1
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Mark IT, Glastonbury CM. MR Imaging Appearance of Ruptured Rathke Cleft Cyst and Associated Bone Marrow Enhancement. AJNR Am J Neuroradiol 2023; 44:1314-1317. [PMID: 37798112 PMCID: PMC10631529 DOI: 10.3174/ajnr.a8009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 08/30/2023] [Indexed: 10/07/2023]
Abstract
Rathke cleft cysts are common cystic pituitary lesions seen on MR imaging. A subset of Rathke cleft cysts can rupture within the sella and are uncommon. The imaging appearance of a ruptured Rathke cleft cyst has been previously described with nonspecific imaging findings. We present 7 cases of ruptured Rathke cleft cysts and basisphenoid bone marrow enhancement below the sella that could be used to potentially distinguish a ruptured Rathke cleft cyst from other cystic lesions.
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Affiliation(s)
- Ian T Mark
- From the Department of Radiology (I.T.M.), Mayo Clinic, Rochester, Minnesota
- Department of Radiology and Biomedical Imaging (I.T.M., C.M.G.), University of California San Francisco, San Francisco, California
| | - Christine M Glastonbury
- Department of Radiology and Biomedical Imaging (I.T.M., C.M.G.), University of California San Francisco, San Francisco, California
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2
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Chong GYC, Tan KCB, Lau EYF, Lai AYT, Man KKY, Chan TM, Leung WKW, Leung JYY. A study on clinical outcomes of Rathke's cleft cyst in patients managed conservatively. Pituitary 2022; 25:258-266. [PMID: 34807360 DOI: 10.1007/s11102-021-01194-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The primary objective was to investigate the clinical presentation, hormonal dysfunction, imaging characteristics and natural history of RCCs that were managed conservatively. Secondary objective was to identify factors associated with cyst progression. METHODS A retrospective review of patients with the clinical diagnosis of RCC-identified from word search from radiology reports that were followed up from January 1999 to March 2019 was performed. The demographics, clinical data, radiological features and outcomes were reviewed and analyzed. RESULTS 105 patients were identified with a median follow up of 6 years. 68 patients (64.8%) were managed conservatively from diagnosis till last follow up while 37 patients (35.2%) underwent surgery, with 26 operated at time of diagnosis and 11 operated upon monitoring. For patients managed conservatively from diagnosis till last follow up, incidental finding was the most common presentation. 19.1% had either one or more axes of hormonal dysfunction, with hypogonadism and hypocortisolemia being the commonest ones. Imaging features were variable. 66.2% of patients had T2W hyperintensity on MRI. Pathognomonic feature of intracystic nodule was present in only 14.7% of patients. Among the 79 patients with repeated MRI imaging (68 from conservative group and 11 from surgical group), 32.9% of patients developed cyst progression while 67.1% had either static disease or regression in size of RCC. Median time to progression of cyst was 14 months. Longer median follow up duration and presence of pituitary stalk displacement at presentation were associated with cyst progression. Only one patient developed new endocrine dysfunction. CONCLUSION 2/3 of the RCCs had static disease or even regression in the size of the cyst. They rarely gave rise to additional endocrine dysfunction by adopting observant approach. Cyst progression was demonstrated in 1/3 of patients. Conservative treatment remained a reasonable treatment for patients without significant symptoms.
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Affiliation(s)
- Gigi Y C Chong
- Department of Medicine and Geriatrics, Ruttonjee Hospital, Wan Chai, Hong Kong.
| | - Kathryn C B Tan
- Department of Medicine, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Emmy Y F Lau
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Alta Y T Lai
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Kenyon K Y Man
- Department of Radiology, Queen Mary Hospital, Pokfulam, Hong Kong
| | - T M Chan
- Department of Radiology, Ruttonjee Hospital, Wan Chai, Hong Kong
| | - Warren K W Leung
- Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Jenny Y Y Leung
- Department of Medicine and Geriatrics, Ruttonjee Hospital, Wan Chai, Hong Kong
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3
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Elarjani T, Alhuthayl MR, Dababo M, Kanaan IN. Rathke cleft cyst apoplexy: Hormonal and clinical presentation. Surg Neurol Int 2021; 12:504. [PMID: 34754554 PMCID: PMC8571240 DOI: 10.25259/sni_382_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Rathke cleft cyst (RCC) apoplexy is an uncommon type of lesion that is challenging to diagnose without histopathological samples. Very few articles have been published describing the details of RCC apoplexy. We studied a good number of published articles to analyze its demographics, clinical and hormonal presentations, and outcomes. Methods: A literature review of English language publications about RCC apoplexy or pituitary apoplexy was conducted using Medline and EMBASE search engines. Thirty articles with histological diagnosis of RCC apoplexy were identified, the earliest of which was published in 1990 and the latest in 2019. We combined the findings of these articles with our own case report and then compared the demographics, clinical and hormonal presentations, and outcomes between RCC apoplexy and pituitary adenoma apoplexy. Results: Our data included 29 patients with RCC, with a mean age of 36.87 years (8–72) and a predominance of female patients (68%). The hemorrhagic type was most common, reported in 86%. Headache was the most common presenting symptom, being reported in 93% followed by hypogonadism (73%) and hormonal deficits (52%). All but three patients improved neurologically (90%); however, 45% of patients required long-term hormonal replacement, mostly thyroid hormone. No cases of worsening neurological or hormonal status were reported. Conclusion: RCC apoplexy presents with less severe neurological and hormonal abnormalities than pituitary adenoma apoplexy; it also has a better prognosis in endocrine functional recovery. We recommend applying current management guidelines of pituitary adenoma apoplexy to RCC apoplexy.
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Affiliation(s)
- Turki Elarjani
- Department of Neurological Surgery, University of Miami MILLER School of medicine Jackson Memorial Hospital, Miami, Florida, United States
| | - Meshari Rashed Alhuthayl
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Tachassoussi, Riyadh, Saudi Arabia
| | - Mahammad Dababo
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Tachassoussi, Riyadh, Saudi Arabia
| | - Imad N Kanaan
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Tachassoussi, Riyadh, Saudi Arabia
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4
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Manjila S, Asmar NE, Vidalis BM, Alonso F, Singh G, Vadamalai K, Cohen ML, Bambakidis NC, Arafah BM, Selman WR. Intratumoral Rathke's Cleft Cyst Remnants Within Craniopharyngioma, Pituitary Adenoma, Suprasellar Dermoid, and Epidermoid Cysts: A Ubiquitous Signature of Ectodermal Lineage or a Transitional Entity? Neurosurgery 2020; 85:180-188. [PMID: 30010935 DOI: 10.1093/neuros/nyy285] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 06/03/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The authors present cystic epithelial masses in the suprasellar region which on histopathology revealed 4 mixed tumors having simple cuboidal epithelium of Rathke's Cleft Cyst (RCC) elements trapped within pituitary adenoma, epidermoid cyst, dermoid cyst, and papillary craniopharyngioma respectively. OBJECTIVE To highlight the developmental theory of ectodermal continuum in the realm of suprasellar epithelial cystic lesions and examines the cardinal aspects that distinguish RCC from its confounder, ciliary craniopharyngioma. METHODS The authors performed a medical chart review on 4 patients who had coexisting RCC with craniopharyngioma, pituitary adenoma, suprasellar dermoid, and epidermoid cysts. RESULTS This series of unique suprasellar lesions elucidate the spectrum of cases from Rathke's cyst to other suprasellar epithelial cysts including a recently identified clinical entity called ciliary craniopharyngioma, which authors feel is a misnomer. The authors also report the first case of ruptured dermoid cyst admixed with elements of Rathke's cyst elements and xanthogranuloma in neurosurgical literature. CONCLUSION We propose that the new entity of ciliary craniopharyngioma could be just another variant of RCC elements nested within a typical papillary or adamantinomatous lesion. Further study is warranted to understand the implications of natural history with tumors containing RCC elements.
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Affiliation(s)
- Sunil Manjila
- Department of Neurological Surgery, The Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Nadine El Asmar
- Department of En-docrinology, University Hospitals Cleve-land Medical Center, Cleveland, Ohio
| | - Benjamin M Vidalis
- Department of Neurological Surgery, University of New Mexico Hospitals, Albuquerque, New Mexico
| | - Fernando Alonso
- Department of Neurological Surgery, The Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Gagandeep Singh
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Karthik Vadamalai
- Department of Neurological Surgery, The Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Mark L Cohen
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Nicholas C Bambakidis
- Department of Neurological Surgery, The Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Baha M Arafah
- Department of En-docrinology, University Hospitals Cleve-land Medical Center, Cleveland, Ohio
| | - Warren R Selman
- Department of Neurological Surgery, The Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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5
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Jung HN, Kim ST, Kong DS, Suh SI, Ryoo I. Rathke Cleft Cysts with Apoplexy-Like Symptoms: Clinicoradiologic Comparisons with Pituitary Adenomas with Apoplexy. World Neurosurg 2020; 142:e1-e9. [PMID: 32217176 DOI: 10.1016/j.wneu.2020.03.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/13/2020] [Accepted: 03/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Rathke cleft cyst (RCC) can cause acute symptoms mimicking pituitary adenoma (PA) apoplexy. We evaluated the clinicoradiologic features for distinguishing RCC from PA apoplexy. METHODS We retrospectively evaluated 22 patients with RCC and 24 patients with PA with apoplexy-like symptoms who underwent surgery via a transsphenoidal approach between November 1999 and December 2016. We compared the clinical data and magnetic resonance (MR) images between the 2 groups. RESULTS The RCC group was younger and had smaller tumors compared with the PA group (P = 0.02 and 0.001, respectively). The incidences of visual deficits and cranial nerve palsy were lower in the RCCs than in the PAs (P ≤ 0.02 for all). MR images showed more frequent intracystic nodules in the RCCs (P < 0.001), whereas nodular enhancement and lateral deviation of the pituitary stalk were more commonly seen in the PAs (P ≤ 0.003 for both). However, the presence of endocrine dysfunction or decreased consciousness, and the recurrence ratio, were not significantly different between the groups (P ≥ 0.48 for all). In the multivariable logistic regression analysis, patients without nodular enhancement had a 15.84-fold greater risk of RCC than did those with nodular enhancement (P = 0.031). The probability of RCC decreased 0.59-fold with each 1-cm3 increase in tumor volume. CONCLUSIONS RCC with apoplexy-like symptoms has different clinicoradiologic features compared with PA apoplexy. Patients with RCC present with milder ocular symptoms and smaller tumor volumes compared with those with PA apoplexy. The absence of nodular enhancement on MR images could suggest RCC.
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Affiliation(s)
- Hye Na Jung
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Guro, Seoul, South Korea; Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Sungkyunkwan, South Korea
| | - Sung Tae Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Sungkyunkwan, South Korea.
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Sungkyunkwan, South Korea
| | - Sang-Il Suh
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Guro, Seoul, South Korea
| | - Inseon Ryoo
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Guro, Seoul, South Korea
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6
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Eosinophilia caused by adrenal insufficiency in an elder patient under hemodialysis. Eur Geriatr Med 2016. [DOI: 10.1016/j.eurger.2016.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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7
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Spontaneous Involution of a Presumably Rathke's Cleft Cyst in a Patient with Slight Subclinical Hypopituitarism: A Case Report and Review of the Literature. Case Rep Surg 2015; 2015:971364. [PMID: 26413367 PMCID: PMC4564632 DOI: 10.1155/2015/971364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 08/20/2015] [Indexed: 11/21/2022] Open
Abstract
Rathke cleft cyst is described as benign intrasellar cyst. They are mostly small and asymptomatic; they may become large enough to cause symptoms by compression of intrasellar or suprasellar structures. We report on a case of spontaneous regression of a symptomatic RCC with subsequent recovery of preexisting endocrine dysfunction and resolution of headaches. A 60-year-old man complained about headaches. Laboratory investigation revealed a partial hypopituitarism with a slight central hypothyroidism without need for substitution. An MRI study showed a cystic, T2-hyperintense, sellar lesion compatible with a RCC. At one year follow-up, the patient had no complaints and the hormone work-up revealed a regression of the previous slight hypopituitarism. The MRI study showed a complete regression of the cystic lesion and a normal sized and shaped pituitary gland. The spontaneous regression of cystic sellar lesions is rare. The exact mechanism of the possible spontaneous involution of RCC is until now not well understood. However, spontaneous regression is possible and justifies the conservative therapy with regular clinical and radiological follow-up for asymptomatic patients or patients with symptoms not caused by the mass effect of these lesions.
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8
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Asano T, Yamada H, Yoshida M, Aoki A, Ikoma A, Kusaka I, Toyoshima H, Kakei M, Ishikawa SE. Hypothalamic type of hypopituitarism and central diabetes insipidus probably linked to Rathke's cleft cyst. Intern Med 2015; 54:935-40. [PMID: 25876576 DOI: 10.2169/internalmedicine.54.3289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 73-year-old woman was admitted due to weight loss and generalized malaise. The basal levels of all the anterior pituitary hormones, except for prolactin, were reduced. However, they were all elevated in response to exogenous hypothalamic hormones. After starting hydrocortisone replacement, the patient had polyuria of >5,000 mL/day. T1-weighted MRI depicted a low signal of an oval mass in the sella turcica and an iso-intense signal of another mass at the pituitary stalk. These findings indicate a hypothalamic type of hypopituitarism and masked central diabetes insipidus which possibly derived from the atypical occupation of Rathke's cleft cyst at the pituitary stalk.
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Affiliation(s)
- Tomoko Asano
- Department of Medicine, Jichi Medical University Saitama Medical Center, Japan
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9
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Babu R, Back AG, Komisarow JM, Owens TR, Cummings TJ, Britz GW. Symptomatic Rathke's cleft cyst with a co-existing pituitary tumor; Brief review of the literature. Asian J Neurosurg 2014; 8:183-7. [PMID: 24551002 PMCID: PMC3912769 DOI: 10.4103/1793-5482.125662] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Pituitary adenomas and Rathke's cleft cysts (RCCs) share a common embryological origin. Occasionally, these two lesions can present within the same patient. We present a case of a 39-year-old male who was found to have a large sellar lesion after complaints of persistent headaches and horizontal nystagmus. Surgical resection revealed components of a RCC co-existing with a pituitary adenoma. A brief review of the literature was performed revealing 38 cases of co-existing Rathke's cleft cysts and pituitary adenomas. Among the cases, the most common symptoms included headache and visual changes. Rathke's cleft cysts and pituitary adenomas are rarely found to co-exist, despite having common embryological origins. We review the existing literature, discuss the common embryology to these two lesions and describe a unique case from our institution of a co-existing Rathke's cleft cyst and pituitary adenoma.
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Affiliation(s)
- Ranjith Babu
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Adam G Back
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Jordan M Komisarow
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Timothy R Owens
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Thomas J Cummings
- Division of Pathology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Gavin W Britz
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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10
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Kim E. A Rathke's Cleft Cyst Presenting with Apoplexy. J Korean Neurosurg Soc 2012; 52:404-6. [PMID: 23133732 PMCID: PMC3488652 DOI: 10.3340/jkns.2012.52.4.404] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 09/15/2012] [Accepted: 10/10/2012] [Indexed: 11/27/2022] Open
Abstract
The occurrence of symptomatic pituitary hemorrhage into a Rathke's cleft cyst (RCC) is extremely rare. The author reports an interesting case of intra- and suprasellar RCC presented with features of pituitary apoplexy. This 62-year-old woman suffered acute headache, mental confusion, and partial hypopituitarism. The characteristics of the magnetic resonance imaging seemed most compatible with a hemorrhagic pituitary adenoma. Transsphenoidal drainage of the cyst contents confirmed the diagnosis of hemorrhagic RCC and resolved the symptoms. All published data on this rare clinical entity are extracted and reviewed.
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Affiliation(s)
- Ealmaan Kim
- Department of Neurosurgery, Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea
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11
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Asano T, Aoki A, Sasaki M, Ikoma A, Toyoshima H, Kawakami M, Fujisawa I, Ishikawa SE. Central diabetes insipidus and hypothalamic type of hypopituitarism associated with atypical location of Rathke's cleft cyst. Intern Med 2012; 51:189-94. [PMID: 22246489 DOI: 10.2169/internalmedicine.51.5646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 68-year-old woman was admitted to determine the pathogenesis of weight loss and polyuria. Physical findings on admission showed BMI of 20.9, blood pressure of 147/69 mmHg, and that she had ciliac, axillar and pubic hair loss. Laboratory findings showed that plasma adrenocorticotropic hormone (ACTH) was 4.6 pg/mL with serum cortisol of 1.2 µg/dL. Serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were markedly reduced. Serum growth hormone (GH) and insulin growth factor (IGF)-1 were 0.054 ng/mL and 25 ng/mL, respectively. Serum prolactin was as high as 85.6 ng/mL. The levels of all the pituitary hormones were elevated in response to a mixture of exogenous corticotrophin-releasing hormone (CRH), luteinizing hormone-releasing hormone (LH-RH), thyrotropin-releasing hormone (TRH), and growth hormone-releasing hormone (GRH). However, there was no response of ACTH and GH release to insulin-induced hypoglycemia and no response of LH and FSH release to clomiphene. Urine volume was more than 4,000 mL, with low urine osmolality of 134 mmol/kg. Plasma arginine vasopressin (AVP) was 0.8 pg/mL. There was no increase in urine osmolality and plasma AVP in response to 5% hypertonic saline load. Magnetic resonance imaging revealed Rathke's cleft cyst at the pituitary stalk level, but there was no abnormal finding in the hypothalamus. These findings indicate central diabetes insipidus and hypothalamic type of hypopituitarism, resulting from the atypical location of Rathke's cleft cyst.
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Affiliation(s)
- Tomoko Asano
- Department of Medicine, Jichi Medical University Saitama Medical Center, Japan
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12
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Rincon JL, Nunes J, Camuto P, Goodrich I. Intracranial Approach to Suprasellar Rathke's Cleft Cyst. Skull Base 2011; 9:71-3. [PMID: 17171085 PMCID: PMC1656719 DOI: 10.1055/s-2008-1058176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The occurrence of a symptomatic Rathke's cleft cyst without extension into the sella turcica is rare. The purpose of this report is to present such a case, with its clinical manifestation, diagnostic imaging characteristics, operative approach, pathology and review of the literature.
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13
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Abstract
Our aim is to describe a case of acromegaly that was associated with symptomatic Rathke's cyst. We describe a young male student without any significant family history who presented with clinical and biochemical features consistent with growth hormone excess, which was confirmed with dynamic testing. He also described a persistent headache predating symptoms of growth hormone excess by 4 years. Magnetic resonance imaging (MRI) of the pituitary showed a large sellar mass which was thought to be a somatotroph adenoma. Trans-sphenoidal surgery was performed; however, a colloid lesion was identified by the neurosurgeon that proved to be a Rathke's cyst. The association of acromegaly with Rathke's cyst is very rare, with less than 10 cases found to be reported on review of literature. This is the first report from India.
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Affiliation(s)
- Vishal Gupta
- Department of Endocrinology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Ashley Grossman
- Department of Medicine and Endocrinology, Bart and The London NHS Trust, London
| | - Aneesa Kapadia
- Department of Medicine and Endocrinology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Kiran Thorat
- Department of Histopathology, Saifee Hospital, Mumbai, India
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14
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Chaiban JT, Abdelmannan D, Cohen M, Selman WR, Arafah BM. Rathke cleft cyst apoplexy: a newly characterized distinct clinical entity. J Neurosurg 2011; 114:318-24. [DOI: 10.3171/2010.5.jns091905] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Although most Rathke cleft cysts (RCCs) remain asymptomatic, some present with compression of surrounding structures and pituitary hormone dysfunction. A rare, but distinct presentation of the RCC includes hemorrhage into the cyst—a presentation that mimics the clinical syndrome of pituitary tumor apoplexy. The objective of this article is to present the authors' experience on the prevalence and the clinical, biochemical, pathological, and imaging characteristics of hemorrhage into an RCC and review published reports on this entity.
Methods
An institutional database for patients with pituitary masses was reviewed and data on cases involving surgery for a subsequently documented RCC were identified. Patients with documented hemorrhage within the RCC were included in the analysis. Documentation included intraoperative visualization of hemorrhage by the surgeon and/or pathological confirmation of hemorrhage within the RCC. The clinical, biochemical, pathological, and imaging characteristics of these patients were extracted from the database. All published data on RCC were also reviewed and confirmed cases of hemorrhage were extracted and included in the review.
Results
A total of 11 cases with hemorrhage within an RCC were identified to have been managed at the authors' institution over a 10-year span. This figure represented 20% of all surgically treated cases of RCC from that period. Among published reports, a total of 10 confirmed cases were evaluated. The clinical presentation of patients with hemorrhage within an RCC are classical and include sudden onset of severe headache—or a sudden increase in headache severity—associated with visual disturbances, impairment in pituitary function, and occasionally alterations in mental status. Leakage of the cystic contents into the subarachnoid space can occur rarely and may lead to associated chemical meningitis. There are no known precipitating factors for this phenomenon. The clinical presentation of such patients is difficult to distinguish from that of patients with pituitary tumor apoplexy. However, patients with RCC apoplexy often present with less severe symptoms, have a lower prevalence of pituitary dysfunction, and generally have smaller mass lesions than those with pituitary tumor apoplexy. Management of patients with RCC apoplexy is similar to that of those with pituitary tumor apoplexy. Surgery can provide definitive diagnosis and relief of symptoms and often leads to recovery from hypopituitarism. All patients with this syndrome require long-term follow-up to treat any residual sequelae.
Conclusions
This article provides the first thorough review and characterization of patients with hemorrhage within an RCC. Based on the clinical manifestations of this presentation, we recommend using the term “Rathke cleft cyst apoplexy” to describe the syndrome.
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Affiliation(s)
- Joumana T. Chaiban
- 1The Pituitary Center,
- 2Division of Clinical and Molecular Endocrinology, and
| | - Dima Abdelmannan
- 1The Pituitary Center,
- 2Division of Clinical and Molecular Endocrinology, and
| | | | - Warren R. Selman
- 4Neurological Surgery, University Hospitals Case Medical Center, The Louis Stokes Department of Veterans Affairs Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Baha M. Arafah
- 1The Pituitary Center,
- 2Division of Clinical and Molecular Endocrinology, and
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15
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Li ZS, Wei MQ, Fu X, Cheng H, Li Q. Chordoma coexisting with Rathke's cleft cyst: Case report and literature review. Neuropathology 2011; 31:66-70. [DOI: 10.1111/j.1440-1789.2010.01125.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Tate MC, Jahangiri A, Blevins L, Kunwar S, Aghi MK. Infected Rathke Cleft Cysts. Neurosurgery 2010; 67:762-9; discussion 769. [DOI: 10.1227/01.neu.0000377017.53294.b5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND
Rathke cleft cysts (RCCs) are benign sellar lesions that are generally asymptomatic but sometimes warrant transsphenoidal drainage. Small case reports have described infected RCCs, but this phenomenon remains uncharacterized.
OBJECTIVE
We reviewed RCCs over 23 years at our institution to determine factors predicting infection and recurrence.
METHODS
We retrospectively reviewed the magnetic resonance images, laboratory results, microbiology, and pathology of 176 RCC patients (1985–2008) who underwent initial operation at our institution (n = 170) or at another institution followed by recurrence managed at our institution (n = 6).
RESULTS
There were 3 RCC categories: cysts cultured intraoperatively during initial surgery (n = 21), cysts not cultured during initial surgery but cultured during subsequent surgery (n = 9), and cysts that were never cultured (n = 146). Cultured cysts were larger (1.6 vs 1.2 cm; P = .002) and had more frequent pituitary dysfunction (76% vs 30%; P < .001) than noncultured cysts. Restricted diffusion was also more common in cultured cysts (50% vs 0%; P = .02). Of cysts cultured at initial or subsequent surgery, 48% and 44%, respectively, had positive cultures (n = 14) and were treated with antibiotics. The most common organisms were Staphylococcus epidermidis (64%) and Propionibacterium acnes (57%). Kaplan-Meier recurrence rates were 13% (culture positive/antibiotic treated), 31% (culture negative/not antibiotic treated), and 9% (noncultured) (P = .002, cultured vs noncultured; P = .002, culture negative/not antibiotic treated vs non-cultured; P = .5 culture positive/antibiotic treated vs noncultured).
CONCLUSION
Suspected RCC infection, regardless of culture results, is a strong predictor of recurrence and may warrant antibiotic treatment. With antibiotic treatment, the recurrence rate of infected RCC approaches that of noninfected cysts. The higher recurrence rates reported in other series may reflect underrecognition of occult infection.
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Affiliation(s)
- Matthew C. Tate
- Department of Neurosurgery, University of California at San Francisco, San Francisco, California
| | - Arman Jahangiri
- University of Texas Southwestern Medical School, Dallas, Texas
| | - Lewis Blevins
- Department of Neurosurgery, University of California at San Francisco, San Francisco, California
| | - Sandeep Kunwar
- Department of Neurosurgery, University of California at San Francisco, San Francisco, California
| | - Manish K. Aghi
- Department of Neurosurgery, University of California at San Francisco, San Francisco, California
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18
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Clinical features, management and recurrence of symptomatic Rathke's cleft cyst. J Clin Neurosci 2009; 16:385-9. [PMID: 19147363 DOI: 10.1016/j.jocn.2008.04.023] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Revised: 04/24/2008] [Accepted: 04/29/2008] [Indexed: 11/21/2022]
Abstract
Rathke's cleft cyst (RCC) is a rare lesion of the pituitary gland that is often asymptomatic. The objective of this study was to further characterise the presenting symptoms, endocrinopathy and potential for recurrence of this lesion in an Australian population. The files of 12 patients with pathologically confirmed RCCs were reviewed retrospectively. Common presentations included headache, endocrinopathy, and visual disturbance. Uncommon presentations included 1 patient with pituitary apoplexy. The cysts varied in size from 6 mm to 20 mm; 8 had a suprasellar component. 1 patient had evidence of a RCC with xanthogranulomatous change. RCC recurrence was noted on follow-up MRI in 5 patients. In conclusion, RCCs are rare lesions that can present with an array of clinical symptoms. The relatively high rate of recurrence may indicate a link between this pathology and craniopharyngioma, although many patients with recurrent RCC do not require repeat resection and remain asymptomatic.
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19
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Gondim JA, Schops M, Cavalcante JP, Gomes E. Rathke's cleft cyst and partial feet adactyly: an unusual association. ARQUIVOS DE NEURO-PSIQUIATRIA 2008; 65:1040-2. [PMID: 18094874 DOI: 10.1590/s0004-282x2007000600027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Accepted: 08/25/2007] [Indexed: 11/22/2022]
Abstract
A 53 year-old woman presented a recurrent bifrontal headache of 2 years duration and bilateral progressive visual disturbance. The clinical and neurological examination showed a bilateral feet adactyly and bitemporal hemianopsia. The brain MRI demonstrated a Rathke's cleft cyst. The patient was operated by a transnasal endoscopic approach. It seems that this unusual association has never been described before.
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Affiliation(s)
- Jackson A Gondim
- Neuroendocrinological Department, General Hospital of Fortaleza, Avenida Engenheiro Santana Junior 2977/1402, Fortaleza, CE, Brazil.
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20
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Rathke’s cleft cyst rupture as potential initial event of a secondary perifocal lymphocytic hypophysitis: proposal of an unusual pathogenetic event and review of the literature. Neurosurg Rev 2008; 31:157-63. [DOI: 10.1007/s10143-008-0120-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Revised: 09/19/2007] [Accepted: 11/11/2007] [Indexed: 10/22/2022]
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21
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Choi SH, Kwon BJ, Na DG, Kim JH, Han MH, Chang KH. Pituitary adenoma, craniopharyngioma, and Rathke cleft cyst involving both intrasellar and suprasellar regions: differentiation using MRI. Clin Radiol 2007; 62:453-62. [PMID: 17398271 DOI: 10.1016/j.crad.2006.12.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Revised: 11/23/2006] [Accepted: 12/07/2006] [Indexed: 11/23/2022]
Abstract
AIMS To determine the differential magnetic resonance imaging (MRI) features of pituitary adenoma, craniopharyngioma, and Rathke cleft cyst involving both intrasellar and suprasellar regions. MATERIALS AND METHODS The MRI images of 64 patients with pituitary adenoma (n=38), craniopharyngioma (n=13), or Rathke cleft cyst (n=13) were retrospectively reviewed by three neuroradiologists. The following characteristics were evaluated: shape, volume, extent, component characteristics, signal intensities of solid portions on T2-weighted images, signal intensities of cystic portions on T1-weighted images, and enhancement patterns of solid portions and cyst walls of tumours. Fisher's exact test applied with Bonferroni correction was used for multiple comparison. A flowchart for differential diagnosis was constructed based on statistical analysis of the results. RESULTS A snowman shape, solid characteristics, and homogeneous enhancement of the solid portion were more common in pituitary adenomas (p<0.017). A superiorly lobulated shape, third ventricle compression by superior tumour extension, mixed solid and cystic characteristics, and reticular enhancement of the solid portion were more common in craniopharyngiomas (p<0.017). Finally, an ovoid shape, a small tumour volume, cystic characteristics, and no or thin cyst wall enhancement were more common in Rathke cleft cysts (p<0.017). The flowchart yielded diagnostic accuracies as follows: 92.1% in pituitary adenoma; 92.3% in craniopharyngioma; 92.3% in Rathke cleft cyst; and 92.2% overall. CONCLUSION A combination of MRI findings is helpful in the differential diagnosis of the three tumours involving both intrasellar and suprasellar regions.
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Affiliation(s)
- S H Choi
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republicof Korea
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22
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Nishikawa T, Takahashi JA, Shimatsu A, Hashimoto N. Hypophysitis Caused by Rathke's Cleft Cyst-Case Report-. Neurol Med Chir (Tokyo) 2007; 47:136-9. [PMID: 17384498 DOI: 10.2176/nmc.47.136] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 62-year-old woman presented with general malaise persisting for 2 months and narrowing of her visual field. T1-weighted magnetic resonance (MR) imaging showed swelling of the pituitary gland and stalk, and a homogeneous isointense intra- and suprasellar mass enhanced by gadolinium. During outpatient follow up, her condition deteriorated rapidly and she developed diabetes insipidus and panhypopituitarism. T1-weighted MR imaging demonstrated shrinkage of the lesion and disappearance of the central hypointense area indicating the cyst cavity, especially in the pituitary stalk. She underwent surgical exploration via the transsphenoidal approach under a provisional diagnosis of lymphocytic hypophysitis. Histological examination revealed ciliated columnar cells and squamous metaplasia on the inner surface of the cyst wall, with many foamy cells, infiltration by many lymphoid cells and some eosinophils, and fibrosis in the adenohypophysitis and inflammatory hypophysitis in the anterior and posterior pituitary gland. The present neuroimaging findings of cyst shrinkage associated with rapid clinical deterioration strongly support the suggestion that rupture of Rathke's cleft cyst causes inflammatory hypophysitis.
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Hofmann BM, Kreutzer J, Saeger W, Buchfelder M, Blümcke I, Fahlbusch R, Buslei R. Nuclear β-Catenin Accumulation as Reliable Marker for the Differentiation Between Cystic Craniopharyngiomas and Rathke Cleft Cysts: A Clinico-Pathologic Approach. Am J Surg Pathol 2006; 30:1595-603. [PMID: 17122517 DOI: 10.1097/01.pas.0000213328.64121.12] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Clinical and histopathologic differentiation of cystic lesions from the sellar region, that is, craniopharyngiomas (CPs) and Rathke cleft cysts (RCCs), is challenging and has paramount importance with respect to variable clinical manifestation and adapted surgical treatment strategies in both entities. Here, we retrospectively evaluated clinico-pathologic findings in 81 patients presenting with a cystic tumor located in the sellar region. All patients underwent transsphenoidal or transcranial resections. Microscopic inspection of surgical specimens identified CP in 51 patients, and RCC in 30 patients. Amongst the panel of immunohistochemical marker proteins used for histopathologic analysis, nuclear accumulation of beta-catenin was detectable only in CP. On the basis of the histopathologic and immunohistochemical analysis, clinical presentation (sex, age, ophthalmologic, and endocrinologic deficits), imaging (tumor location, size, and calcification), as well as a description of cyst contents obtained during operation were retrospectively evaluated. In purely cystic CPs, an isointense signal was more frequent in T1-weighted magnetic resonance images and calcification of the tumor capsule in computed tomography scans. In addition, the size of RCC was smaller and this tumor entity was more often located within the sella. Aberrant (nuclear) immunohistochemical staining for beta-catenin appeared, however, as most reliable factor for the differentiation between purely cystic CPs and RCCs, whereas tumor location, tumor size, and calcification of the tumor capsule were less consistent parameters. The data are compatible with distinct pathogenic pathways associated with these related histopathologic entities.
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Affiliation(s)
- Bernd M Hofmann
- Department of Neurosurgery, University of Erlangen-Nuremberg, Erlangen, Germany.
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24
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Nishioka H, Haraoka J, Izawa H, Ikeda Y. Magnetic resonance imaging, clinical manifestations, and management of Rathke's cleft cyst. Clin Endocrinol (Oxf) 2006; 64:184-8. [PMID: 16430718 DOI: 10.1111/j.1365-2265.2006.02446.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The management of Rathke's cleft cyst (RCC), particularly in patients with no symptoms or with only minor endocrinopathies, has not yet been established. We retrospectively analysed patients with RCC to elucidate correlations between the clinical manifestations, magnetic resonance imaging (MRI) findings, histology and therapeutic outcomes. METHODS We retrospectively studied 37 patients with RCC, who underwent computed tomography (CT), MRI and endocrinological examinations, of whom 27 patients underwent surgical intervention. RESULTS The presence of frontal headaches and anterior pituitary dysfunction was unrelated to the cyst size but was more frequent in patients with high- and isointensity cysts on T1-weighted images (WIs) than those with low-intensity cysts (P=0.0159 and P=0.0249, respectively). All three patients with posterior pituitary dysfunction had a high-intensity cyst on T1-WI (P=0.0385), whereas pituitary dysfunction was not observed in patients with a low-intensity cyst on T1-WI. In contrast to the excellent therapeutic outcomes with regard to visual disturbance and hyperprolactinaemia, recovery of pituitary dysfunction was rare; only three of nine patients with hypopituitarism showed improvement. Among six patients with histologically recognized intense chronic inflammation in the cyst wall, five patients had an RCC of T1 high intensity (P=0.0161), two patients had distinct rim enhancement on MRI (P=0.0060), all patients had frontal headaches (P=0.0130), and four patients had associated hypopituitarism (P=0.0243), none of which improved after surgical intervention. CONCLUSION RCCs of high- and isointensity on T1-weighted images, which contain mucous material within the cyst, may be associated with chronic inflammation that can potentially cause irreversible endocrine dysfunction. In asymptomatic patients with RCCs of these MR intensities, close follow-up with precise endocrinological evaluation and gadolinium-enhanced MRI is necessary to avoid occult progression of the inflammation.
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Affiliation(s)
- Hiroshi Nishioka
- Tokyo Medical University, Tokyo Medical University, Tokyo, Japan.
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25
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Sade B, Albrecht S, Assimakopoulos P, Vézina JL, Mohr G. Management of Rathke's cleft cysts. ACTA ACUST UNITED AC 2005; 63:459-66; discussion 466. [PMID: 15883073 DOI: 10.1016/j.surneu.2004.06.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2004] [Accepted: 06/28/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND Incidental diagnosis of Rathke's cleft cysts (RCCs) has increased due to the improvements in imaging techniques; however, symptomatic cases are rare and accurate preoperative diagnosis can be difficult. METHODS Files and magnetic resonance imaging (MRI) of 10 surgically treated patients with RCC and 8 conservatively managed cases with a suspected diagnosis were reviewed retrospectively. Clinical, radiological, and histological features as well as intraoperative findings were scrutinized. RESULTS In the surgical group, headache was present in 4 patients, hormonal abnormality in 4, visual deficits in 3, and otolaryngological symptoms in 2. Two of the nonsurgical cases had hyperprolactinemia, and the remaining were asymptomatic. The cyst had suprasellar extension (SSE) in 9 patients and was entirely suprasellar in 1 in the surgical group. It was purely intrasellar in 6 nonsurgical cases and had SSE in 2. The cyst content showed hyperintense MRI signal in the majority of T1 and T2 images in both groups. Transsphenoidal surgery was performed in 8 and transcranial surgery in 2 patients. Squamous metaplasia and inflammation was present in 3 cases each. Initial hormonal deficiencies did not improve postoperatively and new deficits were observed in 2 cases. There was no recurrence with an average follow-up of 32 months. CONCLUSIONS Rathke's cleft cysts is a rare pathology with a wide spectrum of clinical and radiological features. Reactive inflammation of the normal pituitary gland may have a role in the pathogenesis of hormonal deficiency, in addition to compression. Preoperative recognition of the anteriorly displaced normal residual gland may be important in avoiding postoperative hormonal deficiency after transsphenoidal approach.
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Affiliation(s)
- Burak Sade
- Division of Neurosurgery, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, Quebec, Canada H3T 1E2
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26
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Bakhshi S, Kalpatthi R, Sharma R, Sarkar MKC, Menon PSN. Rathke's cleft cyst: missed etiology of panhypopituitarism in presence of coexistent ocular and neurocysticercosis. J Pediatr Endocrinol Metab 2004; 17:1133-6. [PMID: 15379427 DOI: 10.1515/jpem.2004.17.8.1133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report a 10 year-old girl with panhypopituitarism and coexistent ocular and neurocysticercosis. Intrasellar cystic lesions whether neoplastic or non-neoplastic in origin are often difficult to distinguish because their symptoms, signs, and radiological characteristics are similar. The diagnosis of intrasellar cysticercosis was initially considered because of high endemicity, positive serology for cysticercus and radiological evidence of cysticercosis in the eye and parietal lobe. However, since there was no improvement with cysticidal therapy and no radiological resolution of the sellar lesion, surgery was performed, which revealed a Rathke's cleft cyst.
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Affiliation(s)
- Sameer Bakhshi
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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27
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Kim JE, Kim JH, Kim OL, Paek SH, Kim DG, Chi JG, Jung HW. Surgical treatment of symptomatic Rathke cleft cysts: clinical features and results with special attention to recurrence. J Neurosurg 2004; 100:33-40. [PMID: 14743909 DOI: 10.3171/jns.2004.100.1.0033] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Jeong Eun Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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28
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Bader LJ, Carter KD, Latchaw RE, Ellis WG, Wexler JA, Watson JC. Simultaneous symptomatic Rathke's cleft cyst and GH secreting pituitary adenoma: a case report. Pituitary 2004; 7:39-44. [PMID: 15638297 DOI: 10.1023/b:pitu.0000044632.15978.44] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A case of symptomatic Rathke's cleft cyst and growth hormone (GH) secreting pituitary adenoma is described. A patient presented with a visual field deficit and a brain magnetic resonance imaging (MRI) study demonstrated compression of the optic chiasm by a large suprasellar cyst and a small lesion in the sellar consistent with a microadenoma. Preoperative clinical evaluation revealed mild acromegalic features, glucose intolerance, hypertension, hypercholesterolemia, and carpel tunnel syndrome, and blood testing confirmed an elevated insulin-like growth factor-1 (IGF-1). A modified transsphenoidal skull based approach was performed for selective transsphenoidal adenomectomy and decompression of the surprasellar cyst. The patient had an uneventful postoperative course with resolution of the visual field deficits and dysmenorrhea. Endocrine testing at two-month post procedure were normal. While there have been a small number of cases reported of concomitant pituitary adenomas and Rathke's cleft cysts, there is no report known to these authors of coexisting symptomatic lesions.
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Affiliation(s)
- Lucas J Bader
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, USA
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29
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Billeci D, Marton E, Tripodi M, Orvieto E, Longatti P. Symptomatic Rathke's cleft cysts: a radiological, surgical and pathological review. Pituitary 2004; 7:131-137. [PMID: 16328563 DOI: 10.1007/s11102-005-1755-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
| | - Elisabetta Marton
- Neurosurgical Department, Regional Hospital, Treviso, Italy.
- Neurosurgical and Pathology Department, Regional Hospital, Treviso, Italy.
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30
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Falavigna A, Ferraz FAP, Madalosso FA, Hohmann FB. [Rathke's pouch cyst: case report]. ARQUIVOS DE NEURO-PSIQUIATRIA 2003; 61:281-4. [PMID: 12806513 DOI: 10.1590/s0004-282x2003000200024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The Rathke's pouch cysts are a relatively common autopsy finding, but rarely have they been reported as a clinical entity. We report a Rathke's pouch cyst patient's case with visual impairment and emphasize aspects like clinical presentation, radiological studies and treatment. Many published series about this pathology have been reviewed and compared with the present case.
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Hama S, Arita K, Nishisaka T, Fukuhara T, Tominaga A, Sugiyama K, Yoshioka H, Eguchi K, Sumida M, Heike Y, Kurisu K. Changes in the epithelium of Rathke cleft cyst associated with inflammation. J Neurosurg 2002; 96:209-16. [PMID: 11838792 DOI: 10.3171/jns.2002.96.2.0209] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Rathke cleft cysts (RCCs) are composed of tall, well-differentiated, ciliated columnar epithelia. Their structures are altered by hyperplasia or squamous metaplasia, but their cause remains unknown. METHODS The authors studied pathological findings and anterior pituitary function in 20 patients harboring RCCs. They classified RCC epithelium as either single (a single ciliated columnar cell lining or a flattened cuboidal cell lining) or stratified (a stratified ciliated columnar cell lining, basal cell hyperplasia, columnar cell hyperplasia, or squamous metaplasia). Inflammation was classified as acute, subacute, chronic, or end stage. The epithelial cell lining was observed in 13 specimens obtained during surgery (six specimens contained single and seven contained stratified epithelia). Inflammation had penetrated the cyst epithelium or subjacent stroma in 10 patients, and the stage of inflammation correlated well with the type of epithelia group: early stages of inflammation in the single epithelium group and chronic or end-stage inflammation in the stratified epithelia (p = 0.0027). The adenohypophysis was identified in 21 surgical specimens. Postoperatively, growth hormone (p = 0.019), cortisol (p = 0.027), and thyroid-stimulating hormone (p = 0.039) responses significantly worsened as the inflammation progressed. The presence of diabetes insipidus correlated well with advanced stages of neurohypophysitis (p = 0.025). CONCLUSIONS Epithelial stratification in the RCC is caused by inflammation that may extend into the adjacent adenohypophysis or neurohypophysis and overwhelm the hypophysis, resulting in panhypopituitarism. Transsphenoidal excision may represent the best choice for treatment, at least for cases of RCC in which there is partial impairment of hypophysial function.
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Affiliation(s)
- Seiji Hama
- Department of Neurosurgery, Hiroshima University School of Medicine, Japan.
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33
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Rodrigues FF, Cappabianca P, Violante AH. [Rathke's pouch cysts: diagnosis and treatment]. ARQUIVOS DE NEURO-PSIQUIATRIA 2001; 59:101-5. [PMID: 11299441 DOI: 10.1590/s0004-282x2001000100021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- F F Rodrigues
- Setor Neurocirurgia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Brazil
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34
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Nader R, Frenkiel S, Mohr G, Jacques L, Tampieri D, Albrecht S. Rathke's cleft cyst presenting as sphenoid sinusitis. Otolaryngol Head Neck Surg 2001; 124:174-9. [PMID: 11226953 DOI: 10.1067/mhn.2001.111713] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- R Nader
- Department of Neurosurgery, SMBD-Jewish General Hospital, McGill University, 3755 Cote Ste-Catherine, Montreal, Quebec, Canada, H3T 1E2
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35
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Nishioka H, Ito H, Haraoka J, Hashimoto T, Kato Y. Repeated hemorrhage in ciliated craniopharyngioma--case report. Neurol Med Chir (Tokyo) 2000; 40:324-8. [PMID: 10892270 DOI: 10.2176/nmc.40.324] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 49-year-old female presented with a ciliated craniopharyngioma manifesting as repeated intratumoral hemorrhage. Histological examination suggested that the hemorrhage originated from the many thin blood vessels in the cyst wall stroma associated with inflammation. Symptomatic hemorrhage in cystic craniopharyngioma may mimic pituitary apoplexy but the etiology is quite different. Minor hemorrhage may recur unless the cyst wall is totally removed.
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Affiliation(s)
- H Nishioka
- Department of Neurosurgery, Tokyo Medical University
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36
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Shin JL, Asa SL, Woodhouse LJ, Smyth HS, Ezzat S. Cystic lesions of the pituitary: clinicopathological features distinguishing craniopharyngioma, Rathke's cleft cyst, and arachnoid cyst. J Clin Endocrinol Metab 1999; 84:3972-82. [PMID: 10566636 DOI: 10.1210/jcem.84.11.6114] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- J L Shin
- Department of Medicine, University of Toronto, Ontario, Canada
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37
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Hayashi Y, Tachibana O, Muramatsu N, Tsuchiya H, Tada M, Arakawa Y, Suzuki M, Yamashita J. Rathke cleft cyst: MR and biomedical analysis of cyst content. J Comput Assist Tomogr 1999; 23:34-8. [PMID: 10050804 DOI: 10.1097/00004728-199901000-00008] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE At least one type of Rathke cleft cyst has unique MR findings, specifically, high intensity on T1-weighted images and iso- to low intensity on T2-weighted images relative to white matter. To clarify the influence of cyst content on MR images, we analyzed the cyst content by biomedical methods after surgical removal. METHOD We studied five patients diagnosed with Rathke cleft cyst, whose MR images showed high intensity on T1-weighted images and iso- to low intensity on T2-weighted images. After surgery, total protein and cholesterol levels were quantified, and correlations of protein and cholesterol content with T1 and T2 signal intensities were performed in vitro. RESULTS All five cysts had very high concentrations of protein (11,700-26,600 mg/dl, mean 17,940 mg/dl) with nearly no cholesterol (at most 2.0 mg/dl). Along with increases in protein concentration in vitro, the signal intensity of T1-weighted images increased, while that of T2-weighted images decreased. In contrast, the cholesterol concentration sequence influenced the signal intensity of neither T1- nor T2-weighted images. CONCLUSION The unique MR finding of Rathke cleft cysts--high signal intensity on T1-weighted images and low signal intensity on T2-weighted images--might depend mainly on protein concentration, not on cholesterol.
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Affiliation(s)
- Y Hayashi
- Department of Neurosurgery, Kanazawa University School of Medicine, Japan
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Yokoyama S, Goto M, Hirano H, Hirakawa W, Noguchi S, Hirahara K, Kadota K, Asakura T. Pituitary Adenoma with Cholesterol Clefts. Endocr Pathol 1998; 9:91-95. [PMID: 12114666 DOI: 10.1007/bf02739956] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Histologically, cholesterol clefts are often observed in craniopharyngioma, Rathke's cleft cyst, and various granulomas. However, pituitary adenomas with cholesterol clefts are rare. A 46-year-old woman developed visual field disturbance. She had no history of severe headache that would suggest pituitary apoplexy. She presented with homonymous bitemporal hemianopsia and galactorrhea. Blood prolactin level was 63.1 ng/mL Other hypophysial hormone levels were within normal range. Magnetic resonance imaging revealed a pituitary tumor with intratumoral cyst. The cyst showed high intensity on T1- and T2-weighted images. The tumor was demonstrated with iso intensity on T1-weighted image and with high intensity on 12-weighted image. She underwent trans-sphenoidal surgery. The tumor was soft, with yellowish, oily fluid, probably the cyst content. By light microscopy with hematoxylin and eosin staining, a typical chromophobic adenoma of the pituitary was identified. Immunostaining revealed immunoreactivity for ACTH in several cells. Many cholesterol clefts and several hemosiderin pigment containing macrophages were observed. Electron microscopy demonstrated a pituitary adenoma with sparse and small secretory granules and numerous lysosomes. The cyst was most likely caused by focal hemorrhagic infarction, followed by the formation of cholesterol crystals, the appearance of hemosiderin containing macrophages, foreign body product cells, and accumulation of lysosomes.
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Mukherjee JJ, Islam N, Kaltsas G, Lowe DG, Charlesworth M, Afshar F, Trainer PJ, Monson JP, Besser GM, Grossman AB. Clinical, radiological and pathological features of patients with Rathke's cleft cysts: tumors that may recur. J Clin Endocrinol Metab 1997; 82:2357-62. [PMID: 9215319 DOI: 10.1210/jcem.82.7.4043] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Rathke's cleft cysts are cystic sellar and suprasellar lesions, characteristically lined by a single layer of ciliated cuboidal or columnar epithelium. In contrast, craniopharyngiomass, which are also cystic sellar and suprasellar lesions, are characteristically lined by stratified squamous epithelium with keratinization on a layer of connective tissue. The usual management recommended for Rathke's cleft cysts is simple surgical drainage with partial excision of the cyst wall. Recurrences of these cysts reportedly have been very rare. This retrospective study presents the details of 12 patients (6 females; median age 30 yr, range 21-58 yr) with Rathke's cleft cyst, referred to our department over a 15-yr period (1981-1996), an unusual feature being the recurrence of 4 (33%) of these lesions. Clinical, endocrine, radiological, surgical (10 transsphenoidal; 2 transcranial), and pathological details were recorded. Nine out of 12 patients (75%) were symptomatic; visual symptoms were the commonest, and 8 had visual field defects. The median duration of symptoms was 12 months (range 3-24 months). Three patients (25%) had panhypopituitarism, 2 of whom also had diabetes insipidus (17%). The cysts varied in size from 6 mm to 50 mm, 1 being entirely suprasellar. There were no pathognomonic clinical or radiological features to differentiate them from other pituitary lesions, although the presence of diabetes insipidus in 2 patients suggested that the lesion was not a pituitary adenoma. A definite histological diagnosis was possible in 8 patients; in 4, the diagnosis was presumptive. The median duration of follow-up was 30 months (1-168 months). Four patients (33%) showed reexpansion at 3, 6, 48, and 48 months after initial surgery, 3 of whom were symptomatic and required repeat surgery. Two of these patients were given postoperative external beam pituitary radiotherapy. Apparent recurrence of Rathke's cleft cysts after initially successful surgery in our series was higher than suggested by previous reports, and thus, long-term follow-up with pituitary imaging and neuroophthalmological assessment is essential. There are no specific characteristics of the cyst that predict recurrence. Ideal management of these cysts is unclear, but aspiration, followed by extensive excision of the cyst wall when possible, seems to be the best initial option. For recurrent symptomatic tumors, surgical resection is the treatment of choice. Considering the high recurrence rate with residual structural and functional dysfunction, the role of radiotherapy in preventing recurrence of these cysts needs careful evaluation with a larger study with a longer follow-up period.
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Affiliation(s)
- J J Mukherjee
- Department of Endocrinology, St. Bartholomew's Hospital, London, United Kingdom
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40
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Cervoni L, Artico M, Salvati M, Carloia S. Rathke's cleft cyst: a clinical and radiographic review. ITALIAN JOURNAL OF NEUROLOGICAL SCIENCES 1997; 18:37-40. [PMID: 9115042 DOI: 10.1007/bf02106229] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We report the case of a 62-year-old woman, who had a 4-year history of progressive visual acuity deficit. On neurological examination, visual acuity was 5/20 in the right and 4/20 in the left eye. A hormonal study revealed hypophyseal hypofunction. CT and MRI scans showed an intra-suprasellar cystic lesion, hyperintense in T1 and hyperintense in T2-weighted sequences. At surgery, the cyst wall was opened and the cavity placed in communication with the subarachnoid space. Histological examination showed a Rathke's cleft cyst. After four years of follow-up the patient's visual deficit remained unchanged, whereas the results of the hormonal assays were normal. An MRI scan confirmed the absence of the cyst. We review 216 reported cases of Rathke's cyst and discuss its pathogenesis, clinical features and treatment.
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Affiliation(s)
- L Cervoni
- Divisione di Neurochirurgia, Istituto Neurologico Mediterraneo Neuromed, IRCCS, Pozzilli, Italy
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Erşahin Y, Ozdamar N, Demirtaş E, Mutluer S. A case of Rathke's cleft cyst presenting with diabetes insipidus. Clin Neurol Neurosurg 1995; 97:317-20. [PMID: 8599899 DOI: 10.1016/0303-8467(95)00050-t] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Rathke's cleft cysts (RCCs) are considered to arise from the remnants of Rathke's pouch, an invagination of the stomodeum. They are classically described as benign epithelium lined intrasellar cysts containing mucoid material, and also found in 2-33% of routine autopsy series. The most common presenting symptoms are visual impairment, hypothalamic dysfunction, hypopituitarism and headache. Diabetes insipidus has been described in patients with RCC. Very few cases presented with only diabetes insipidus in adults. To our knowledge, our patient is the first case of RCC presenting with only diabetes insipidus in childhood. A 9-year-old girl presented with diabetes insipidus. The physical, neurological and endocrinological examinations were normal, except for diabetes insipidus. Magnetic resonance imaging scan revealed a hyperintense lesion with supra sellar extension in the posterior pituitary both on T1 and T2 weighted images. Subtotal excision of RCC was performed via transsphenoidal surgery. However, diabetes insipidus persisted after the surgery.
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Affiliation(s)
- Y Erşahin
- Department of Pathology, Ege University Faculty of Medicine, Izmir, Turkey
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