Durable headache relief following endoscopic endonasal resection of sub-centimeter Rathke cleft cysts in medically refractory patients

• Published in: Acta neurochirurgica 2023-08, Vol.165 (8), p.2277-2282
• Main Authors: Mathios, Dimitrios, Joshua, Shejoy, Bobeff, Ernest J., Mistry, Adina A., Schwartz, Alexandra C., Dobri, Georgiana A., Tabaee, Abtin, Kacker, Ashutosh, Anand, Vijay K., Schwartz, Theodore H.
• Format: Article
• Language: English
• Subjects: Analgesics; Carcinoma, Renal Cell; Central Nervous System Cysts - complications; Central Nervous System Cysts - diagnostic imaging; Central Nervous System Cysts - surgery; Cysts; Cysts - complications; Cysts - diagnostic imaging; Cysts - surgery; Endoscopy; Headache; Headache - etiology; Humans; Interventional Radiology; Kidney Neoplasms; Medicine; Medicine & Public Health; Minimally Invasive Surgery; Neurology; Neuroradiology; Neurosurgery; Original Article; Patients; Pituitaries; Questionnaires; Retrospective Studies; Surgical Orthopedics; Treatment Outcome
• ISSN: 0942-0940; 0001-6268; 0942-0940
• DOI: 10.1007/s00701-023-05575-w

Background The most common presenting symptom in patients with both small and large Rathke cleft cysts (RCC) is headache (H/A). It is well established that patients with large RCC can have significant symptomatic improvement after cyst drainage. However, patients with small RCC (≤ 1 cm) are rarely operated on, even if they present with debilitating H/A. It is not well understood whether resection of these smaller RCCs can lead to durable H/A resolution. Methods A retrospective search of our institutional database for sub-centimeter RCCs presenting with intractable H/A and treated with an endoscopic endonasal approach was carried out. A detailed H/A questionnaire as well as patient chart review was conducted to assess the long-term outcome of these patients after surgical intervention. Results Ten consecutive patients with 11 endonasal surgeries met inclusion criteria. Eight responded to the questionnaire. The median cyst diameter was 6 mm (IQR 3–9). Median preoperative H/A duration was 12 months (range 2 months–15 years). H/As occurred on average for 20 days per month and all required analgesics for symptomatic control for more than 15 of these 20 days. Half of the patients also had to miss work because of H/A. Average preoperative H/A intensity was 8.7 (scale 0–10) compared with postoperative scores of 2.9 at one month, 1.6 at 3 months, and 0.9 at 1 year. There were no permanent endocrinological or other surgical complications. After a median follow-up of 2 years, one patient had radiographic and symptomatic recurrence which resolved after re-operation. Conclusions Endoscopic fenestration of sub-centimeter RCCs provides a safe and durable treatment for patients with intractable H/A.