Orbitofrontal craniotomy and anterior clinoidectomy for treatment of a recurrent suprasellar Rathke’s cleft cyst after spontaneous involution: A case report

Abstract The spontaneous involution and rapid recurrence of a Rathke’s cleft cyst (RCC) is not well described. A 16-year-old female with a putatively incidental nearly 2 cm suprasellar lesion arising from the posterior aspect of the infundibulum found on a brain MRI during workup for aseptic meningitis demonstrated a spontaneous and near-complete involution of this lesion on close follow up (leaving only a thickened infundibulum measuring up to 3.6 mm). After a period of cyclic headaches coinciding with subtle changes in pituitary stalk thickness, she developed progressive fatigue, severe headaches, and bitemporal blurry vision, with rapid re-growth of the suprasellar lesion to near its original size seen on repeat MRI. Due to its purely suprasellar and retro-infundibular location an anterolateral rather than an anterior transnasal approach was recommended. She underwent a successful orbitofrontal craniotomy and cyst fenestration/partial resection, with pathologic analysis confirming an RCC. Post-operatively, she had normal vision and no diabetes insipidus or other hormonal disturbances, and improvement of her headaches on ten-month follow up. Awareness of the potentially dynamic nature of RCCs is important for their timely diagnosis. Purely suprasellar RCCs can require an anterolateral surgical approach, especially when located posterior to the infundibulum.