Brain Tumor Res Treat.  2022 Jan;10(1):61-67. 10.14791/btrt.2022.10.e29.

Reverse Trans-Sellar Neuroendoscopic Management of a Large Rathke’s Cleft Cyst Causing Obstructive Hydrocephalus: A Case Report

• Lee HJ
• Kwon HJ
• Choi SW
• Kim SH
• Koh HS
• Youm JY
• Kim KH

• KMID: 2525295
• DOI: http://doi.org/10.14791/btrt.2022.10.e29

Abstract

Symptomatic Rathke’s cleft cysts (RCCs) can be treated by surgical procedures, usually through an endonasal transsphenoidal corridor using either a microscope or an endoscope. We report a large suprasellar extended RCC causing obstructive hydrocephalus, which was efficiently managed by a novel surgical route named “reverse” trans-sellar approach using transventricular neuroendoscopy. A 48-yearold woman complained of persistent headache and a tendency to fall that had begun 6 months previously. The images obtained from MRI scan showed intra- and supra-sellar cystic masses occupying the third ventricle with obstruction of the foramina of Monro and the aqueduct of Sylvius. The cystic wall showed a slight enhancement, and the cystic contents showed iso-signal intensity on T1-and T2-weighted images. Instead of trans-nasal trans-sellar surgery, we decided to operate using a conventional transventricular endoscope. A thin cystic capsule, which blocked the foramina of Monro and the aqueduct of Sylvius, was fenestrated and removed and a third ventriculostomy was performed. The defect in the infundibulum between sellar and suprasellar cysts was widened and used as a corridor to drain cystic contents (reverse trans-sellar route). The final pathological finding revealed an RCC with focal metaplasia. We efficiently managed a large RCC by transventricular neuroendoscopic surgery with cyst fenestration and third ventriculostomy and simultaneously drained the sellar contents using a novel surgical route. Reverse trans-sellar neuroendoscopic surgery is a relevant treatment option for selective patients with large suprasellar extensions of RCCs.

Keyword

Rathke's cleft cyst; Neuroendoscopy; Obstructive hydrocephalus

Figure

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  Fig. 1 Preoperative MRI. A-C: T1-weighted gadolinium enhanced axial (A), coronal (B), and sagittal (C) images show intra- and supra-sellar cystic mass occupying third ventricle with the obstruction of foramina of Monro and aqueduct of Sylvius. C and D: The cystic wall shows a slight enhancement and the cystic contents show isotense signal in T1- and T2-weighted images. Note that arrow indicates the direction of 'reverse' trans-sellar approach.

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  Fig. 2 Intraoperative endoscopic photographs. A: Foramina of Monro is obstructed by the cyst wall (green arrow). B: A thin cystic capsule was fenestrated using bipolar coagulator and widened by forceps. C: A cloudy cystic fluid spread out, which was a mixture of cerebrospinal fluid and mucinous cyst content (green arrow). D: The cyst wall was partially removed and especially cyst wall fragments covering aqueduct of Sylvius were completely removed. E and F: Whitish mucinous cystic contents (green arrow) spilled out from the sellar cavity through the defect on infundibulum when the sellar compartment was compressed by forceps, and were removed completely. G: Thinned tuber cinereum was perforated and widened using forceps (basilar artery: green arrow); infundibular tissues around the defect are collected for histologic examination as well as widening reverse trans-sellar corridor. H: Endoscopic examination through the infundibular corridor and the site of third ventriculostomy confirmed absence of residual cystic contents and basilar artery, respectively.

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  Fig. 3 Histopathologic findings. A: The cyst is lined with a single cell layer of ciliated cuboidal or columnar epithelium (hematoxylin and eosin [H&E] stain, ×25). B: The cystic lesion contains eosinophilic mucoid materials with focal calcification (blue arrow); the lesion partly demonstrates the solid proliferation of epithelial cells with palisading columnar cells at their periphery (green arrows) (H&E stain, ×100). C: The lesion shows squamoid epithelial cells with a vague whirling pattern (blue arrows) (H&E stain, ×200).

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  Fig. 4 One-year postoperative MRI shows the resolution of hydrocephalus and residual sellar lesion with a shrunken and fragmented suprasellar cyst.

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