What is the workup for a Rathke's (Rathke) cleft cyst?

From the Guidelines

The workup for a Rathke's cleft cyst should begin with an MRI of the sella region with gadolinium-based contrast, as it is the preferred imaging modality for evaluating the hypothalamic-pituitary axis and parasellar regions. This approach is supported by the American College of Radiology Appropriateness Criteria, which recommends MRI with contrast for characterizing lesions in this area 1. The use of contrast-enhanced MRI is particularly important for small pituitary lesions, such as adenomas and Rathke cleft cysts, which may be occult without postcontrast sequences.

Key components of the workup include:

• MRI of the sella region with gadolinium-based contrast to evaluate the size and characteristics of the cyst
• Laboratory evaluation, including a complete pituitary hormone panel to assess for hypopituitarism, with tests such as morning cortisol, ACTH, TSH, free T4, prolactin, LH, FSH, testosterone (in men) or estradiol (in women), and IGF-1
• Visual field testing if the cyst is large or compressing the optic chiasm

Most Rathke cleft cysts are incidental findings that require no intervention beyond periodic monitoring with repeat MRI every 1-2 years. Surgical intervention, typically via transsphenoidal approach, is only indicated for symptomatic cysts causing visual disturbances, significant headaches, or hormonal abnormalities. Postoperatively, patients need ongoing endocrine monitoring as hypopituitarism may develop or worsen after surgery, as noted in the evaluation of pituitary lesions 1.

From the Research

Workup for Rathke's Cleft Cyst

The workup for a Rathke's cleft cyst typically involves:

• Initial evaluation of symptoms, such as headache, galactorrhea, visual field loss, and hypopituitarism 2
• Endocrinological evaluation to assess hormonal function, including tests for adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), growth hormone (GH), and luteinizing hormone (LH)/follicle-stimulating hormone (FSH) 3
• Imaging studies, such as:
  • Magnetic Resonance Imaging (MRI) to characterize the cyst and its location, including T1-weighted and T2-weighted images 4, 5, 6
  • Computed Tomography (CT) scans to evaluate the cyst's size and location 2
• Analysis of cyst content and signal characteristics on MRI to predict the natural course of the cyst and potential need for surgical intervention 4

Surgical Intervention

Surgical treatment is typically reserved for symptomatic Rathke's cleft cysts, and may involve:

• Transsphenoidal surgery to drain the cyst and biopsy the wall 2, 6
• Endoscopic transsphenoidal surgery (eTSS) to minimize invasion and preserve pituitary function 3
• Craniotomy in some cases, depending on the cyst's location and size 2

Conservative Management

Asymptomatic patients or those with mild symptoms may be managed conservatively with:

• Regular clinical and radiological follow-up to monitor the cyst's size and symptoms 5
• Hormone replacement therapy as needed to manage hormonal deficiencies 3, 6