. In order to find general recommendations for the surgical treatment of RCCs also with regard to recurrence, the object of this study is the analysis and comparison of both techniques.

METHODS

Twenty-nine patients having been surgically treated between January 2004 and August 2019 were retrospectively analysed. The transsphenoidal approach was chosen in 16 cases and the transcranial keyhole approach in 13 cases. Both surgical techniques were analyzed and compared concerning preoperative symptoms and cyst characteristics, complications, surgical radicality, endocrinological and ophthalmological outcome and recurrences in patients´ follow up.

RESULTS

The postoperative outcome of both techniques was identic and showed highly satisfying success rates with 92% for neurological deficits, 82% for endocrinological dysfunctions and 86% for visual deficits. In contrast, momentous postoperative complications were significantly more likely after transsphenoidal operations. After a mean follow-up time of 5.7 years, the recurrence rates of both cohorts were the same with 0% each.

CONCLUSIONS

Regarding its equal outcome with its lower complication rate, the authors suggest using the supraorbital keyhole approach for RCCs whose anatomical configuration allow both techniques. Yet, the decision should always consider the surgeon's personal experience and other individual patient characteristics. Further studies with higher numbers of cases and longer follow-up periods are necessary to analyse the effect of the selected approach on recurrence.

Long-term outcomes and potential predictive recurrence factors after endonasal endoscopic surgical treatment of symptomatic Rathke's cleft cysts

Although patients with symptomatic Rathke's cleft cysts (RCCs) receive surgical treatment, recurrence sometimes occurs after surgery. However, the mechanism underlying recurrence remains unclear. We evaluated the outcomes of RCC decompression over a long-term follow-up period. We retrospectively reviewed the medical records of 35 patients with symptomatic RCC who underwent endonasal endoscopic surgery (EES) at our institution between 2008 and 2023. Patients' characteristics, intraoperative findings, and postoperative follow-up outcomes were evaluated. A univariate regression model was used to identify the predictors of recurrence. The median patient age was 48.0 years, and 74.2% of the patients were female. The mean follow-up duration was 94.7 ± 47.6 months. Cyst content recurrence was observed in 15 patients (42.8%). Five patients (14.2%) with symptomatic recurrence underwent reoperation. Postoperative vision improved in all 23 patients (100%); headaches improved in 20 patients (90.9%). A new hormonal deficit occurred in two patients (5.7%). Complications included intraoperative cerebrospinal fluid (CSF) leak in 10 patients (28.5%), postoperative CSF leak in two patients (5.7%), permanent diabetes insipidus in two patients (5.7%), and postoperative infection in three patients (8.5%). Univariate analyses revealed that the position of the anterior pituitary lobe (p = 0.019) and preoperative visual disturbances (p = 0.008) significantly affected recurrence after surgery. Although EES was efficient, the recurrence rate was relatively high over a long-term period. The anterior pituitary lobe position and preoperative visual disturbances were significantly associated with recurrence. The anterior-inferior position can predict a high risk of recurrence before surgery.

Intraoperative ultrasound-assisted endoscopic endonasal transclival marsupialization of an ectopic retrosellar Rathke's cleft cyst: A rare case illustration and systematic review of the literature

Not every Rathke's cleft cyst (RCC) is confined within the sella between the posterior and anterior lobes of the pituitary gland. Intracranial ectopic RCCs are extremely rare, with only seven cases reported in the literature. In this study, the authors presented a rare case of a symptomatic ectopic retrosellar RCC posterior to the pituitary gland, causing extensive clival erosion. The surgical nuances of the wide marsupialization of the cyst through intraoperative ultrasound-assisted endoscopic endonasal transclival approach are described, and a systematic literature review of intracranial ectopic RCCs is conducted.

Pituitary surgery outcome in patients 75 years and older: a retrospective study

BACKGROUND

As the population ages, the number of elderly patients with an indication for pituitary surgery is rising. Information on the outcome of patients aged over 75 is limited. This study reports a large series assessing the feasibility of surgical resection in this specific age range, focusing on surgical complications and postoperative results.

METHODS

A retrospective cohort study of patients with pituitary adenomas and Rathke's cleft cysts was conducted. All patients were aged 75 years or over and treated by a single expert neurosurgical team. A control population included 2379 younger adult patients operated by the same surgeons during the same period.

RESULTS

Between 2008 and 2022, 155 patients underwent surgery. Indication was based on vision impairment in most patients (79%). Median follow-up was 13 months (range: 3-96). The first surgery was performed with an endoscopic transsellar approach, an extended endonasal transtuberculum approach and a microscopic transcranial approach in 96%, 3%, and 1% of patients, respectively. Single surgery was sufficient to obtain volume control in 97% of patients. From Kaplan-Meier estimates, 2-year and 5-year disease control with a single surgery were 97.3% and 86.2%, respectively. Resection higher than 80% was achieved in 77% of patients. No vision worsening occurred. In acromegaly and Cushing's disease, endocrine remission was obtained in 90% of non-invasive adenomas. Surgical complications were noted in 5% of patients, with 30-day mortality, hematoma, cerebrospinal fluid leak, meningitis, and epistaxis occurring in 0.6%, 0.6%, 1.9%, 0.6%, and 1.3% respectively. New endocrine anterior deficits occurred in only 5%, while no persistent diabetes insipidus was noted. Compared with younger patients, the complication rate was not statistically different.

CONCLUSIONS

Surgery beyond the age of 75, mainly relying on an endoscopic endonasal transsellar approach, is effective and safe, provided that patients are managed in tertiary centers.

Rathke's cleft cyst classification and outcomes after endoscopic endonasal approach

BACKGROUND

Rathke's cleft cyst is rare, with variable characteristics and no unified categorization system. This study aimed to evaluate long-term outcomes, based on different categorizations, of symptomatic Rathke's cleft cysts treated with endoscopic endonasal approach.

METHODS

This retrospective study of 38 patients with symptomatic Rathke's cleft cyst treated with endoscopic endonasal approach from 2006/06-2021/08 recorded pre- and post-operative clinical presentation, endocrine and visual tests, radiological findings, and resection status. Rathke's cleft cysts were categorized by both cyst consistency and radiological features and clinical characteristics were analyzed.

RESULTS

The most common pre-operative symptoms were visual field deficit (65.8%) and hypopituitarism (39.5 %). Visual field deficit improved in 84% of affected patients, and hyperprolactinemia improved in 80% of affected patients. Pre-operative hypothyroidism and hypogonadism were associated with radiological type 3 cysts, while headache was more common in type B and C. Type 3 cysts were also associated post-operative hypogonadism and hypothyroidism. Permanent Diabetes insipidus was found in 3 patients (7.9%). Cyst height was a significant factor related to pre-operative visual field deficit and post-operative Diabetes insipidus. Residual cysts were found in 11 cases (30.6%) and 9 patients experienced regrowth/recurrence. Residual cysts were a significant factor in regrowth/recurrence. Recurrence rate and post-operative complications were not correlated with different subtypes.

CONCLUSIONS

Endoscopic endonasal approach for removal of Rathke's cleft cyst is a safe and effective intervention. It leads to significant improvement in visual field deficit and recovery of hyperprolactinemia. Although the incidence of post-operative Diabetes insipidus is high, it is usually temporary. Although different categorizations are not correlated to recurrence rate, they could help predict the status of hormone deficit.

Nuclear translocation of beta catenin in patients with Rathke cleft cysts-clinical and imaging characteristics and risk of recurrence

PURPOSE

Although Rathke cleft cysts (RCC) are benign lesions of the sellar region, recurrence is frequent after surgical treatment. Nuclear translocation of ß-catenin (NTßC), a key effector of the wnt-signaling pathway that is responsible for cell renewal, has been shown to act as a proto-oncogene and is considered to be a potential risk factor for increased recurrence in RCC. In this study, we analyzed a surgically treated cohort into patients with and without NTßC expression in order to identify clinical and imaging differences and further evaluate the risk of recurrence.

METHODS

Patients with resection of RCC between 04/2001 and 11/2020 were included. Histological specimens were immunohistochemically stained for ß-catenin. Study endpoints were time to cyst recurrence (TTR) and functional outcome. Functional outcome included ophthalmological and endocrinological data. Furthermore, MRI data were assessed.

RESULTS

Seventy-three patients (median age 42.3 years) with RCC underwent mainly transsphenoidal cyst resection (95.9%), 4.1% via transcranial approach. Immunohistochemical staining for ß-catenin was feasible in 61/73 (83.6%) patients, with nuclear translocation detected in 13/61 cases (21.3%). Patients with and without NTßC were equally likely to present with endocrine dysfunction before surgery (p = 0.49). Postoperative new hypopituitarism occurred in 14/73 (19.2%) patients. Preoperative visual impairment was equal in both groups (p = 0.52). Vision improved in 8/21 (33.3%) patients and visual field deficits in 22/34 (64.7%) after surgery. There was no difference in visual and perimetric outcome between patients with and without NTßC (p = 0.45 and p = 0.23, respectively). On preoperative MRI, cyst volume (9.9 vs. 8.2 cm3; p = 0.4) and evidence of hemorrhage (30.8% vs. 35.4%; p = 0.99) were equal and postoperative cyst volume decreased significantly in both groups (0.7 vs. 0.5 cm3; p < 0.0001 each). Cyst progression occurred in 13/73 (17.8%) patients after 39.3 ± 60.3 months. Cyst drainage with partial removal of the cyst wall resulted in improved recurrence-free survival without increasing the risk of complications compared with cyst fenestration alone. Patients with postoperative diabetes insipidus had an increased risk for recurrence according to multivariate analysis (p = 0.005). NTßC was evident in 4/15 patients (26.7%) and was not associated with a higher risk for recurrence (p = 0.67).

CONCLUSION

Transnasal transsphenoidal cyst drainage with partial removal of the cyst wall reduces the risk of recurrence without increasing the risk of complications compared with fenestration of the cyst alone. Patients with postoperative diabetes insipidus seem to have an increased risk for recurrence. In contrast, NTßC was not associated with a higher risk of recurrence and did not provide stratification for clinically distinct patients.

Durable headache relief following endoscopic endonasal resection of sub-centimeter Rathke cleft cysts in medically refractory patients

BACKGROUND

The most common presenting symptom in patients with both small and large Rathke cleft cysts (RCC) is headache (H/A). It is well established that patients with large RCC can have significant symptomatic improvement after cyst drainage. However, patients with small RCC (≤ 1 cm) are rarely operated on, even if they present with debilitating H/A. It is not well understood whether resection of these smaller RCCs can lead to durable H/A resolution.

METHODS

A retrospective search of our institutional database for sub-centimeter RCCs presenting with intractable H/A and treated with an endoscopic endonasal approach was carried out. A detailed H/A questionnaire as well as patient chart review was conducted to assess the long-term outcome of these patients after surgical intervention.

RESULTS

Ten consecutive patients with 11 endonasal surgeries met inclusion criteria. Eight responded to the questionnaire. The median cyst diameter was 6 mm (IQR 3-9). Median preoperative H/A duration was 12 months (range 2 months-15 years). H/As occurred on average for 20 days per month and all required analgesics for symptomatic control for more than 15 of these 20 days. Half of the patients also had to miss work because of H/A. Average preoperative H/A intensity was 8.7 (scale 0-10) compared with postoperative scores of 2.9 at one month, 1.6 at 3 months, and 0.9 at 1 year. There were no permanent endocrinological or other surgical complications. After a median follow-up of 2 years, one patient had radiographic and symptomatic recurrence which resolved after re-operation.

CONCLUSIONS

Endoscopic fenestration of sub-centimeter RCCs provides a safe and durable treatment for patients with intractable H/A.

Modified Nasoseptal Flap Technique to Prevent the Recurrence of Rathke's Cleft Cyst

Background

Rathke's cleft cysts (RCCs) are benign epithelial lesions arising from the Rathke's pouch remnants that fail to regress during embryogenesis. Some RCCs become symptomatic and require treatment. Cyst fenestration and drainage of its contents is the preferred procedure to treat symptomatic cases but carries a risk of recurrence. We propose the use of a novel modified nasoseptal flap technique to partially line the cyst wall to avoid recurrence.

Methods

This was a prospective, observational study that included all RCC patients admitted to the Department of Neurosurgery, Aster Medcity, from April 2015 to May 2018. The modified nasoseptal flap technique was performed in all patients. They underwent preoperative and postoperative ophthalmological, endocrine, endoscopic, and MRI evaluations to look for recurrence.

Results

Ten patients underwent the modified nasoseptal flap technique. The median follow-up was 36 months. Postoperatively, all patients were relieved from headaches. Moreover, their visual fields and pituitary functions normalized. None of the patients developed recurrence of RCC on follow-up brain MRI. On endoscopic examination, all patients had retained patency of the fenestra. The longest follow-up was 72 months.

Conclusions

The modified nasoseptal flap technique maintains patency and avoids recurrence of RCCs on long-term follow-up.

Incidence and factors associated with the recurrence of Rathke's cleft cyst after surgery: A systematic review and meta-analysis

Backgroud

Recurrence of Rathke's cleft cyst (RCC) is not uncommon after surgery, and the associated factors and incidence of relapse deserve a systematic summary.

Methods

This study was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The Pubmed, Embase, Cochrane, and Web of Science databases were searched until September 12, 2022. Studies with significant results of recurrent factors or specific incidences of RCC recurrence and mean/median follow-up time were included. Based on a protocol of a 2-year interval grouping, included studies were categorized into four groups with follow-up periods  <24 months, 24-48 months, 48-72 months, and ≥72 months, respectively. Quality assessment was performed using the NOS score. Pooled estimations were computed by using a random-effects model in the STATA "metaprop" command. Publication bias was assessed visually through a funnel plot and statistically through Egger's linear regression test and Begg's correlation test.

Results

A total of 44 studies were included containing 2,539 cases. Squamous metaplasia was the most commonly reported factor, followed by the extent of cyst removal. The other factors were reported individually. The pooled overall incidences of RCC recurrence after surgery in four groups of the follow-up period were 7.4% (95%CI = 4.1-11.3%) in <24 months, 13.1% (95%CI = 9.7-17.0%) in 24-48 months, 13.7% (95%CI = 7.7-21.0%) in 48-72 months, and 33.8% (95%CI = 19.6-49.6%) in ≥72 months. The pooled symptomatic incidences were 2.3% (95%CI = 0.4-5.1%) in <24 months, 5.6% (95%CI = 3.6-7.9%) in 24-48 months, 5.9% (95%CI = 2.4-10.6%) in 48-72 months, and 14.1% (95%CI = 6.0-24.5%) in ≥72 months. A dramatic increase in recurrent incidence was observed when the follow-up period was more than 72 months in both overall and symptomatic recurrence. A similar trend of recurrence was found in subgroup analyses stratified by publication year, cohort size, and cyst resection strategy.

Conclusion

This study systematically reviewed recurrent factors and described the profile of trends in RCC recurrent incidence after surgery with a follow-up time based on a protocol of a 2-year interval, finding a dramatic increase in recurrent rates with a follow-up period of more than 72 months. This encouraged us to put forward a recommendation of at least a 6-year follow-up after surgery for patients with RCC.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021278970.

Pituitary Incidentalomas: Best Practices and Looking Ahead

Pituitary Incidentalomas (PI) are pituitary lesions serendipitously identified on imaging. PIs have become common in clinical practice because of increased use of imaging and radiologic advances. The most frequently incidentally detected lesions in adults are pituitary adenomas, followed by cystic lesions, and rarely other types of tumors and infiltrative and inflammatory disorders. Biochemical screening for hyperprolactinemia and acromegaly is needed in all patients with PI, whereas testing for hyposecretion is recommended for lesions larger than 6.0 mm. Most PIs are small nonfunctioning adenomas or cysts, which can be conservatively managed. For larger lesions, a multidisciplinary approach including endocrinology, neurosurgery, and neuro-ophthalmology is required. For incidentally detected lactotroph, somatotroph, and corticotroph adenomas, disease-specific management guidelines apply. Prospective studies are needed to enhance our understanding of the long-term course and response to treatment.

Endoscopic Treatment of Rathke’s Cleft Cysts: The Case for Simple Fenestration

Background: Rathke’s cleft cysts (RCC) arise from the pars intermedia because of incomplete regression of the embryologic Rathke pouch. A subset of RCC becomes symptomatic causing headaches, visual and endocrinological disturbances such that surgical intervention is indicated. Several points in surgical management remain controversial including operative strategy (simple fenestration (SF) vs complete cyst wall resection (CWR)) as well as reconstructive techniques. Methods: A retrospective analysis was conducted of pathologically confirmed RCC operated on by endoscopic endonasal approach from 2006 to 2019. Pre-operative symptoms, imaging characteristics, operative strategy, symptom response, complications and recurrences were recorded. Results: Thirty-nine patients were identified. Thirty-three underwent SF and six underwent CWR. Worsening pituitary function was significantly increased with CWR (50%) compared to SF (3%) (p = 0.008). All patients underwent “closed” reconstruction with a post-operative CSF leak rate of 5% (3% SF vs 16% CWR, p = 0.287). Six (15%) recurrences necessitating surgery were reported. Recurrence rates stratified by surgical technique (18% SF vs 0% CWR, p = 0.564) were not found to be significantly different. Conclusions: The current series illustrates variability in the surgical management of RCCs. SF with closed reconstruction is a reasonable operative strategy for most symptomatic RCCs cases while CWR can be reserved for selected cases.

Stereotactic radiosurgery for Rathke's cleft cysts: an international multicenter study

OBJECTIVE

Rathke's cleft cysts (RCCs) are sellar collections from an incompletely regressed Rathke's pouch. Common symptoms of RCCs can include headaches, visual loss, and endocrinopathy. Surgery is required in some cases of symptomatic or growing RCCs. Recurrence after surgery is common (range 10%-40%). Stereotactic radiosurgery (SRS) has been used in an attempt to control growth and symptoms, but outcomes are not well known. The authors sought to study the outcomes of RCCs following Gamma Knife surgery for both salvage and initial treatment.

METHODS

The outcomes of 25 patients with RCCs who underwent SRS between 2001 and 2020 were reviewed. Four patients received initial SRS and 21 were treated with salvage SRS. Diagnosis was based on imaging or histopathology. Cyst control was defined as stability or regression of the cyst. Kaplan-Meier analysis was used to determine time to recurrence and determine potential factors for recurrence.

RESULTS

The respective median clinical follow-up and margin dose were 6.5 years and 12 Gy. Overall control was achieved in 19 (76%) of 25 patients, and 4 recurrences required further intervention. The average time to recurrence was 35.6 months in those RCCs that recurred. Visual recovery occurred in 14 (93.3%) of 15 patients and no new post-SRS visual deficits occurred. The presence of a pretreatment visual deficit was often an indicator of RCC regrowth. All 3 patients with pretreatment hyperprolactinemia experienced resolution after SRS. New endocrinopathy related to SRS was noted in 5 (20%) of 25 patients, all of which were thyroid and/or cortisol axis related. Upfront SRS was used in 4 patients. No new endocrinopathies or visual deficits developed after upfront SRS, and the 1 patient with a pretreatment visual deficit recovered. One of the 4 patients with upfront SRS experienced a recurrence after 7.5 years.

CONCLUSIONS

SRS produced effective recovery of visual deficits and carries a low risk for new visual deficits. Cyst control was achieved in approximately three-fourths of the patients. Following SRS, patients without pretreatment visual deficits are less likely to have RCC regrowth. Endocrinopathy can occur after SRS, similar to other sellar mass lesions. Initial SRS shows the potential for long-term cyst control, with improvement of symptoms and a low risk for complications.

Incidence and risk factors of delayed postoperative hyponatremia after endoscopic endonasal surgery for Rathke’s cleft cyst: A single-center study

Backgroud

Delayed postoperative hyponatremia (DPH) is common for sellar lesions. However, the true prevalence and associated factors of DPH after endoscopic endonasal surgery (EES) for Rathke’s cleft cyst (RCC) have not been studied in a large patient cohort.

Methods

A retrospective analysis was conducted over 6 years at our institution, and patients with RCC treated by EES were enrolled according to our inclusion criteria. Patient demographics, clinical characteristics, images, and surgical procedures were documented. Serum sodium was routinely measured before surgery, on postoperative day 1, and every 2 days thereafter until discharge. For patients with DPH, electrolyte, hematocrit, serum protein levels, and plasma and urinary osmolality were daily measured to explore potential etiology.

Results

Of the 149 eligible patients, 25 (16.8%) developed DPH, which was similar to other sellar lesions, except craniopharyngioma, in the same period in our institution. Significant risk factors suggested by univariate analysis were cyst location, requirement of postoperative hydrocortisone therapy, postoperative meningitis, intraoperative cerebrospinal fluid (CSF) leakage, and subtotal resection (STR) of the cyst wall (all p &lt; 0.05). In addition, other supplementary 11 cases of suprasellar RCC with different surgical strategies (aggressive resection) and relevant factors were enrolled into multivariate analysis. Suprasellar location [odds ratio (OR) 8.387, 95% confidence interval (CI) 1.014–69.365, p = 0.049], requirement of postoperative hydrocortisone therapy (OR 4.208, 95%CI 1.246–14.209, p = 0.021), and intraoperative CSF leakage (OR 6.631, 95%CI 1.728–25.440, p = 0.006) were found to be the independent predictors of DPH.

Conclusion

DPH is a common complication after EES for RCC. Suprasellar location, requirement of postoperative hydrocortisone therapy, and intraoperative CSF leakage are the most reliable risk factors. Cortisol deficiency and syndrome of inappropriate antidiuretic hormone (SIADH) are considered as the main etiologies of DPH in RCC. Conservative excision of the cyst wall may reduce DPH occurrence.

Xanthogranuloma of the Sellar Region: A Comprehensive Review of Neuroimaging in a Rare Inflammatory Entity

Xanthogranuloma of the sellar region is a rare chronic inflammatory lesion resulting from secondary hemorrhage, inflammation, infarction, and necrosis of an existing Rathke’s cleft cyst, craniopharyngioma, or pituitary adenoma. Sellar xanthogranulomas are challenging to differentiate from other cystic lesions preoperatively due to the lack of characteristic imaging features. We performed a literature overview of the clinical and paraclinical features, treatment options, and long-term outcomes of patients with sellar xanthogranuloma, focusing on the preoperative radiological diagnosis. The hyperintense signal in both T1- and T2-weighted sequences, cystic or partially cystic morphology, ovoid shape, sellar epicenter, intra- and suprasellar location, intratumoral calcifications, linear rim contrast enhancement, and the absence of cavernous sinus invasion suggest xanthogranuloma in the preoperative differential diagnosis. An endoscopic endonasal gross total resection without radiotherapy is the preferred first-line treatment. Given the low rate of recurrence rate and low chance of endocrinological recovery, a mass reduction with decompression of the optic apparatus may represent an appropriate surgical goal. Identifying the xanthogranulomas’ mutational profile could complement histopathological diagnosis and give insight into their histo-pathogenesis. A better preoperative neuroimagistic diagnosis of sellar xanthogranulomas and differentiation from lesions with a poorer prognosis, such as craniopharyngioma, would result in an optimal personalized surgical approach.

Rathke's cleft cyst marsupialization and repair with a free mucosal graft - Video case report and literature review

Rathke's cleft cysts (RCCs) are sellar or suprasellar cystic lesions arising from the remnants of the embryological Rathke's pouch. When symptomatic, RCCs are usually treated surgically via marsupialization. Free mucosal graft (FMG) repair has shown promise in decreasing recurrence versus marsupialization alone. The authors present a case report with operative video of a patient with visual and endocrinological symptoms with a RCC treated with FMG following marsupialization. A search of the PubMed database from July 1997 through April 2022 was conducted using the terms 'Rathke's cleft cyst', 'Rathke's cleft cyst management', 'Rathke's cleft cyst repair', 'mucosal graft', 'mucosal coupling', 'transsphenoidal', and 'endoscopic endonasal'. Clinical and pathological aspects of the case presented were compared with information obtained from literature review. A 25-year-old female presented with a six-year history of amenorrhea, one-year history of anemia, headaches, and progressive visual loss. Imaging revealed an RCC. The patient underwent surgical treatment via an endoscopic endonasal approach. Marsupialization was achieved with placement of an FMG to help prevent restenosis. Post-operative examination revealed that the patient's OD vision returned to normal, although her OS vision was only slightly improved. Our review of the English literature resulted in 35 full-length articles that were published between 1997 and 2022. The literature suggests that FMG prevents scar formation by allowing for adequate epithelialization, thus decreasing the recurrence rate and being well tolerated by patients. Our findings support the utility of the FMG as a superior surgical treatment option for RCC management.

Long-Term Outcomes of Endoscopic Cyst Fenestration for Rathke Cleft Cyst

OBJECTIVE

We sought to elucidate the long-term surgical outcomes and incidence of recurrence and reoperation of endoscopic endonasal cyst fenestration for Rathke cleft cyst (RCC).

METHODS

A retrospective review of the chart and operation record of RCC surgical cases between January 2008 and August 2021 at our institution was conducted. Patient characteristics, intraoperative findings, and postoperative follow-up outcomes were evaluated.

RESULTS

A total of 27 patients were analyzed, with a median postoperative follow-up period of 52 months (range, 1-150 months). Preoperative symptoms were visual dysfunction (59%), headache (41%), and pituitary dysfunction (22%). Endoscopic cyst fenestration was performed in all patients. Ten (37%) patients had intraoperative cerebrospinal fluid leakage. Among them, the only patient in whom sellar floor reconstruction was not performed experienced a repair operation due to postoperative cerebrospinal fluid leakage. No patients experienced postoperative hypopituitarism. Preoperative headache, visual dysfunction, and pituitary hormone disorder improved in 73%, 75%, and 67% of patients, respectively. Although postoperative cyst regrowth was observed in 8 patients (30%), no patient experienced worsening or novel symptoms and none required reoperation.

CONCLUSIONS

Patients with a symptomatic RCC can be effectively treated with endoscopic endonasal cyst fenestration. Reversal of the presenting symptoms resulted, including headache, visual dysfunction, and pituitary hormone dysfunction, in the majority of patients. In our series, appropriate reconstruction of the sellar floor reduced the risk of postoperative cerebrospinal fluid leakage without impacting cyst regrowth. This simple technique appears to effectively disrupt cyst progression in most cases, even after a relatively long-term follow-up period.

Natural history and surgical outcome of Rathke's cleft cysts-A study from the Swedish Pituitary Registry

OBJECTIVE

Rathke's cleft cysts are benign, embryological remnants in the pituitary gland. The majority of them are small and asymptomatic but a few may become large, and cause mass effects, pituitary hormone deficiencies and visual impairment. Recommendations for the follow-up of Rathke's cleft cysts vary since data on the natural history are sparse.

PATIENTS AND DESIGN

Data at diagnosis and at 1, 5 and 10 years for patients with a Rathke's cleft cyst (434 at diagnosis, 317 females) were retrieved from the Swedish Pituitary Registry. Cysts ≤3 mm in diameter were excluded from the study.

MEASUREMENTS

Data included demographics, cyst size, pituitary function, visual defects and surgery.

RESULTS

The mean age at diagnosis was 45 years. In patients with cysts <10 mm in diameter (n = 204) 2.9% had pituitary hormone deficiencies and 2% had visual field impairments. Cyst size did not progress during the 5 years. Cysts with a diameter of ≥10 mm that were not operated (n = 174) decreased in size over the years (p < .01). Pituitary hormone deficiencies and visual impairments were more frequent (18% and 5.7%, respectively) but were stable over time. Transphenoidal surgery was performed in 56 patients of whom 51 underwent surgery before the 1-year follow-up. The mean cyst diameter at diagnosis was 18 mm (range: 9─30 mm), 36% had pituitary hormone deficiency, 45% had visual field defects and 20% had impaired visual acuity. One year after surgery 60% had no cyst remnants, 50% had a pituitary deficiency, 26% had visual field defects and 12% had impaired visual acuity. No major changes were observed after 5 years. Twelve of the operated patients had a follow-up at 10 years, in eight the cyst remnants or recurrences increased in size over time (p < .05).

CONCLUSIONS

Rathke's cleft cysts with a size less than 10 mm rarely grow and our results indicate that radiological follow-up can be restricted to 5 years. In contrast, progression of postoperative remnants or recurrent cysts is more likely and require long-term follow-up.

Spinal dural arteriovenous fistula rupture after Rathke's cleft cyst endoscopic resection: Case report and literature review

Background:

Spinal dural arteriovenous fistula (SDAVF) is the most frequent vascular malformation of the spine and accounts for approximately 70% of all vascular spinal malformations. In rare cases, SDAVF rupture and subsequent subarachnoid hemorrhage or intramedullary hematoma may occur. The aim of this article is to present a fatal case of SDAVF rupture after a Rathke’s cleft cyst (RCC) endoscopic resection.

Case Description:

An 80-year-old female was referred to our hospital with a clinical presentation of bilateral reduction in visual acuity, bitemporal hemianopsia, and sellar magnetic resonance imaging (MRI) highly suggestive of RCC. After the first endonasal endoscopic surgery, the cyst was partially removed and vision improved. No signs of cerebrospinal fluid (CSF) leak were observed. After 1 year, the patient returned because of RCC recurrence and decreased visual acuity. In the second procedure, the lesion was totally resected and CSF leak was observed. A nasoseptal flap was rotated to cover the skull base defect. The patient developed subtle paraparesis followed by paraplegia on the 4^th postoperative day. The dorsal spine MRI revealed a T3-T4 intramedullary hematoma. A dorsal laminectomy was performed and a SDAVF was observed. During microsurgery, at the right T3 nerve root level, an arteriovenous shunting point was identified, coagulated, and divided. The intramedullary hematoma was evacuated. The patient developed neurogenic and septic shock and died.

Conclusion:

Venous hypertension, venous wall fragility, and venous thrombosis seem to be the main factors involved in SDAVF rupture. In this particular case, reduction of the extravascular pressure and sudden variation in the pressure gradient caused by sustained CSF leak, also appeared to play an important role in SDAVF rupture. It may represent one more complication related to radical resection of RCC.

Rathke's cleft cysts following transsphenoidal surgery: long-term outcomes and development of an optimal follow-up strategy

BACKGROUND

In patients with symptomatic Rathke's cleft cyst, transsphenoidal surgery is highly effective at preventing further visual loss and usually allows for some recovery of vision. However, cyst recurrence and the need for re-operation are well recognized. To this end, the aim of this study was to investigate patterns of recurrence and long-term outcomes and to use this information to develop an optimal follow-up strategy.

METHOD

A prospectively maintained database was searched over a 10-year period between 1 January 2008 and the 1 January 2018 to identify all adults that underwent transsphenoidal surgery with a new diagnosis of Rathke's cleft cyst. A retrospective case note review was performed for each patient to extract data on their presentation, investigation, treatment, and outcome.

RESULTS

In all, 61 eligible patients were identified. The median follow-up was 34 months (range 2-112 months). In the 22 patients with pre-operative visual loss, the outcomes at 6 months were as follows: normal vision (2/22; 9.1%), improved but not normal (7/22; 31.8%), stable (12/22; 54.5%), worse but not blind (1/22; 4.5%), and blind (0/22; 0%). The overall rate of regrowth and re-operation in our study was 19.7 and 11.5%, respectively. The only factor that was significantly associated with recurrence was the presence of residual cystic disease on the post-operative MRI (p < 0.001).

CONCLUSIONS

We propose a follow-up strategy that stratifies patients at "low risk" if there is no residual cyst, with increasing interval scans, or "high risk" if there is residual cyst, with annual visual assessment and scans.