Individualized surgical strategies for Rathke cleft cyst based on cyst location

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An assessment regarding both surgical approaches and the extent of resection for Rathke cleft cysts (RCCs) based on their locations has not been reported. The aim of this study was to report the results of a large series of surgically treated patients with RCCs and to evaluate the feasibility of individualized surgical strategies for different RCCs.


We retrospectively reviewed 87 cases involving patients with RCCs (16 intrasellar, 50 intra- and suprasellar, and 21 purely suprasellar lesions). Forty-nine patients were treated via a transsphenoidal (TS) approach, and 38 were treated via a transcranial (TC) approach (traditional craniotomy in 21 cases and supraorbital keyhole craniotomy in 17). The extent of resection was classified as gross-total resection (GTR) or subtotal resection (STR) of the cyst wall. Patients were thus divided into 3 groups according to the approach selected and the extent of resection: TS/STR (n = 49), TC/STR (n = 23), and TC/GTR (n = 15).


Preoperative headaches, visual dysfunction, hypopituitarism, and diabetes insipidus (DI) resolved in 85%, 95%, 55%, and 65% of patients, respectively. These rates did not differ significantly among the 3 groups. Overall, complications occurred in 8% of patients in TS/STR group, 9% in TC/STR group, and 47% in TC/GTR group, respectively (p = 0.002). Cerebrospinal fluid (CSF) leakage (3%), new hypopituitarism (9%), and DI (6%) were observed after surgery. All CSF leaks occurred in the endonasal group, while the TC/GTR group showed a higher rate of postoperative hypopituitarism (p = 0.7 and p < 0.001, respectively). It should be particularly noted that preoperative hypopituitarism and DI returned to normal, respectively, in 100% and 83% of patients who underwent supraorbital surgery, and with the exception of 1 patient who had transient postoperative DI, there were no complications in patients treated with supraorbital surgery. Kaplan-Meier 3-year recurrence-free rates were 84%, 87%, and 86% in the TS/STR, TC/STR, and TC/GTR groups, respectively (p = 0.9).


It is reasonable to adopt individualized surgical strategies for RCCs based on cyst location. Gross-total resection does not appear to reduce the recurrence rate but increase the risk of postoperative complications. The endonasal approach seems more appropriate for primarily intrasellar RCCs, while the craniotomy is recommended for purely or mainly suprasellar cysts. The supraorbital route appears to be preferred over traditional craniotomy for its minimal invasiveness and favorable outcomes. The endoscopic technique is helpful for either endonasal or supraorbital surgery.

Abbreviations used in this paper:DI = diabetes insipidus; GTR = gross-total resection; RCC = Rathke cleft cyst; STR = subtotal resection; TC = transcranial; TS = transsphenoidal.

Article Information

Drs. Fan and Peng contributed equally to this work.

Address correspondence to: Songtao Qi, M.D., Ph.D., Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Dadao Bei St., Guangzhou 510515, P.R. China. email:

Please include this information when citing this paper: published online September 20, 2013; DOI: 10.3171/2013.8.JNS13777.

© AANS, except where prohibited by US copyright law.



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    A case of an intrasellar RCC treated by an endoscopic endonasal route. A and B: Preoperative T1-weighted Gd-enhanced sagittal and coronal MR images demonstrating a 13-mm cyst with an entirely intrasellar location. The sagittal image (A) shows the cyst arising between the anterior and posterior lobes, with only a small amount of residual gland left overlying the sellar floor (arrow). Therefore, an endonasal approach, which may minimize damage to the gland, was suitable for this case. C and D: Postoperative T1-weighted Gd-enhanced sagittal and coronal MR images demonstrating resection of the cyst. E and F: Intraoperative endoscopic photographs showing incision and evacuation of the cyst (E) and the cyst floor left open after resection (F), with the residual gland remaining intact. CC = cyst contents; DS = diaphragma sellae; PG = pituitary gland.

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    A case of a suprasellar RCC treated by a fully endoscopic supraorbital route. A and B: Preoperative T1-weighted Gd-enhanced sagittal and coronal MR images demonstrating a 15-mm cyst with purely suprasellar location. The sagittal image (A) shows the normal gland (arrow) occupying the entire sellar space, and an endonasal approach could therefore cause a higher risk of gland injury. C and D: Postoperative T1-weighted Gd-enhanced sagittal and coronal MR images demonstrating resection of the cyst. E and F: Intraoperative endoscopic photographs showing identification of the cyst and its adjacent structures (E) and partial removal of the cyst wall (F), performed without damage to the pituitary gland and the infundibulum. The cyst was left open, allowing for its drainage into the suprasellar cistern. ICA = internal carotid artery; OC = optic chiasm; PS = pituitary stalk; RCC = Rathke cleft cyst; TS = tuberculum sellae.

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    A case of an intra- and suprasellar RCC treated by a fully endoscopic supraorbital route. A and B: Preoperative T1-weighted Gd-enhanced sagittal and coronal MR images demonstrating a 17-mm sellar cyst with suprasellar extension. Although the cyst is in both the sellar and suprasellar space, normal gland (arrow) can be seen occupying almost the entire sellar space in the sagittal image (A). An endonasal approach was therefore not recommended for this case. C and D: Postoperative T1-weighted Gd-enhanced sagittal and coronal MR images demonstrating resection of the cyst. E–H: Intraoperative endoscopic photographs showing the cyst and the infundibulum (E); incision of the cyst (where there were no neurovascular structures) and evacuation of the contents (F); partial removal of the cyst wall (G), with the cyst left open; and the intact residual gland (H, view from within cyst via 30° endoscope), which would have been likely to suffer damage in an endonasal approach. BAM = basal arachnoid membrane.

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    Radiological recurrence-free survival rates in different surgical groups. The y-axis denotes the percentage of patients who had no radiological recurrence. The Kaplan-Meier 3-year actuarial recurrence-free survival rate was 84% for the TS/STR group, 87% for the TC/STR group, and 86% for the TC/GTR group. Statistical analysis showed no significant between-groups difference (p = 0.9).



Aho CJLiu CZelman VCouldwell WTWeiss MH: Surgical outcomes in 118 patients with Rathke cleft cysts. J Neurosurg 102:1891932005


Barrow DLSpector RHTakei YTindall GT: Symptomatic Rathke's cleft cysts located entirely in the suprasellar region: review of diagnosis, management, and pathogenesis. Neurosurgery 16:7667721985


Benveniste RJKing WAWalsh JLee JSNaidich TPPost KD: Surgery for Rathke cleft cysts: technical considerations and outcomes. J Neurosurg 101:5775842004


Berhouma MJacquesson TJouanneau E: The fully endoscopic supraorbital trans-eyebrow keyhole approach to the anterior and middle skull base. Acta Neurochir (Wien) 153:194919542011


Brassier GMorandi XTayiar ERiffaud LChabert EHeresbach N: Rathke's cleft cysts: surgical-MRI correlation in 16 symptomatic cases. J Neuroradiol 26:1621711999


Duz BHarman FSecer HIBolu EGonul E: Transsphenoidal approaches to the pituitary: a progression in experience in a single centre. Acta Neurochir (Wien) 150:113311392008


Eguchi KUozumi TArita KKurisu KYano TSumida M: Pituitary function in patients with Rathke's cleft cyst: significance of surgical management. Endocr J 41:5355401994


el-Mahdy WPowell M: Transsphenoidal management of 28 symptomatic Rathke's cleft cysts, with special reference to visual and hormonal recovery. Neurosurgery 42:7171998


Famini PMaya MMMelmed S: Pituitary magnetic resonance imaging for sellar and parasellar masses: ten-year experience in 2598 patients. J Clin Endocrinol Metab 96:163316412011


Fatemi NDusick JRde Paiva Neto MAMalkasian DKelly DF: Endonasal versus supraorbital keyhole removal of craniopharyngiomas and tuberculum sellae meningiomas. Neurosurgery 64:5 Suppl 22692862009


Frank GSciarretta VMazzatenta DFarneti GModugno GCPasquini E: Transsphenoidal endoscopic approach in the treatment of Rathke's cleft cyst. Neurosurgery 56:1241292005


Hama SArita KNishisaka TFukuhara TTominaga ASugiyama K: Changes in the epithelium of Rathke cleft cyst associated with inflammation. J Neurosurg 96:2092162002


Higgins DMVan Gompel JJNippoldt TBMeyer FB: Symptomatic Rathke cleft cysts: extent of resection and surgical complications. Neurosurg Focus 31:1E22011


Ikeda HYoshimoto T: Clinicopathological study of Rathke's cleft cysts. Clin Neuropathol 21:82912002


Isono MKamida TKobayashi HShimomura TMatsuyama J: Clinical features of symptomatic Rathke's cleft cyst. Clin Neurol Neurosurg 103:961002001


Itoh JUsui K: An entirely suprasellar symptomatic Rathke's cleft cyst: case report. Neurosurgery 30:5815851992


Jagannathan JKanter ASSheehan JPJane JA JrLaws ER Jr: Benign brain tumors: sellar/parasellar tumors. Neurol Clin 25:12311249xi2007


Jallo GIBognár L: Eyebrow surgery: the supraciliary craniotomy: technical note. Neurosurgery 59:ONSE157ONSE1582006


Jallo GISuk IBognár L: A superciliary approach for anterior cranial fossa lesions in children. Technical note. J Neurosurg 103:1 Suppl88932005


Kabil MSShahinian HK: The endoscopic supraorbital approach to tumors of the middle cranial base. Surg Neurol 66:3964012006


Kanter ASSansur CAJane JA JrLaws ER Jr: Rathke's cleft cysts. Front Horm Res 34:1271572006


Kaptain GJKanter ASHamilton DKLaws ER: Management and implications of intraoperative cerebrospinal fluid leak in transnasoseptal transsphenoidal microsurgery. Neurosurgery 68:1 Suppl Operative1441512011


Kasperbauer JLOrvidas LJAtkinson JLAbboud CF: Rathke cleft cyst: diagnostic and therapeutic considerations. Laryngoscope 112:183618392002


Kim E: Symptomatic Rathke cleft cyst: clinical features and surgical outcomes. World Neurosurg 78:5275342012


Kim JEKim JHKim OLPaek SHKim DGChi JG: Surgical treatment of symptomatic Rathke cleft cysts: clinical features and results with special attention to recurrence. J Neurosurg 100:33402004


Lee AGVan Gilder JCWhite ML: Progressive visual loss because of a suprasellar pneumatocele after trans-sphenoidal resection of a pituitary adenoma. J Neuroophthalmol 23:1421442003


Lillehei KOWiddel LAstete CAWierman MEKleinschmidt-DeMasters BKKerr JM: Transsphenoidal resection of 82 Rathke cleft cysts: limited value of alcohol cauterization in reducing recurrence rates. J Neurosurg 114:3103172011


Madhok RPrevedello DMGardner PCarrau RLSnyderman CHKassam AB: Endoscopic endonasal resection of Rathke cleft cysts: clinical outcomes and surgical nuances. Clinical article. J Neurosurg 112:133313392010


Mukherjee JJIslam NKaltsas GLowe DGCharlesworth MAfshar F: Clinical, radiological and pathological features of patients with Rathke's cleft cysts: tumors that may recur. J Clin Endocrinol Metab 82:235723621997


Nishioka HHaraoka JIzawa HIkeda Y: Magnetic resonance imaging, clinical manifestations, and management of Rathke's cleft cyst. Clin Endocrinol (Oxf) 64:1841882006


Ogawa YWatanabe MTominaga T: Prognostic factors of operated Rathke's cleft cysts with special reference to re-accumulation and recommended surgical strategy. Acta Neurochir (Wien) 153:242724332011


Osborn AGPreece MT: Intracranial cysts: radiologic-pathologic correlation and imaging approach. Radiology 239:6506642006


Oyama NTahara SOyama KIshii YTeramoto A: Assessment of pre- and postoperative endocrine function in 94 patients with Rathke's cleft cyst. Endocr J 60:2072132013


Park JKLee EJKim SH: Optimal surgical approaches for Rathke cleft cyst with consideration of endocrine function. Neurosurgery 70:2 Suppl Operative2502572012


Potts MBJahangiri ALamborn KRBlevins LSKunwar SAghi MK: Suprasellar Rathke cleft cysts: clinical presentation and treatment outcomes. Neurosurgery 69:105810692011


Raper DMBesser M: Clinical features, management and recurrence of symptomatic Rathke's cleft cyst. J Clin Neurosci 16:3853892009


Reisch RPerneczky A: Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 57:4 Suppl2422552005


Rincon JLNunes JCamuto PGoodrich I: Intracranial approach to suprasellar Rathke's cleft cyst. Skull Base Surg 9:71731999


Rittierodt MHori A: Pre-morbid morphological conditions of the human pituitary. Neuropathology 27:43482007


Ross DANorman DWilson CB: Radiologic characteristics and results of surgical management of Rathke's cysts in 43 patients. Neurosurgery 30:1731791992


Sade BAlbrecht SAssimakopoulos PVézina JLMohr G: Management of Rathke's cleft cysts. Surg Neurol 63:4594662005


Shimoji TShinohara AShimizu ASato KIshii S: Rathke cleft cysts. Surg Neurol 21:2953101984


Shin JLAsa SLWoodhouse LJSmyth HSEzzat S: Cystic lesions of the pituitary: clinicopathological features distinguishing craniopharyngioma, Rathke's cleft cyst, and arachnoid cyst. J Clin Endocrinol Metab 84:397239821999


Slavin MLLam BLDecker RESchatz NJGlaser JSReynolds MG: Chiasmal compression from fat packing after transsphenoidal resection of intrasellar tumor in two patients. Am J Ophthalmol 115:3683711993


Steinberg GKKoenig GHGolden JB: Symptomatic Rathke's cleft cysts. Report of two cases. J Neurosurg 56:2902951982


Teramoto AHirakawa KSanno NOsamura Y: Incidental pituitary lesions in 1,000 unselected autopsy specimens. Radiology 193:1611641994


Trifanescu RAnsorge OWass JAGrossman ABKaravitaki N: Rathke's cleft cysts. Clin Endocrinol (Oxf) 76:1511602012


Trifanescu RStavrinides VPlaha PCudlip SByrne JVAnsorge O: Outcome in surgically treated Rathke's cleft cysts: long-term monitoring needed. Eur J Endocrinol 165:33372011


Voelker JLCampbell RLMuller J: Clinical, radiographic, and pathological features of symptomatic Rathke's cleft cysts. J Neurosurg 74:5355441991


Wait SDGarrett MPLittle ASKillory BDWhite WL: Endocrinopathy, vision, headache, and recurrence after transsphenoidal surgery for Rathke cleft cysts. Neurosurgery 67:8378432010


Wenger MSimko MMarkwalder RTaub E: An entirely suprasellar Rathke's cleft cyst: case report and review of the literature. J Clin Neurosci 8:5645672001


Wiedemayer HSandalcioglu IEWiedemayer HStolke D: The supraorbital keyhole approach via an eyebrow incision for resection of tumors around the sella and the anterior skull base. Minim Invasive Neurosurg 47:2212252004


Zada G: Rathke cleft cysts: a review of clinical and surgical management. Neurosurg Focus 31:1E12011


Zada GLin NOjerholm ERamkissoon SLaws ER: Craniopharyngioma and other cystic epithelial lesions of the sellar region: a review of clinical, imaging, and histopathological relationships. Neurosurg Focus 28:4E42010




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