Endoscopic Endonasal Approach in the Management of Rathke's Cleft Cysts

Abstract

Objective: Rathke's cleft cysts (RCCs) are quite uncommon sellar lesions that can extend or even arise in the suprasellar area. The purpose of this study is to evaluate the effectiveness of both standard and extended endoscopic endonasal approaches in the management of different located RCCs.

Methods: We retrospectively analyzed a series of 29 patients (9 males, 20 females) complaining of a RCC, who underwent a standard or an extended endoscopic transsphenoidal approach at the Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, of the Università degli Studi di Napoli "Federico II". Data regarding patients' demographics, clinical evaluation, cyst characteristics, surgical treatments, complications and outcomes were extracted from our electronic database (Filemaker Pro 11, File Maker Inc., Santa Clara, California, USA).

Results: A standard transsphenoidal approach was used in 19 cases, while the extended variation of the approach in 10 cases (5 purely suprasellar and 5 intra-suprasellar RCC). Cysts contents was fully drained in all the 29 cases, whilst a gross total removal, that accounts on the complete cyst wall removal, was achieved in an overall 55,1% of patients (16/29), specifically 36,8% (7/19) that received standard approach and 90% (9/10) of those that underwent to extended approach. We reported a 56.2% of recovery from headache, 38.5% of complete recovery and 53.8% of improvement from visual field defect and an overall 46.7% of improvement of the endocrine functions. Postoperative permanent DI rate was 10.3%, overall post-operative CSF leak rate 6.9%; recurrence/regrowth occurred in 4 patients (4/29, 13.8%), but only one required a second surgery.

Conclusion: The endoscopic transsphenoidal approach for the removal of a symptomatic RCC offers several advantages in terms of visualization of the surgical field during both the exposure and removal of the lesion. The "extended" variation of the endoscopic approach provides a direct access to the supradiaphragmatic space, allowing adequate view and room for the safe removal of selected supradiaphragmatic RCCs, regardless of the sellar size (even a not enlarged sella), and provides a higher likelihood of preserving normal pituitary tissue and functions.

Fig 1. Intraoperative images showing an intra and suprasellar Ratkhe’s Cleft Cyst removed via a standard endoscopic endonasalapproach.

(A) colloid suctioning after dural opening; (B: cyst wall removal (C) and (D) intrasellar view after the cyst wall removal. Suprasellar cistern covered by the stratified pituitary gland. Co: colloid; CW: cystwall; D: dura mater; SC: suprasellar cistern.

Fig 2. MRI scan after gadolinium showing an intra and suprasellar Rathke’s Cleft Cyst before and after the surgical removal via a standard endoscopic endonasal approach (case showed in the Fig 1).

(A-B) Sagittal and a coronal T1-weighted scans of the lesion before being removed. The colloid has a hypointense signal and the cyst wall has post contrast enhancement. These features do not define typical aspect of RCC, whose differential diagnosis with sellar arachnoid cysts could be often challenging. (C) Axial T2-weighted scan of the lesion showing the colloid with a hyperintense signal. (D-E) Sagittal and a coronal T1-weighted scans and (F) axial T2-weightedscan at the three months postoperative MRI showing the cyst removal. It is possible to identify the decompression of the optic chiasm and the pituitary stalk.

Fig 3. Intraoperative images showing a suprasellar Ratkhe’s Cleft Cyst removed via an extended endoscopic endonasalapproach.

(A) colloid suctioning after dural opening and exposure of the cyst’s wall (B)Imagine showing the cyst’s wall covering the neurovascular structures of the suprasellar area. (C) cyst wall removal with a forceps and aspirator. (D) after cyst wall removal it is possible to identify: A1 and A2; optic chiasm with optic nerves; pituitary stalk and gland. Co: colloid; CW: cystwall; D: dura mater; Ch: optic chiasm; Ps: pituitary stalk; Pg: pituitary gland; A1: A1 segment of the anterior cerebral artery; A2: A2 segment of the anterior cerebral artery.

Fig 4. MRI scan showing a purely suprasellar Rathke’s Cleft Cyst before and after the surgical removal via an endoscopic endonasal approach (case showed in Fig 3).

(A-B) Sagittal and coronal T1 weighted scans showing the lesion before being removed. The colloid has an isointense signal. (C-D) Sagittal and coronal post-gad scans after three months showing the cyst removal. It is possible to identify the optic chiasm the pituitary stalk and the normal pituitary gland.