Sellar surprises: a single-centre experience of unusual sellar masses

Background Most common incidentally detected sellar-suprasellar region (SSR) masses are pituitary adenomas, followed by craniopharyngioma, rathke’s cleft cyst, hypophysitis, and meningioma. Besides these, certain unusual SSR lesions can sometimes present as diagnostic challenges, where diagnosis is often made post-operatively on histopathology, the pre-operative suspicion of which might have influenced the management strategies. Series describing such masses are few. Objective To present clinical, biochemical, and radiological characteristics and management outcomes of rare SSR lesions other than pituitary adenomas, craniopharyngioma, rathke’s cleft cyst, hypophysitis, and meningioma. Design, setting, patients Retrospective case record analysis of patients with uncommon SSR masses (from January 2006 to December 2016). Results Our series consisted of ten patients, five with neoplastic and five with non-neoplastic lesions. Neoplastic masses included granular cell tumor (n = 2), astrocytoma (n = 1), malignant peripheral nerve sheath tumor (MPNST, n = 1), and metastasis from occult papillary carcinoma of thyroid (n = 1), while non-neoplastic masses were aspergillus abscess (n = 1), sterile abscess (n = 1), and tubercular abscess (n = 1), aneurysm of left internal carotid artery (n = 1), and ruptured dermoid cyst (n = 1). All patients (except one) presented with headache and/or visual disturbance. Only one patient had acromegaly while most others had hypopituitarism. We describe detailed MRI characteristics of each of the lesion. Seven patients underwent trans-sphenoidal surgery. Post-operatively, five patients had permanent diabetes insipidus, while two patients died in early post-operative period. Conclusion Our series expand the differential diagnostic considerations of SSR lesions. Most of the rare SSR masses present with symptoms of mass effects and hypopituitarism. Except for some non-neoplastic lesions like sellar abscesses, aneurysms, and dermoid cysts which can have some specific imaging characteristics that can provide clue to pre-operative diagnosis, most of the other neoplastic masses have overlapping radiological features, and pre-operative suspicion remains difficult.

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Cortisol Levels as Predictors of Short- and Long-Term Adrenal Function After Endonasal Transsphenoidal Surgery for Pituitary Adenomas and Rathke's Cleft Cyst

World Neurosurgery ◽

10.1016/j.wneu.2012.10.039 ◽

2013 ◽

Vol 80 (5) ◽

pp. 493-494

Author(s):

Mauro Loyo-Varela ◽

Aquiles R. Ayala-Ruiz ◽

Salvador Manrique-Guzman

Keyword(s):

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Adrenal Function ◽

Rathke’S Cleft Cyst ◽

Rathke's Cleft Cyst ◽

Short And Long Term ◽

Cortisol Levels ◽

Rathke's Cleft

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Pituitary Hyposecretion and Hypersecretion Produced by a Rathke's Cleft Cyst Presenting as a Noncystic Hypothalamic Mass

Neurosurgery ◽

10.1227/00006123-198903000-00021 ◽

1989 ◽

Vol 24 (3) ◽

pp. 424-428 ◽

Cited By ~ 21

Author(s):

Marc Wenzel ◽

Michael Salcman ◽

Donald A. Kristt ◽

Fouad E. Gellad ◽

Leonard P. Kapcala

Keyword(s):

Optic Tract ◽

Pituitary Hormone ◽

Pituitary Insufficiency ◽

Rathke’S Cleft Cyst ◽

Rathke's Cleft Cyst ◽

Pituitary Dysfunction ◽

Suprasellar Region ◽

Rathke's Cleft ◽

Anterior Pituitary Insufficiency ◽

Tomography Scan

Abstract A 53-year-old man presented with polydipsia, polyuria, lightheadedness on standing, and syncope. Visual field deficits suggesting left optic tract compression and pituitary dysfunction consisting of diabetes insipidus, hyperprolactinemia, and anterior pituitary insufficiency were diagnosed. On the computed tomography scan, an isodense, ring-enhancing, parasellar mass was localized primarily in the suprasellar region and also extended into the sella. It was believed that the pituitary hormone hypersecretion and hyposecretion were due to hypothalamic dysfunction from the mass which was initially believed to be a craniopharyngioma. At surgery a Rathke's cleft cyst was resected. The unusual presentation of this Rathke's cleft cyst presenting as a hypothalamic lesion is discussed.

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A Case of Apoplexy of Rathke’s Cleft Cyst Followed by Cerebral Infarction

Case Reports in Neurological Medicine ◽

10.1155/2015/645370 ◽

2015 ◽

Vol 2015 ◽

pp. 1-8 ◽

Cited By ~ 1

Author(s):

Yu-ichiro Ohnishi ◽

Yasunori Fujimoto ◽

Koichi Iwatsuki ◽

Toshiki Yoshimine

Keyword(s):

Cerebral Infarction ◽

Mr Angiography ◽

Cerebral Arteries ◽

Neurological Deficits ◽

Rathke’S Cleft Cyst ◽

Rathke's Cleft Cyst ◽

Abnormal Finding ◽

Suprasellar Region ◽

Middle Cerebral Arteries ◽

Rathke's Cleft

Rathke’s cleft cyst (RCC) apoplexy is a rare clinical entity. We report a case of apoplexy of an RCC followed by cerebral infarction. A 67-year-old woman was found lying on the street unconscious. She had fallen from her motorbike. On referral to our hospital she gradually regained consciousness and presented with no neurological deficits. CT showed a round and slightly hyperdense area in the suprasellar region. However, the attending physician did not find this abnormal finding on CT and the patient was discharged the same day. Thirteen days after the first emergency visit she developed left hemiparesis and dysarthria. CT showed a round hypodense area in the suprasellar region. The change of the density in the suprasellar region on CT suggested the pituitary apoplexy. CT also showed a low density area in the territory of the right middle cerebral artery, which indicated the cerebral infarction. MR angiography revealed poor visibility and stenotic changes of right middle cerebral arteries. Transsphenoidal surgery was performed. Histopathological findings confirmed a hemorrhagic RCC. Postoperative MR angiography showed that the visibility and stenosis of right middle cerebral arteries were recovered. This is the rare case of apoplexy of an RCC followed by cerebral infarction.

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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 ◽

10.1093/neuros/nyy285 ◽

2018 ◽

Vol 85 (2) ◽

pp. 180-188

Author(s):

Sunil Manjila ◽

Nadine El Asmar ◽

Benjamin M Vidalis ◽

Fernando Alonso ◽

Gagandeep Singh ◽

...

Keyword(s):

Pituitary Adenoma ◽

Dermoid Cyst ◽

Developmental Theory ◽

Rathke’S Cleft Cyst ◽

Rathke's Cleft Cyst ◽

Epidermoid Cysts ◽

Medical Chart Review ◽

First Case ◽

Suprasellar Region ◽

Rathke's Cleft

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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Symptomatic Rathke's Cleft Cysts Located Entirely in the Suprasellar Region: Review of Diagnosis, Management, and Pathogenesis

Neurosurgery ◽

10.1227/00006123-198506000-00005 ◽

1985 ◽

Vol 16 (6) ◽

pp. 766-772 ◽

Cited By ~ 58

Author(s):

Daniel L. Barrow ◽

Robert H. Spector ◽

Yoshio Takei ◽

George T. Tindall

Keyword(s):

Surgical Treatment ◽

Optic Chiasm ◽

Rathke’S Cleft Cyst ◽

Rathke's Cleft Cyst ◽

Hypothalamic Dysfunction ◽

Suprasellar Region ◽

Rathke's Cleft Cysts ◽

Metrizamide Cisternography ◽

Rathke's Cleft

Abstract Three cases of an entirely suprasellar symptomatic Rathke's cleft cyst, two of which were associated with normal sella turcicas, are reported. In all cases, the cysts caused compression of the optic chiasm, and two produced hypothalamic dysfunction. The diagnosis of these entirely suprasellar masses was enhanced by metrizamide cisternography. Two cases were treated by frontal craniotomy and one was treated transsphenoidally, with good results in all cases. The radiology, pathology, and surgical treatment of these unusual cases is presented. An embryological pathogenesis for the occurrence of an entirely suprasellar Rathke's cleft cyst is discussed.

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Rathke's cleft cyst mimiking pituitary apoplexy: a case report

Endocrine Abstracts ◽

10.1530/endoabs.56.p765 ◽

2018 ◽

Author(s):

Ines Barka ◽

Faiza Bensmaine ◽

Moctar Bah ◽

Clara Bouche ◽

Jean Francois Gautier

Keyword(s):

Case Report ◽

Pituitary Apoplexy ◽

Rathke’S Cleft Cyst ◽

Rathke's Cleft Cyst ◽

Rathke's Cleft

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Rathke’s cleft cyst infections and pituitary abscesses: case series and review of the literature

Pituitary ◽

10.1007/s11102-020-01115-2 ◽

2021 ◽

Author(s):

F. Aranda ◽

R. García ◽

F. J. Guarda ◽

F. Nilo ◽

J. P. Cruz ◽

...

Keyword(s):

Case Series ◽

Rathke’S Cleft Cyst ◽

Review Of The Literature ◽

Rathke's Cleft Cyst ◽

Rathke's Cleft

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Relationship between Recurrence Rates of Rathke's Cleft Cysts and Surgical Approaches to Sellar Reconstruction

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1701223 ◽

2020 ◽

Author(s):

Rebecca Limb ◽

James King

Keyword(s):

Recurrence Rate ◽

Case Series ◽

Redo Surgery ◽

Rathke’S Cleft Cyst ◽

Recurrence Rates ◽

Rathke's Cleft Cyst ◽

Study Objective ◽

Cyst Recurrence ◽

Rathke's Cleft ◽

Sellar Floor

Abstract Study Objective The main purpose of this article is to address the question of whether reconstructing the sellar floor following Rathke's cleft cyst excision results in increased rates of recurrence. Methods and Design A retrospective case series was compiled from medical records and radiological investigations at a single institution over a time period spanning 25 years. Episodes of cyst recurrence were determined from magnetic resonance imaging scans and outpatient encounters. Details regarding surgical procedure and techniques were obtained from operation notes. Perioperative morbidity was also recorded. Results Twenty-three adult patients were treated surgically for a Rathke's cleft cyst at the study institution between 1992 and 2017. The overall cyst recurrence rate was 48%, with 39% of all patients requiring redo surgery within the timeframe of the study. The mean time to redo surgery for recurrence was 4 years. Cyst recurrence rates were 57% postmicroscopic procedures, and 26% postendoscopic procedures (p = 0.148). In the nonreconstructed group, the recurrence rate was 17%, and in the reconstructed group the recurrence rate was 41% (p = 0.3792). Complications arising after nonreconstructive procedures were delayed cerebrospinal fluid rhinorrhea, pneumocephaly, and multiple episodes of meningitis. All these patients required return to theater for secondary reconstruction of the pituitary fossa floor. Conclusion The results of this small study suggest that reconstruction of the sellar floor, and microscopic rather than endoscopic techniques, may be associated with a higher rate of Rathke's cleft cyst recurrence. However, these trends did not reach statistical significance. Patients undergoing nonreconstructive procedures may be more prone to certain postoperative complications.

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