P-49 Unexpected spontaneous evolution of a symptomatic Rathke's cleft cyst

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Abstract Introduction Rathke's cleft cysts (RCCs) are relatively rare sellar and suprasellar lesions that arise from remnants of Rathke's pouch, an embryonic precursor to the anterior pituitary gland. These cysts are often found incidentally during neuroimaging studies for unrelated issues. Despite their non-neoplastic nature, RCCs can lead to a spectrum of clinical manifestations due to their potential to compress surrounding structures, including the pituitary gland, optic chiasm, and adjacent neurovascular structures. However, the majority of Rathke's cysts will remain asymptomatic and typically do not necessitate any medical intervention. Instances of spontaneous regression of these cysts are infrequent, and cases of regression occurring after a recurrence are exceptionally rare. Clinical Case The patient is a 57-year-old individual with a medical history of well-controlled type 2 diabetes and high blood pressure. Additionally, the patient had a history of right ocular trauma in 1989 resulting in a decrease of visual acuity. The patient presented with persistent chronic headaches, leading to the detection of a Rathke's cleft cyst as revealed by a pituitary MRI showing a cystic structure measuring 15×11 mm in the sellar region. The cyst displayed a predominant left-sided lateralization and was characterized by T1 hypointensity as well as T2 hyperintensity. No enhancement was observed on post-gadolinium contrast injection. The cyst exerted a mass effect on the optic chiasm. Hypophyseal axis assessment revealed intact function. Notably, the patient exhibited significant visual field impairment in the right eye, marked by loss of the superior, nasal, and inferior fields, while the right visual field remained unaffected. The patient was managed conservatively based on the rationale that the visual disturbances were attributed to the ocular trauma and not linked to the RCC. Follow-up hypothalamo-hypophysial MRI conducted in April 2023 demonstrated complete spontaneous regression of the Rathke's cleft cyst, with an improvement of his chronic headache. Conclusion The natural history of RCCs is multifaceted leading to heterogenous outcomes ranging from volume progression with hormonal deficiencies and/or visual disturbances to stability over time to even spontaneous involution. The precise mechanism underlying the latter remains unclear. One possible explanation could involve disruptions in the equilibrium between the secretion and absorption of the cystic fluid, or even the potential occurrence of cyst rupture. The potential for involution or stability of the cyst is influenced by the cyst size. The likelihood of spontaneous involution advocates for a conservative strategy in cases of symptomatic RCCs where headaches are the sole presenting symptom.

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