Volume 4, Issue 1 (Winter 2018)                   IrJNS 2018, 4(1): 41-44 | Back to browse issues page


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Samadian M, Ebrahim Zadeh K, Moradian Kokhdan K, Razmeh S, Sharifi G, Rezaee O, et al . Symptomatic Rathke’s Cleft Cyst Presenting With Decreased Visual Acuity. IrJNS. 2018; 4 (1) :41-44
URL: http://irjns.org/article-1-118-en.html
1- Department of Neurosurgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
2- Department of Neurosurgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. , srazme82@gmail.com
3- Department of Neurology, School of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran.
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1. Background and Importance
he Rathke’s cleft cyst is an uncommon lesion that originates from remnant of Rathke’s pouch. Most of these cysts are asymptomatic and are equally seen in men and women [1-3]. In this report, we present a 40-year-old woman with a Rathke’s cleft cysts in the intrasellar and suprasellar location. Although the symptomatic Rathke’s cleft cyst is rare, the differential diagnosis must be done with other intrasellar and suprasellar lesions.
2. Case Presentation
A 40-year-old female patient presented with 2-week history of visual disturbance, bilateral temporal throbbing headache that was refractory to treatment. A few months later, she was gaining weight and then developed amenorrhea which laboratory tests showed hypothyroidism. Her past medical and family history, social and review of systems were noncontributory. In physical examination, she was oriented and all cranial nerves and muscle strength were intact. The perimetry showed bitemporal hemianopia. The Brain MRI T1 and 
T2 images showed the sellar and suprasellar cystic lesions with ring enhancement (Figure 1). 
The patient underwent operation with endoscopic transnasal transsphenoidal surgery and the entire tumor was resected. The pathological examination confirmed Rathke’s cleft cyst with pseudo stratified ciliated epithelium and compressed normal adenohypophysis around the cyst (Figure 2). We obtained the written informed consent from the patient to report the case.

3. Discussion
Rathke’s cleft cysts are non-neoplastic lesions that commonly located in the intrasellar or both intrasellar and suprasellar regions. These cysts are often asymptomatic but if enlarged, they can cause symptoms like headaches, visual disturbances, hypopituitarism, hyperprolactinemia, and rarely pituitary apoplexy, abscess formation and aseptic meningitis [4-8]. 
In a study by Isono et al. on 15 patients with Rathke’s cleft cysts, hormonal impairment, visual disturbance 
and headache were the most common symptoms, respectively. The most common hormonal impairment was hyperprolactinemia and increased growth hormone. Also diabetes insipidus has been reported in these patients [1]. On imaging, these cysts are usually non-calcified with low attenuation and non-enhancement but in some cases, cyst wall enhancement may occur. A small nodule is seen in a large number of patients within the cyst [4, 9, 10]. Nishikawa et al. presented a case of Rathke’s cleft cyst that raptured and caused inflammatory hypophysitis. This case presented with malaise, visual disturbance and hypopituitarism [5]. 
Agarwal et al. reported a case of Rathke’s cleft cyst in the parasellar and paraventricular area that extended to frontotemporoparietal region. This case presented with visual disturbance and optic atrophy in her right eye [11]. The main treatment for symptomatic patients is transsphenoidal surgery, drainage of cysts and partial resection of the wall to confirm histologic diagnosis. Complete removing the tumor can damage the surrounding tissues. In cases where transsphenoidal surgery is not possible, the craniotomy was done [12-15].
4. Conclusion
Although the symptomatic Rathke’s cleft cyst is rare and this cyst usually is found accidentally in brain imaging and autopsy, its timely diagnosis and treatment can prevent its complications.
Ethical Considerations
Compliance with ethical guidelines

There was no ethical considerations to be considered in this research.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgements
The authors thank to Dr. Farid Moradian Kokhedan for typing and editing the manuscript.


References
  1. Isono M, Kamida T, Kobayashi H, Shimomura T, Matsuyama J. Clinical features of symptomatic Rathke’s cleft cyst. Clinical Neurology and Neurosurgery. 2001; 103(2):96-100. [DOI:10.1016/S0303-8467(01)00121-4]
  2. Laws ER, Kanter AS. Rathke cleft cysts. Journal of Neurosurgery. 2004; 101(4):571-2. [DOI:10.3171/jns.2004.101.4.0571] [PMID]
  3. Osborn AG, Preece MT. Intracranial cysts: Radiologic-pathologic correlation and imaging approach. Radiology. 2006; 239(3):650-64. [DOI:10.1148/radiol.2393050823] [PMID]
  4. Kim E. Symptomatic Rathke cleft cyst: Clinical features and surgical outcomes. World Neurosurgery. 2012; 78(5):527-34. [DOI:10.1016/j.wneu.2011.12.091] [PMID]
  5. Nishikawa T, Takahashi JA, Shimatsu A, Hashimoto N. Hypophysitis caused by Rathke’s cleft cyst. Neurologia Medico-Chirurgica. 2007; 47(3):136-9. [DOI:10.2176/nmc.47.136] [PMID]
  6. Pawar SJ, Sharma RR, Lad SD, Dev E, Devadas RV. Rathke’s cleft cyst presenting as pituitary apoplexy. Journal of Clinical Neuroscience. 2002; 9(1):76-9. [DOI:10.1054/jocn.2001.0974] [PMID]
  7. Raper DM, Besser M. Clinical features, management and recurrence of symptomatic Rathke’s cleft cyst. Journal of Clinical Neuroscience. 2009; 16(3):385-9. [DOI:10.1016/j.jocn.2008.04.023] [PMID]
  8. Tate MC, Jahangiri A, Blevins L, Kunwar S, Aghi MK. Infected Rathke cleft cysts: Distinguishing factors and factors predicting recurrence. Neurosurgery. 2010; 67(3):762-9. [DOI:10.1227/01.NEU.0000377017.53294.B5] [PMID]
  9. Tominaga JY, Higano S, Takahashi S. Characteristics of Rathke’s cleft cyst in MR imaging. Magnetic Resonance in Medical Sciences. 2003; 2(1):1-8. [DOI:10.2463/mrms.2.1]
  10. Wen L, Hu LB, Feng XY, Gaurav D, Zou LG, Wang WX, et al. Rathke’s cleft cyst: Clinicopathological and MRI findings in 22 patients. Clinical Radiology. 2010; 65(1):47-55. [DOI:10.1016/j.crad.2009.09.010] [PMID]
  11. Agarwal V, Palande D, Velho V, Binayke RS. Unusual site of Rathke’s cleft cyst: A case report and review of literature. Asian Journal of Neurosurgery. 2017; 12(1):44-6. [DOI:10.4103/1793-5482.150003] [PMID] [PMCID]
  12. Aho CJ, Liu C, Zelman V, Couldwell WT, Weiss MH. Surgical outcomes in 118 patients with Rathke cleft cysts. Journal of Neurosurgery. 2005; 102(2):189-93. [DOI:10.3171/jns.2005.102.2.0189] [PMID]
  13. Benveniste RJ, King WA, Walsh J, Lee JS, Naidich TP, Post KD. Surgery for Rathke cleft cysts: Technical considerations and outcomes. Journal of Neurosurgery. 2004; 101(4):577-84. [DOI:10.3171/jns.2004.101.4.0577] [PMID]
  14. Kim JE, Kim JH, Kim OL, Paek SH, Kim DG, Chi JG, et al. Surgical treatment of symptomatic Rathke cleft cysts: Clinical features and results with special attention to recurrence. Journal of Neurosurgery. 2004; 100(1):33-40. [DOI:10.3171/jns.2004.100.1.0033] [PMID]
  15. Trifanescu R, Stavrinides V, Plaha P, Cudlip S, Byrne JV, Ansorge O, et al. Outcome in surgically treated Rathke’s cleft cysts: long-term monitoring needed. European Journal of Endocrinology. 2011; 165(1):33-7. [DOI:10.1530/EJE-11-0142] [PMID]
Type of Study: Case report | Subject: Skull Base

References
1. Isono M, Kamida T, Kobayashi H, Shimomura T, Matsuyama J. Clinical features of symptomatic Rathke's cleft cyst. Clinical Neurology and Neurosurgery. 2001; 103(2):96-100. [DOI:10.1016/S0303-8467(01)00121-4] [DOI:10.1016/S0303-8467(01)00121-4]
2. Laws ER, Kanter AS. Rathke cleft cysts. Journal of Neurosurgery. 2004; 101(4):571-2. [DOI:10.3171/jns.2004.101.4.0571] [PMID] [DOI:10.3171/jns.2004.101.4.0571]
3. Osborn AG, Preece MT. Intracranial cysts: Radiologic-pathologic correlation and imaging approach. Radiology. 2006; 239(3):650-64. [DOI:10.1148/radiol.2393050823] [PMID] [DOI:10.1148/radiol.2393050823]
4. Kim E. Symptomatic Rathke cleft cyst: Clinical features and surgical outcomes. World Neurosurgery. 2012; 78(5):527-34. [DOI:10.1016/j.wneu.2011.12.091] [PMID] [DOI:10.1016/j.wneu.2011.12.091]
5. Nishikawa T, Takahashi JA, Shimatsu A, Hashimoto N. Hypophysitis caused by Rathke's cleft cyst. Neurologia Medico-Chirurgica. 2007; 47(3):136-9. [DOI:10.2176/nmc.47.136] [PMID] [DOI:10.2176/nmc.47.136]
6. Pawar SJ, Sharma RR, Lad SD, Dev E, Devadas RV. Rathke's cleft cyst presenting as pituitary apoplexy. Journal of Clinical Neuroscience. 2002; 9(1):76-9. [DOI:10.1054/jocn.2001.0974] [PMID] [DOI:10.1054/jocn.2001.0974]
7. Raper DM, Besser M. Clinical features, management and recurrence of symptomatic Rathke's cleft cyst. Journal of Clinical Neuroscience. 2009; 16(3):385-9. [DOI:10.1016/j.jocn.2008.04.023] [PMID] [DOI:10.1016/j.jocn.2008.04.023]
8. Tate MC, Jahangiri A, Blevins L, Kunwar S, Aghi MK. Infected Rathke cleft cysts: Distinguishing factors and factors predicting recurrence. Neurosurgery. 2010; 67(3):762-9. [DOI:10.1227/01.NEU.0000377017.53294.B5] [PMID] [DOI:10.1227/01.NEU.0000377017.53294.B5]
9. Tominaga JY, Higano S, Takahashi S. Characteristics of Rathke's cleft cyst in MR imaging. Magnetic Resonance in Medical Sciences. 2003; 2(1):1-8. [DOI:10.2463/mrms.2.1] [DOI:10.2463/mrms.2.1]
10. Wen L, Hu LB, Feng XY, Gaurav D, Zou LG, Wang WX, et al. Rathke's cleft cyst: Clinicopathological and MRI findings in 22 patients. Clinical Radiology. 2010; 65(1):47-55. [DOI:10.1016/j.crad.2009.09.010] [PMID] [DOI:10.1016/j.crad.2009.09.010]
11. Agarwal V, Palande D, Velho V, Binayke RS. Unusual site of Rathke's cleft cyst: A case report and review of literature. Asian Journal of Neurosurgery. 2017; 12(1):44-6. [DOI:10.4103/1793-5482.150003] [PMID] [PMCID] [DOI:10.4103/1793-5482.150003]
12. Aho CJ, Liu C, Zelman V, Couldwell WT, Weiss MH. Surgical outcomes in 118 patients with Rathke cleft cysts. Journal of Neurosurgery. 2005; 102(2):189-93. [DOI:10.3171/jns.2005.102.2.0189] [PMID] [DOI:10.3171/jns.2005.102.2.0189]
13. Benveniste RJ, King WA, Walsh J, Lee JS, Naidich TP, Post KD. Surgery for Rathke cleft cysts: Technical considerations and outcomes. Journal of Neurosurgery. 2004; 101(4):577-84. [DOI:10.3171/jns.2004.101.4.0577] [PMID] [DOI:10.3171/jns.2004.101.4.0577]
14. Kim JE, Kim JH, Kim OL, Paek SH, Kim DG, Chi JG, et al. Surgical treatment of symptomatic Rathke cleft cysts: Clinical features and results with special attention to recurrence. Journal of Neurosurgery. 2004; 100(1):33-40. [DOI:10.3171/jns.2004.100.1.0033] [PMID] [DOI:10.3171/jns.2004.100.1.0033]
15. Trifanescu R, Stavrinides V, Plaha P, Cudlip S, Byrne JV, Ansorge O, et al. Outcome in surgically treated Rathke's cleft cysts: long-term monitoring needed. European Journal of Endocrinology. 2011; 165(1):33-7. [DOI:10.1530/EJE-11-0142] [PMID] [DOI:10.1530/EJE-11-0142]

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