Refractory Delayed Pneumocephalus after Transsphenoidal Cyst Drainage for Rathke's Cleft Cyst in a Patient with a Cerebrospinal Fluid Shunt
A 75-year-old man presented with bilateral lower limb weakness to our hospital from another clinic. Radiological examinations implied the possibilities of idiopathic normal pressure hydrocephalus (iNPH) and a suprasellar cyst, but both were observed conservatively at that time. Due to the progressive gait disturbance, a lumboperitoneal shunt was implanted 1 year later. The clinical symptoms improved, but the cyst had grown after another year, causing visual impairment. Transsphenoidal drainage of the cyst was performed, but delayed pneumocephalus occurred. Repair surgery was performed with temporary suspension of shunt function, but pneumocephalus relapsed two and a half months after the resumption of shunt flow. In the second repair surgery, the shunt was removed because it was assumed that it would prevent closure of the fistula by lowering intracranial pressure. Two and a half months later, after confirming involution of the cyst and no pneumocephalus, a ventriculoperitoneal shunt was implanted, and cerebrospinal fluid (CSF) leakage has not relapsed since then. The coexistence of idiopathic normal pressure hydrocephalus (iNPH) and Rathke's cleft cyst (RCC) is rare, but it can occur. RCC can be cured by simple drainage, but delayed pneumocephalus can occur in cases whose intracranial pressure decreases due to CSF shunting. When simple drainage without sellar reconstruction for RCC is attempted after CSF shunting for coexistent iNPH, attention should be paid to changes in intracranial pressure, and it is desirable to stop the flow of the shunt for a certain period.
Keywordsdelayed pneumocephalus - idiopathic normal pressure hydrocephalus - lumboperitoneal shunt - Rathke's cleft cyst - transsphenoidal surgery
Ethical Approval and Informed Consent
This study was approved by the Ethics Committee of Kansai Medical University (No. 2020055). Need for written patient consent was waived by the Ethics Committee because data were deidentified.
Artikel online veröffentlicht:
06. Juni 2023
© 2023. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
- 1 Nakajima M, Yamada S, Miyajima M. et al. Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (3rd ed.): Endorsed by the Japanese Society of Normal Pressure Hydrocephalus. Neurol Med Chir (Tokyo) 2021;61: 63-97
- 2 Kazui H, Miyajima M, Mori E, Ishikawa M. SINPHONI-2 Investigators. Lumboperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (SINPHONI-2): an open-label randomised trial. Lancet Neurol 2015; 14 (06) 585-594
- 3 Billeci D, Marton E, Tripodi M, Orvieto E, Longatti P. Symptomatic Rathke's cleft cysts: a radiological, surgical and pathological review. Pituitary 2004; 7 (03) 131-137
- 4 Mendelson ZS, Husain Q, Elmoursi S, Svider PF, Eloy JA, Liu JK. Rathke's cleft cyst recurrence after transsphenoidal surgery: a meta-analysis of 1151 cases. J Clin Neurosci 2014; 21 (03) 378-385
- 5 Zada G. Rathke cleft cysts: a review of clinical and surgical management. Neurosurg Focus 2011; 31 (01) E1
- 6 Strickland BA, Lucas J, Harris B. et al. Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients. J Neurosurg 2018; 129 (02) 425-429
- 7 Lobatto DJ, de Vries F, Zamanipoor Najafabadi AH. et al. Preoperative risk factors for postoperative complications in endoscopic pituitary surgery: a systematic review. Pituitary 2018; 21 (01) 84-97
- 8 Marcus HJ, Borg A, Hussein Z. et al. Rathke's cleft cysts following transsphenoidal surgery: long-term outcomes and development of an optimal follow-up strategy. Acta Neurochir (Wien) 2020; 162 (04) 853-861
- 9 Krishnan SS, Manuel A, Vasudevan MC. Delayed Pneumoventricle following endonasal cerebrospinal fluid rhinorrhea repair with the coperitoneal shunt. Asian J Neurosurg 2019; 14 (01) 325-328
- 10 Rasmussen Z, Abode-Iyamah KO, Kirby P, Greenlee JDW. Rathke's cleft cyst: a case report of recurrence and spontaneous involution. J Clin Neurosci 2016; 32: 122-125