Endoscopic endonasal transsphenoidal removal of an intra-suprasellar schwannoma mimicking a pituitary adenoma.

Intracranial schwannomas, accounting for 8 to 10 % of all primary brain neoplasms, are relatively frequent intracranial tumors, but a "pure" intrasellar localization is exceptional. We report the case of an intra-suprasellar schwannoma mimicking a non-functioning pituitary macroadenoma both radiographically and clinically. A 73-year-old man presented with an episode of lipothymia followed by episodes of mental confusion. The neurological investigations revealed a bitemporal hemianopia and a hypopituitaric status. The neuroradiological investigations showed an intra-suprasellar mass resembling a pituitary adenoma. The patient underwent surgery performed by means of an endoscopic endonasal transsphenoidal approach, with a subtotal excision of the tumor. The histopathological studies revealed a cellular schwannoma. The review of the literature disclosed another 8 cases of intrasellar schwannomas. The possibility of an intrasellar schwannoma has to be considered in the differential diagnoses of neoplastic and non-neoplastic lesions of the sellar area.     

Symptomatic Rathke's cleft cyst in an old patient case report

Summary A 71-year-old woman with a symptomatic Rathke's cleft cyst is reported. Our patient is unique in that both metrizamide computed tomographic cisternography and a transsphenoidal surgery were safe and successful procedures in spite of the advanced age of the patient.     

An entirely suprasellar symptomatic Rathke's cleft cyst: case report.

An entirely suprasellar symptomatic Rathke's cleft cyst in a 21-year-old woman is reported. An unusual feature of this cyst was the fact that the subepithelial tissues were composed of pituitary gland cells. High resolution magnetic resonance imaging is sensitive in the detection of subtle suprasellar abnormalities. We review the literature regarding the embryological pathogenesis of Rathke's cleft cyst, with special reference to the entirely suprasellar type.     

Trans-sphenoidal removal of a Rathke's cleft cyst.

Symptomatic Rathke's cleft cysts are uncommon. We present a case with suprasellar extension manifested by hypopituitarism and visual disturbances. The treatment was trans-sphenoidal evacuation and partial removal of the capsule. We suggest that the trans-sphenoidal approach to these lesions is usually adequate and that radical removal of the capsule is not necessary.     

Tension pneumocyst after transsphenoidal surgery for Rathke's cleft cyst: case report

OBJECTIVE AND IMPORTANCE: Tension pneumocephalus is a rare but well-described complication of transsphenoidal surgery. It is usually associated with postoperative cerebrospinal fluid fistulae causing lower intracranial pressure, with air located in the subdural, subarachnoid, or intraventricular space. We report a case of suprasellar tension pneumocyst that caused visual deterioration to develop after an operation for a Rathke's cleft cyst. Only one similar case has been reported previously. CLINICAL PRESENTATION: A 54-year-old woman with a cystic sellar-suprasellar mass compressing the chiasm was operated on via a standard transsphenoidal approach. The intraoperative diagnosis was Rathke's cleft cyst, and the floor of sella was left open to avoid recurrence. The sphenoid sinus was filled with a fat graft, and the rostrum of the sphenoid was reconstructed with a bone fragment. The patient's postoperative course was uneventful, and her vision improved. Ten days after discharge, the patient was readmitted to the emergency service with headache and visual impairment. Emergent computed tomography confirmed a suprasellar tension pneumocyst. INTERVENTION: The patient underwent immediate reoperation via an endonasal endoscopic approach. After the trapped air was evacuated, the sella was closed with fascia lata and muscle using fibrin glue. The patient's vision improved postoperatively. CONCLUSION: Suprasellar tension pneumocyst is an extremely rare complication of transsphenoidal surgery. To avoid this complication, the sellar floor should be repaired in a watertight fashion, and patients should be instructed to avoid blowing the nose, sneezing, straining, and coughing postoperatively.     

Hypophysitis caused by Rathke's cleft cyst. Case report

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.     

Rathke's cleft cyst with xanthogranulomatous change--case report

A 58-year-old man presented with a rare case of Rathke's cleft cyst (RCC) manifesting as headache and visual disturbance. Goldman's perimeter showed he had bitemporal hemianopia. Magnetic resonance imaging revealed a solid intrasellar lesion. He underwent surgery via a right pterional approach. The lesion was red, solid, and fibrous. Histological examination revealed a few columnar epithelial cells with poor cilia in a xanthogranulomatous lesion. Only 13 cases of RCC with granulomatous change have been diagnosed by pathological examination, including 4 xanthogranulomatous cases. Xanthogranuloma of the sellar region is relatively rare. The etiology is still unknown. We speculate that xanthogranulomas of the sellar region may be caused by reaction to the presence of RCC.     

Magnetic resonance imaging of symptomatic Rathke's cleft cyst: report of a case

A case of symptomatic Rathke's cleft cyst is described. In spite of the intrasellar component and radiological and clinical evidence of involvement of the pituitary gland, the sella turcica was minimally involved. MRI afforded optimal visualization and localization of the intra- and suprasellar components vis-à-vis the pituitary gland, optic chiasm, infundibular stalk, and carotid arteries.     

Secondary pan-hypophysitis caused by rupture of Rathke's cleft cyst: case report]

We report a case of secondary hypophysitis caused by rupture of Rathke's cleft cyst. A 30-year-old woman was admitted to our hospital with complaints of polyuria and left visual acuity impairment. These symptoms were preceded by aseptic meningitis one month prior to admission. An MRI on admission showed a suprasellar cystic mass and a swelling pituitary stalk. The mass was partially resected via the transsphenoidal approach. Pathological diagnosis was adeno- and neuro-hypophysitis and ruptured Rathke's cleft cyst. These findings strongly suggested that the hypophysitis was caused by rupture of Rathke's cleft cyst. After the operation, the patient's visual acuity improved with steroid administration. An MRI performed 5 months after the operation showed marked reduction of the mass. To our knowledge, there have been only 5 reports of secondary hypophysitis caused by ruptured Rathke's cleft cyst.     

A symptomatic Rathke's cleft cyst with pituitary apoplexy: a case report]

We encountered a rare case of symptomatic Rathke's cleft cyst associated with pituitary apoplexy. To our knowledge, six cases have been reported in the literature. The mechanism of this symptom is still obscure because of the rare pathological findings concerning Rathke's cleft cysts. Judging from the operative and the histopathologic findings, we speculate that pituitary apoplexy could occur due to hemorrhage from certain vessels such as compressed portal veins or newly organized vessels of the granulation tissue of the cyst wall.     

Symptomatic Rathke's cleft cyst simulating arachnoid cyst--case report

A case of symptomatic Rathke's cleft cyst simulating an arachnoid cyst is presented. Although computed tomography and magnetic resonance imaging showed that the cyst content was identical to cerebrospinal fluid, there was faint contrast enhancement in part of the wall. Histological observation suggested that the somewhat vascular connective tissue associated with nests of pituitary cells might have contributed to the enhancement. This type of Rathke's cleft cyst requires further clinical and neuroradiological studies.     

Suprasellar xanthomatous Rathke's cleft cyst.

A case of a symptomatic suprasellar Rathke's cleft cyst in a 35-year-old woman is presented. The cyst wall and contents showed large collections of xanthomatous cells. With the exception of a few pituitary hormone-positive cells, immunohistochemical and ultrastructural features of the lining epithelium in this case of Rathke's cleft cyst were indistinguishable from colloid cysts of the third ventricle with similar secondary changes.     

Granulomatous change of the pituitary stalk caused by Rathke's cleft cyst: a case report

We report a case of granulomatous change of the pituitary stalk caused by Rathke's cleft cyst. A 50-year-old woman complained of thirst and polyuria in December 2000. In January 2001, the patient was suspected to have diabetes inspidus, and MR Imaging showed a suprasellar mass of the pituitary stalk. The mass was totally resected by the trans-sylvian approach. Pathological diagnosis was Rathke's cleft cyst with subsequent granulomatous change. To our knowledge, there have been 11 cases of Rathke's cleft cyst and subsequent granulomatous change. In the literature, diabetes inspidus was not improved by surgical procedures. However, we suggest that the mass should be totally resected, because some cases in literature showed visual disturbance or hypo-pituitarism under observation.     

Rathke's cleft cyst presenting as sphenoid sinusitis.

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.     

A case of prolactinoma in close association with Rathke's cleft cyst

We report a case of Rathke's cleft cyst in pituitary tumor. A 31-year-old woman admitted to our hospital complained of visual disturbance, headache, amenorrhea and galactorrhea. Serum prolactin level was 3,060 ng/ml. By means of CT scan and MRI, we found suprasellar-extending tumor to have cystic component in the center of the tumor. Transsphenoidal surgery revealed grayish jelly-like content in the cyst. Histologically tumor cells were composed of chromophobic, basophilic and eosinophilic cells. The cyst wall in the pituitary adenoma was composed of ciliated or non-ciliated columnar epithelium intermingled with goblet cells, being similar to Rathke's cleft cyst. Except for the cells of the cyst wall, most of the tumor cells were immunoreactive for prolactin. As for intermediate filament, tumor cells in both solid and cystic portions showed positive immunoreactivity for cytokeratin and GFAP, and not for vimentin and neurofilament. These results suggest that the nature of the intracytoplasmic filament in the pituitary tumor with Rathke's cleft cyst may be not only keratin but also GFAP.     

A case of non-functional pituitary adenoma associated with Rathke's cleft cyst

A very rare case of non-functional pituitary adenoma associated with Rathke's cleft cyst is reported. A 42-year-old male suffering from visual disturbance and headache was admitted. Visual acuity was 1.2 on the right and 0.5 on the left, and visual field examination showed bitemporal hemianopsia. Endocrinological study disclosed that the basal serum level of prolactin was elevated slightly to 52.6 ng/ml, whereas those of other hormones were within normal limits. MRI showed a dumbbell-shaped cystic sellar mass extending to the suprasellar region beyond the diaphragm sellae, which consisted of two isolated components around the sellar turcica. At the middle of May, the tumor was partially removed by bifrontal craniotomy. The suprasellar tumor tightly adhered to the frontal lobe and the optic nerve, the tumor was grayish cyst and cyst fluid from the suprasellar mass had the appearance of motor oil and the intrasellar tumor contained old hematoma. Histological findings revealed that the suprasellar mass was Rathke's cleft cyst and the intrasellar mass was diagnosed as pituitary adenoma (non-functional). Visual acuity was improved following surgical operation. So far twenty-three cases of pituitary adenoma associated with Rathke's cleft cysts have been reported in the literature, but there was only one case reported of a non-functional pituitary adenoma associated with a Rathke's cleft cyst. Etiology and pathogenesis of the coexistence of non-functional pituitary adenoma and Rathke's cleft cyst in the present case were not elucidated.     

Glial cyst of the pineal gland: case report and considerations about surgical management

Symptomatic glial cyst of the pineal gland are rare lesions. Origin, natural history and factors leading to cyst enlargement are not completely clear; thus management remain uncertain in some cases. We report a case of symptomatic glial cyst and analyze the implication for surgery. Surgical management is indicated in patients presenting hydrocephalus, mass effect or symptoms related to mesencephalic dysfunction. The infratentorial supracerebellar approach represent the first choice for this condition allowing easy orientation with wide exposure of the tumor and good visibility of deep venous systems that may be preserved. Size of the tumor is a key element in evaluation of the treatment and the appropriate course for asymptomatic cyst less than 1 cm in size consist of conservative management. Periodic follow up is always indicated.     

Rathke's cleft cyst: computed tomographic and magnetic resonance imaging appearances

A case of symptomatic Rathke's cleft cyst was studied preoperatively with x-ray computed tomographic and magnetic resonance imaging. A Rathke's cleft cyst may be differentiated from other cystic-appearing sellar masses.     

Surgical treatment of a calcified Rathke's cleft cyst with endoscopic extended transsphenoidal surgery--case report

A 34-year-old male presented with a rare case of Rathke's cleft cyst (RCC) with calcification manifesting as persistent high fever and impaired consciousness. Physical findings revealed panhypopituitarism and bitemporal hemianopsia. Computed tomography showed mass lesions with marked calcification within the sella turcica and the suprasellar region. Magnetic resonance imaging showed solid and cystic components compressing the optic nerve. The preoperative diagnosis was craniopharyngioma. Initial endonasal transsphenoidal surgery (TSS) was performed with a surgical microscope, but the mass was extremely hard, so only partial removal was possible. Second endonasal extended TSS was performed with a neuroendoscope. The solid components were totally removed, but calcifications adhering to the optic nerve could not be removed completely. The histological diagnosis was RCC with marked granulation reaction. RCC with calcification is rare and difficult to differentiate from craniopharyngioma on neuroimages. Extremely thick calcification of the sella turcica enclosing granulation tissue and the cyst similar to armor, here called "armor-like calcification," is a characteristic imaging finding of RCC with calcification. The most important aspect is choosing a surgical approach to carefully and effectively relieve pressure upon the optic nerve. Endonasal extended TSS with an endoscope was effective in the present case.