Introduction: Rathke’s cleft cysts (RCCs) are common benign skull-base lesions arising from embryologic remnants of Rathke’s pouch. Though frequently asymptomatic, RCCs can become symptomatic due to compression of adjacent neural structures. Both transcranial and neuroendoscopic surgical treatments have been described for symptomatic RCCs but recurrence rates remain as high as 30%. Bioabsorbable steroid-eluting (BASE) stents significantly decrease adhesions and recurrent ostia obstruction following endoscopic sinus surgery for chronic sinusitis. We present our initial experience with endoscopic-endonasal fenestration and placement of BASE-stents for RCCs.

Methods: Patients undergoing neuroendoscopic transsphenoidal fenestration of RCCs with BASE-stent placement were identified and their medical records retrospectively reviewed.

Results: Two patients underwent neuroendoscopic transsphenoidal RCC fenestration and BASE-stent placement from 3/2016 to 3/2018. A 79-year old woman presented 31-years status-post transcranial RCC resection and was diagnosed with a symptomatic 5x6cm RCC recurrence. She was initially managed with stereotactic cyst aspiration and subsequently underwent Ommaya reservoir placement. After repeated admissions for symptom recurrence, a 3 x 3cm cyst persisted despite repeated reservoir aspirations. A 24-year old woman presented with subacute left monocular vision loss and was subsequently diagnosed with a 1.9 x 2cm RCC. Both patients underwent neuroendoscopic transsphenoidal cyst fenestration. After the cyst contents were evacuated, a BASE stent was deployed in the sella opening to prevent cyst wall regrowth or closure. No perioperative complications were encountered. Both patients had symptomatic resolution by 4-weeks postoperatively. Postoperative endoscopic evaluation at 3- and 2-months, respectively, demonstrated epithelization of the cyst wall opening and marsupialization into the sphenoid sinus. After 24- and 2- months of follow-up, respectively, both patients remain asymptomatic with return of baseline visual function and without radiographic evidence of RCC recurrence.

Conclusions: Bioabsorbable steroid-eluting stent placement is a safe, viable, less-invasive augmentation of neuroendoscopic technique for symptomatic and surgically-recalcitrant Rathke’s cleft cysts with the potential to reduce recurrence rates.

Patient Care: This technical case series describes the novel application of bioabsorbable steroid-eluting stents in the treatment of both symptomatic and surgically refractory Rathke’s cleft cysts. This is the second case series, to our knowledge, and first to be presented in the US demonstrating the safety and feasibility of bioabsorbable steroid-eluting stent placement after endoscopic fenestration with long-term follow up. We document durable symptomatic and radiographic resolution, even in a surgically refractory recurrent Rathke’s cleft cyst. This case series highlights the off-label application of FDA-approved technology pioneered in functional endoscopic sinus surgery for the treatment of refractory Rathke’s cleft cysts and demonstrates the potential for this technique to improve recurrence rates.

Learning Objectives: By the conclusion of this session, participants should be able to: (1) Describe bioabsorbable steroid-eluting stents, their development, and the trials demonstrating their efficacy in functional endoscopic sinus surgery. (2) Discuss, in small groups, surgical treatment options for symptomatic and surgically-refractory Rathke’s cleft cysts. (3) Discuss the technical steps to augment neuroendoscopic transsphenoidal cyst fenestration with bioabsorbable steroid-eluting stent placement for symptomatic and surgically-refractory Rathke’s cleft cysts from a series of illustrative cases.

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