Third ventricle herniation into the sphenoid sinus following endoscopic transnasal transsphenoidal fenestration of rathke's cleft cyst

Abstract

Rathke cleft cyst (RCC) is an uncommon albeit benign sellar lesion with an incidence rate of between 2 to 33%. RCCs are usually asymptomatic except in the large cases whit suprasellar extension. We herein describe a unique case of RCC, which presented with severe visual loss owing to massive herniation of the optic chiasm and third ventricle down into the sphenoid sinus through a small 8×8 mm foramen after transnasal endoscopic surgical fenestration and marsupialization of the cyst. We describe a reconstruction method via endonasal transsphenoidal approach in this case and suggest prophylactic reconstruction of the sellar floor in sellar lesions with equal or more voluminous suprasellar extensions that are susceptible to such massive herniation and secondary empty sella syndrome.KeywOrds: Rathke cleft cysts, Sella turcica, Secondary empty sella syndrome ÖZRathke yarığı kisti nadir ve benign bir sellar lezyon olup insidansı %2 ila 33 arasındadır. Rathke yarığı kistleri genellikle suprasellar uzantılı büyük olgular dışında asemptomatiktir. Burada optik kiazm ve üçüncü ventrikülün transnazal endoskopik cerrahi ile fenestrasyon ve kist marsüpializasyonundan sonra küçük 8x8 mm bir foramen içinden sfenoid sinüse masif herniasyonu nedeniyle şiddetli görme kaybıyla gelen benzersiz bir Rathke yarığı kisti olgusu sunuyoruz. Bu olguda endonazal transsfenoidal yaklaşımla bir rekonstrüksiyon yöntemi öneriyor ve bu tür masif herniasyon ve sekonder boş sella sendromuna yatkın olan eşit derecede veya daha hacimli suprasellar uzantılara sahip sellar lezyonlarda, sella tabanının profilaktik olarak rekonstrüksiyonunu öneriyoruz.AnAhtAr sÖZCÜKler: Rathke yarığı kistleri, Sella tursika, Sekonder boş sella sendromu

Endoscopic repair of transsellar transsphenoidal meningoencephalocele; case report and review of approaches

“…We usually deal with the dural defect using either of the two following techniques: harvesting fascia lata plus its overlying fat or using abdominal wall fat plus a septonasal flap mobilization. The first author has performed hard reconstruction with titanium mesh in only two cases out of more than eight hundreds patients operated in the past ten years; In a case of Rathke's cleft cyst [5], a severe herniation of optic system and third ventricle into the sphenoid sinus persuaded us to use a mesh to minimize the risk of recurrence. In the current case a severe anatomic distortion was present.…”

“…Binostril endoscopic endonasal approach was adopted as previously described [5,6]. After general anesthesia, the right middle turbine was partially removed.…”

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

“…Similar case reports in the literature are rare. 14,15 The changing surgical approaches over time at this institution (with techniques evolving from microscopic to endoscopic in later years) are reflective of the changing practice worldwide in trans-sphenoidal surgery. 9,10,16 The difference in recurrence rates between endoscopic and microscopic procedures (which did not, however reach statistical significance here) may reflect the fact that endoscopic trans-sphenoidal approaches allow a more panoramic view of the pituitary fossa, and particularly with the help of a 30 degree angled lens, may allow the cyst wall to be better visualized and more aggressively removed than in a microscopic procedure.…”

Rhino-Neurochirurgie

“…Neue endokrinologische Defizite werden postoperativ in 4-30 % beobachtet [80,133,306,308,348,[676][677][678]. Bei kleineren Eingriffen wegen Rathke-Zysten wird auf eine Rekonstruktion des Sellabodens verzichtet [679]. In anderen Fällen (z.…”

“…Selten wurde eine Herniation von Anteilen des Tractus opticus und des 3. Ventrikels durch die operativ eröffnete Sella beobachtet [679]. Durch örtlichen Druck kann auch ein postoperatives intraselläres Hämatom zur Visus-Minderung führen [525].…”