Hemorrhagic Rathke's cleft cyst presenting as diplopia.

OBJECTIVE

To report a case of uncommon presentation of hemorrhagic Rathke's cleft cyst (RCC) extending into the cavernous sinus, causing diplopia.

METHOD: We present clinical, radiologic, and histologic findings on this patient, and review related medical literature.

RESULTS

A 34-year-old man presented with a 4-month duration of worsening left-sided headache with acute development of diplopia which worsened upon looking to the left. Magnetic resonance imaging identified a left pituitary mass with posterior extension and involvement of the cavernous sinus. Hormone level evaluation revealed a low free thyroxine index and elevated prolactin levels, and normal levels of thyroid stimulating hormone, growth hormone, insulin-like growth factor type 1, and cortisol. The patient underwent transsphenoidal resection of a yellow fibrous mass from the left side of the sella. Tumor tissue pathology was consistent with a RCC that may have undergone secondary hemorrhage and rupture. Postoperatively, this patient developed transient diabetes insipidus, and required levothyroxine therapy for hypothyroidism. The diplopia improved, though he continues to complain of episodic headaches.

CONCLUSION

RCCs are challenging to diagnose, as they can cause symptoms related to enlargement and hemorrhage. Imaging studies and other diagnostic measures may, therefore, describe heterogeneous features. The most common clinical presentation of this disorder is a manifestation of pituitary dysfunction, such as hyperprolactinemia, diabetes insipidus, and, occasionally, apoplexy. These symptoms may be accompanied by headache. Visual disturbances often appear, usually as visual field defects and decreased visual acuity. This case demonstrates that nonpituitary masses such as RCC can hemorrhage and extend into the cavernous sinus, causing acute ophthalmoplegia.