Symptomatic Rathke's Cleft Cyst with Rapid Enlargement Masquerading as Rathke's Cleft Cyst Apoplexy

To the Editor: A 35-year-old Chinese woman was admitted to our hospital complaining of a 1-year history of bilateral temporal chronic intermittent moderate headache which used to be alleviated by ibuprofen tablets or rest and had increased in intensity in the past 1 month. The patient also presented with the slow development of visual deficit. In January 2012, the patient presented with polyuria and polydipsia suggestive of central diabetes insipidus. Endocrine studies showed no clinically significant results. The patient also underwent a brain magnetic resonance imaging (MRI) which demonstrated an ovoid sellar lesion measuring 6 mm × 6 mm, with hyperintense, with no apparent enhancement after administration of gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA) on T1-weighted images and iso-to hypo-intense on T2-weighted images [Figure 1a]. The patient was initially diagnosed with Rathke's cleft cyst (RCC) and refused to undergo the operation. By the end of 2013, she once again presented with polyuria and polydipsia that were in spontaneous remission in the following 6 months with no medical intervention. A radiographic follow-up was administrated in July 2014 demonstrating an ovoid sellar lesion measuring 9 mm × 11 mm × 14 mm indicative of enlargement of the former cyst, with hyperintense, with no obvious enhancement after administration of Gd-DTPA on T1-weighted images and iso-to hyper-intense on T2-weighted images [Figure 1b], and apparently, the signal characteristics of the MRI were almost the same as the initial one suggesting likely hemorrhage. From July 2014 to May 2015, she sought for medical services in the Department of Traditional Chinese Medicine and regularly took medicinal herbs aiming to promote circulation and remove stasis. In May 2015, she complained of a slightly blurred vision of her right eye. In November 2015, she was attacked by a severe unbearable headache, a vision's sharp decline of the right eye, and mild right temporal hemianopsia. The pain was diffuse, dull, and persistent for a week and could not be alleviated by tablets or rest as before. Her medical history was otherwise unremarkable. The general physical examination was uneventful. The neurological examination showed an awake, alert, and completely oriented patient with no focal sign. The muscular strength and tension of her four limbs were completely normal. Various physiological reflexes could be elicited in response to external stimulus. Pathological signs were absent. The results of ophthalmologic tests were in accordance with her self-reported symptoms indicating remarkable changes of visual acuity (VA) and visual field. Preoperatively, VA of the right eye was 0.5+, and VA of the left eye was 0.8. Partial temporal hemianopia was observed with no suspect [Figure 1c]. The results of hematologic and biochemical tests were uneventful. Endocrine evaluations were within the normal ranges. MRI studies demonstrated a sellar and suprasellar lesion with hyperintense, with no apparent enhancement after administration of Gd-DTPA on T1-weighted images and hyperintense on T2-weighted images, measuring 16.8 mm × 16.0 mm × 14.6 mm [Figure 1d]. Located in the inferoposterior position of RCC, there was an irregular-shaped lesion showing hypointense on T1-weighted images and hypointense on T2-weighted images suggesting internal apoplexy. The mixed signal intensity was thought to be consistent with the symptom of apoplexy indicating intracystic old hemorrhage of RCC. Repeated MRI findings revealed the rapid enlargement of RCC within <4 years which was quite uncommon and likely to be described in published cases for the first time.