Sellar Region Research Articles

An ophthalmologic overview of pituitary adenoma

Pituitary adenomas are the most common tumours of the sellar region. They generally have a slow but severe impact on vision due to compression of the optic nerves, optic chiasm and cavernous sinus. They can have varied presentation depending on the size, location and extension of the mass and its relation to the surrounding structures. This 8 case series reviews the clinical presentation, varied visual field defects, histopathological and neuroimaging findings and the management of the pituitary adenomas.

Rathke’s Cleft Cyst Presented with Central Diabetes Insipidus in a Young Female

Rathke’s cleft cyst (RCC) is a benign lesion originating from remnant of Rathke’s pouch. RCC presenting as diabetes insipidus is rare. Here we present a case of a 32 year young female presented to our outpatient department with history of polyuria, polydipsia, nocturia with preference to cold liquids and diffuse mild to moderate intensity headache for last 2 months. On investigation, she was found to have partial central diabetes insipidus without other pituitary hormone deficiency. Magnetic resonance imaging (MRI) of sellar region was done which revealed Rathke’s cleft cyst with deviation of the infundibulum and loss of posterior pituitary bright spot. Patient was given a trial of oral desmopressin, and within 2 days patient responded with reduction of urine volume.

Gut microbiota composition and metabolic characteristics in patients with Craniopharyngioma

BackgroundEmerging evidence suggests that the gut microbiota is associated with various intracranial neoplastic diseases. It has been observed that alterations in the gut microbiota are present in gliomas, meningiomas, and pituitary neuroendocrine tumors (Pit-NETs). However, the correlation between gut microbiota and craniopharyngioma (CP), a rare embryonic malformation tumor in the sellar region, has not been previously mentioned. Consequently, this study aimed to investigate the gut microbiota composition and metabolic patterns in CP patients, with the goal of identifying potential therapeutic approaches.MethodsWe enrolled 15 medication-free and non-operated patients with CP and 15 healthy controls (HCs), conducting sequential metagenomic and metabolomic analyses on fecal samples to investigate changes in the gut microbiota of CP patients.ResultsThe composition of gut microbiota in patients with CP compared to HCs show significant discrepancies at both the genus and species levels. The CP group exhibits greater species diversity. And the metabolic patterns between the two groups vary markedly.ConclusionsThe gut microbiota composition and metabolic patterns in patients with CP differ significantly from the healthy population, presenting potential new therapeutic opportunities.

Proposing a sphenoid bone quality score: a novel concept for transsphenoidal surgery.

Transsphenoid surgery is a common procedure for removing pituitary and other sellar tumors. The quality and density of the sphenoid bone, which serves as the access route to the sellar region, can affect the surgical outcomes and complications. However, there is no standardized method to assess sphenoid bone quality. I propose a sphenoid bone quality score, based on criteria and parameters derived from preoperative imaging techniques. This score could provide information on the bone characteristics and challenges of each case, and help to select the optimal surgical approach, instruments, grafts, and measures. This score could also enable a consistent evaluation of the surgery and the outcomes, and facilitate the communication and collaboration among different medical disciplines.

Sellar metastasis: A rare intraoperative finding – surgical treatment, strategies and outcome

ObjectiveThe sellar region, though uncommon for metastatic spread, may become more prevalent due to longer survival of patients with metastatic malignancies. Compression of adjacent vital anatomy can cause disabling symptoms and endocrine disturbances, leading to significant morbidity MethodsThis study analyzed sellar pathologies treated via endonasal approach from January 2011 to December 2021 to assess the incidence of sellar metastases. Patient demographics, presenting symptoms, radiological and histological findings, management, and outcomes were evaluated ResultsAmong 334 patients treated during the study period, eight (2.3 %) had metastases confirmed histopathologically, with one having a known malignant tumor history. Preoperative imaging suspected malignancy or metastasis in two cases. Diagnosis was unexpectedly confirmed in 57 % of cases. Subtotal resection was achieved in three cases, near-total resection in one. Mean follow-up was 2.4 years, with 71 % mortality ConclusionsThe sellar region can manifest metastatic disease, with sellar symptoms potentially indicating neoplastic disease onset. Rapid hormonal dysfunction or ophthalmoplegia suggests metastasis, even without a known primary. Further meta analysis of reported cases is necessary to determine the incidence and optimal treatment of these rare metastases.

Long-term outcome of surgically treated and conservatively managed Rathke cleft cysts

ObjectiveRathke cleft cysts (RCC) are benign lesions of the sellar region that require surgical treatment in case of visual deterioration or progression of the cyst. However, the natural course is often stable and asymptomatic.We aimed to investigate the characteristics of patients with cyst progression during follow-up (FU) and to compare the natural history of patients with RCC with patients who underwent surgery.MethodsPatients with an MR morphologic cystic sellar lesion classified as RCC between 04/2001 and 11/2020 were included. Functional outcomes, including ophthalmologic, endocrinologic, and MRI data, were retrospectively analyzed and compared between surgically treated patients, patients on a “watch and wait” strategy (WWS), and patients on a WWS who underwent secondary surgery due to cyst progression.ResultsOne hundred forty patients (median age 42.8 years) with RCC on MRI were identified. 52/140 (37.1%) underwent primary surgery. Of 88 patients (62.9%) with initial WWS, 21 (23.9%) underwent surgery for secondary cyst progression. Patients on the WWS had significantly smaller cyst volumes (p = 0.0001) and fewer visual disturbances (p = 0.0004), but a similar rate of hormone deficiencies (p = 0.99) compared with surgically treated patients preoperatively. Postoperatively patients suffered significantly more often from hormone deficiencies than WWS patients (p = 0.001).Patients who switched to the surgical group were significantly more likely to have preoperative T1 hyperintense signals on MRI (p = 0.0001) and visual disturbances (p = 0.001) than patients with continuous WWS. Postoperatively, these patients suffered more frequently from new hormonal deficiencies (p = 0.001). Endocrine and ophthalmologic outcomes in patients with primary and secondary surgery were comparable.Multivariate analysis showed that WWS patients were at a higher risk of requiring surgery for cyst progression when perimetric deficits (p = 0.006), hyperprolactinemia (p = 0.003), and corticotropic deficits (p = 0.005) were present.ConclusionSurgical treatment of RCC may cause new hormonal deficiencies, which are rare in the natural course. Therefore, the indication for surgery should be carefully evaluated. Hyperprolactinemia and corticotropic deficits were significant indicators for a secondary cyst progression in patients with RCC. However, a significant amount of almost 25% of initially conservatively managed cysts showed deterioration, necessary for surgical intervention.

Demographic Profile of CNS Tumors and Histopathological Evaluation of Pituitary Lesions: An Institutional Study

Primary Central Nervous System tumors (CNS trs) are a diverse group of neoplasm showing significant geographic variations in incidence, morbidity, mortality, and survival. Pituitary adenomas (PA) recently termed as Pituitary Neuroendocrine Tumours (PitNET) are the commonest mass in the sellar region, can produce local, and distant effects.1 However, some developmental, inflammatory, and neoplastic lesions may primarily or secondarily involve the sella, mimicking pituitary tumors; recognition of which is crucial for the appropriate management. Aims: To evaluate the histopathological profile of primary CNS trs and to correlate with age, sex and site at presentation. Pituitary lesions are further analyzed to find out prevalence of non adenomatous lesions in pituitary Materials and methods: Histologically diagnosed 79 primary CNS trs and 18 pituitary lesions are analyzed. Results: Meningioma is the commonest brain and CNS trs. The PA being the second commonest CNS trs, constitute 17% of CNS trs, 22% of brain tumors and 78% of pituitary lesions. Other sellar lesions were single cases of Rathkeys cleft cyst (RCC), Arachnoid cyst, craniopharyngioma and pituitary apoplexy. Conclusion: This retrospective study established a baseline profile of brain tumors and sellar lesions based primarily on the histopathological experience at a tertiary care hospital in the Southern Kerala.

Imaging Features and Misdiagnosis of Giant Cerebral Cavernous Malformations.

While cerebral cavernous malformations (CCMs) have been extensively described, few reports have described the imaging appearance of giant CCMs (GCCMs). To describe the imaging characteristics of GCCMs and study the reasons for preoperative misdiagnosis. We retrospectively analyzed the data of 12 patients (5 men, 7 women; mean age, 35.23 ± 12.64 years) with histopathologically confirmed GCCMs. Two radiologists analyzed the CT (n = 12) and MRI (n = 10) features: location, number, size, shape, boundary, signal intensity, and enhancement. The sellar region, cerebral hemisphere, skull bone, and ventricle were involved in 5, 4, 2, and 1 patients, respectively. Three tumors were irregularly shaped, while nine were oval. Eleven lesions showed slightly high- and/or high-density on CT; 1 lesion appeared as a low-density cyst. Calcifications were found in 11 lesions. Four tumors showed uniform hypointensity on T1-weighted imaging (T1WI) and hyperintense signals on T2-weighted imaging (T2WI). Six tumors showed mixed low-, equal-, and high-intensity signals on T1WI and T2WI. Noticeable contrast enhancement and gradual strengthening were noted on T1WI. Ten lesions showed hemorrhage and hemosiderin deposition. The GCCMs were wrongly diagnosed as cartilage-derived tumors/ meningioma (3 patients); tumor and hematoma (2 patients each); and pituitary tumor/ meningioma, chondroma, chordoma, ependymoma, and macroadenoma (1 patient each). GCCMs present as an oval mass with slightly high- and/or high-density calcifications on CT and show hemorrhage and hemosiderin accumulation on MRI. Therefore, slightly high- and/or high-density calcification and hemosiderin accumulation are critical clinical characteristics of GCCMs.

Suprasellar granular cell tumor: A rare case report

Granular cell tumor (GCT) originating from the sellar and suprasellar regions, specifically from the neurohypophysis, is a rare neoplasm. Symptomatic GCT of the neurohypophysis is exceedingly rare, being <70 cases described so far. GCTs predominantly exhibit benign behavior, while the malignancy rate remains at 2%. Imaging is quite unspecific and diagnosis is difficult to establish preoperatively. Histopathology and immunohistochemistry serve as the definitive diagnostic approach for GCTs and help in distinguishing GCT from other pituitary tumors, including pituitary adenoma, pituicytoma, and spindle cell oncocytoma. These tumors are resistant to radiotherapy and chemotherapy, necessitating surgical resection as the primary treatment modality. Due to the potential absence of distinct tumor masses and local tissue infiltration by tumor cells, complete excision is crucial, with resection extent extending beyond areas of infiltration. Here, we present a rare case of GCT originating from the posterior pituitary in the suprasellar region. On immunohistochemistry, tumor cells expressed diffusely thyroid transcription factor-1, S-100 protein, and vimentin confirming the diagnosis of supra-sellar GCT. The reported case is noteworthy for the rarity of the clinicopathological entity.

Outcome After Modern Proton Beam Therapy in Childhood Craniopharyngioma: Results of the Prospective Registry Study KiProReg

BackgroundCraniopharyngiomas (CPs) are rare tumours of the sellar region often leading to significant comorbidities due to their close proximity to critical structures. Aim of this study was to analyse survival outcome and late toxicities after surgery and proton beam therapy (PBT) in childhood CPs. Patients and methodsWithin the prospective XXXX study (XXXX), data of 74 childhood patients with CP, receiving PBT between 08/2013-06/2022 were eligible. Late toxicities were analysed according to the grading system of CTCAE 4.0. Results: Median follow-up (FU) since first diagnosis was 4.3 years (range, 0.8-14.7). 75.7% of patients received PBT at time of disease progression or recurrence, whereas 24.3% as part of their primary therapy (definitive or adjuvant). Predominantly (85.1%), pencil beam scanning technique was used. Median total dose and initial tumour volume were 5400 cGyRBE (relative biological effectiveness) and 17.64 cm³ (range, 3.07-300.59), respectively. The estimated (±SE) 3-year overall survival, progression-free and cystic failure-free survival rate after PBT were 98.2% (±1.7), 94.7% (±3.0), and 76.8% (±5.4), respectively. All local failures (n=3) were in-field relapses necessitating intervention and occurred exclusively in patients receiving PBT at progression or recurrence. Early cystic enlargements after PBT were typically asymptomatic and self-limiting. Fatigue, headaches, vision disorders, obesity and endocrinopathies were the predominant late toxicities. No high grade (≥3) new-onset visual impairment or cognitive deterioration occurred compared to baseline. The presence of cognitive impairments at the end of FU correlated with size of the planning target volume (p=0.034), Dmean dose to the temporal lobes (p=0.032,p=0.045) and the number of surgical interventions prior to PBT (p=0.029). Conclusions: Our findings demonstrate favourable local control rates using modern PBT with acceptable late toxicities. Cyst growth within 12 month after radiotherapy is typically not associated with tumour progression. Longer FU has to be awaited to confirm results.

Serum sodium level fluctuations following the resection of childhood-onset craniopharyngioma.

Craniopharyngiomas are low-grade malignancies (WHO I) in the sellar region. Most cases of childhood-onset craniopharyngioma are adamantinomatous craniopharyngioma, and neurosurgery is the treatment of choice. Affected patients have postoperative complications, including water and electrolyte disturbances, because these malignancies develop near the hypothalamus and pituitary gland. Determining postoperative serum sodium fluctuation patterns in these patients can reduce postoperative mortality and improve prognosis. To measure changes in serum sodium levels in pediatric patients who underwent craniopharyngioma surgery and identify influencing factors. This retrospective study measured the serum sodium levels of 202 patients aged 0-18 years who underwent craniopharyngioma resection in Beijing Tiantan Hospital and Beijing Children's Hospital and identified predictors of severe hyponatremia and hypernatremia. The mean age of the cohort was 8.35±4.35 years. The prevalence of hypernatremia, hyponatremia, and their severe forms (serum Na+ >150mmol/L and serum Na+ <130mmol/L) within 14 days after surgery was 66.3%, 72.8%, 37.1%, and 40.6%, respectively. The mean postoperative serum sodium level showed a triphasic pattern, characterized by two peaks separated by a nadir. Sodium levels peaked on days 2 (143.6±7.6mmol/L) and 14 (143.2±6.7mmol/L) and reached their lowest on day 6 (135.5±7.5mmol/L). A total of 31 (15.3%) patients met the diagnostic threshold for hyponatremia and hypernatremia of the triphase response, whereas 116 (57.4%) patients presented this pattern, regardless of met the diagnostic criteria or not. The prevalence of severe hyponatremia varied depending on preoperative endocrine hormone deficiency, tumor status (primary or recurrent), and surgical approach. Serum sodium levels after craniopharyngioma resection in children showed a triphasic pattern in most cases. The risk of postoperative hyponatremia varied depending on preoperative endocrine hormone deficiency, tumor status (primary or recurrent), and surgical approach.

Genomic drivers in craniopharyngiomas: Analysis of the AACR project GENIE database.

Craniopharyngiomas are rare tumors originating in the sellar region, with limited information on their somatic mutational landscape. In this study, we utilized a publicly available genomic database to profile the somatic mutational landscape of craniopharyngioma patients and interrogate differences based on histologic subtype. We utilized the American Association for Cancer Research (AACR) Project Genomics Evidence Neoplasia Information Exchange (GENIE)® database accessed from cBioPortal (v13.1-public) to query all patients with craniopharyngiomas. Of the 336 patients with sellar tumors, 51 (15.2%) had craniopharyngiomas. Of these 51 patients, 42 (82.4%) were adamantinomatous subtype and 9 (17.6%) were papillary subtype. In this cohort, 32 (62.7%) patients were pediatric, while 19 (37.3%) were adult. The top mutations in the cohort were: CTNNB1 (n = 37; 73%), BRAF (n = 7; 14%), ARID1B (n = 5; 10%), KMT2D (n = 4; 8%), FANCA (n = 4; 8%), ATM (n = 4; 8%), and TERT (n = 3; 8%). Of the 37 patients with CTNNB1 mutations, 8 (21.6%) had S33X, 9 (24.3%) had S37X, 7 (18.9%) had T41X, and 5 (13.5%) had D32X. In this cohort, CTNNB1 mutations tended to co-occur with ATM (n = 4; 10.8%), KMT2C (n = 4; 10.8%), TERT (n = 3; 8.1%), BLM (n = 3; 8.1%), and ERBB2/3 (n = 3; 8.1%), suggesting CTNNB1 mutations tended to co-occur with mutations in genes important in cell growth and survival, chromatin accessibility, and DNA damage response pathways. CTNNB1 mutations account for a large proportion of somatic mutations in craniopharyngiomas. Identification of specific point mutations and secondary drivers may advance development of novel craniopharyngioma preclinical models for targeted therapy testing.

Predictive visual field outcomes after optic chiasm decompressive surgery by retinal vessels parameters using optical coherence tomography angiography.

To evaluate the predictive value of superficial retinal capillary plexus (SRCP) and radial peripapillary capillary (RPC) for visual field recovery after optic cross decompression and compare them with peripapillary nerve fiber layer (pRNFL) and ganglion cell complex (GCC). This prospective longitudinal observational study included patients with chiasmal compression due to sellar region mass scheduled for decompressive surgery. Generalized estimating equations were used to compare retinal vessel density and retinal layer thickness pre- and post-operatively and with healthy controls. Logistic regression models were used to assess the relationship between preoperative GCC, pRNFL, SRCP, and RPC parameters and visual field recovery after surgery. The study included 43 eyes of 24 patients and 48 eyes of 24 healthy controls. Preoperative RPC and SRCP vessel density and pRNFL and GCC thickness were lower than healthy controls and higher than postoperative values. The best predictive GCC and pRNFL models were based on the superior GCC [area under the curve (AUC)=0.866] and the tempo-inferior pRNFL (AUC=0.824), and the best predictive SRCP and RPC models were based on the nasal SRCP (AUC=0.718) and tempo-inferior RPC (AUC=0.825). There was no statistical difference in the predictive value of the superior GCC, tempo-inferior pRNFL, and tempo-inferior RPC (all P>0.05). Compression of the optic chiasm by tumors in the saddle area can reduce retinal thickness and blood perfusion. This reduction persists despite the recovery of the visual field after decompression surgery. GCC, pRNFL, and RPC can be used as sensitive predictors of visual field recovery after decompression surgery.

Endoscopic endonasal transsphenoidal surgery for unusual sellar lesions: eight cases and review of the literature.

Preoperative imaging for some unusual lesions in the sellar region can pose challenges in establishing a definitive diagnosis, impacting treatment strategies. This study is a retrospective analysis of eight cases involving unusual sellar region lesions, all treated with endoscopic endonasal transsphenoidal surgery (EETS). We present the clinical, endocrine, and radiological characteristics, along with the outcomes of these cases. Among the eight cases, the lesions were identified as follows: Solitary fibrous tumor (SFT) in one case, Lymphocytic hypophysitis (LYH) in one case, Cavernous sinus hemangiomas (CSH) in one case, Ossifying fibroma (OF) in two cases; Sphenoid sinus mucocele (SSM) in one case, Pituitary abscess (PA) in two cases. All patients underwent successful EETS, and their diagnoses were confirmed through pathological examination. Postoperatively, all patients had uneventful recoveries without occurrences of diabetes insipidus or visual impairment. Our study retrospectively analyzed eight unusual lesions of the sellar region. Some lesions exhibit specific imaging characteristics and clinical details that can aid in preoperative diagnosis and inform treatment strategies for these unusual sellar diseases.

The Sellar Region as Seen from Transcranial and Endonasal Perspectives: Exploring Bony Landmarks Through New Surface Photorealistic Three-Dimensional Model Reconstruction for Neurosurgical Anatomy Training

BackgroundVirtual reality-based learning of neuroanatomy is a new feasible method to explore, visualize, and “dissect” interactively complex anatomical regions.We provide a new interactive photorealistic 3D-model of sellar region microsurgical anatomy which allows to explore side-by-side views of exocranial and endocranial surfaces with the aim of assisting young neurosurgery residents in learning microsurgical anatomy of this complex region. MethodsFour head specimens underwent endoscopic endonasal approach extended to anterior and posterior skull base to expose main bony anatomical landmarks of sellar region. The same bony structures were exposed from transcranial perspective. By using photogrammetry method, multiple photos from both endocranial and exocranial perspectives, different for angulations and depth, were captured, fused and processed through dedicated software. ResultsAll relevant bony structures were clearly distinguishable in the 3D-model reconstruction, which provides several benefits in neuroanatomy learning: first, it replicates bony structures with high degrees of realism, accuracy and fidelity; in addition, it provides realistic spatial perception of depth of the visualized structures and their anatomical relationships; again, the 3D model is interactive and allows a 360 degrees self-guided tour of the reconstructed object, so that the learner can “read the bones” and their anatomical relationship from all desired points of view. ConclusionDetailed knowledge of key surgical landmarks representing keyholes and/or anatomical structures to not violate is mandatory for a safer surgery, especially for complex region like skull base. Highly accurate virtual and functional neurosurgical models, like photogrammetry, can generate realistic look to further improve surgical simulators and learning neuroanatomy.

WITHDRAWN: Clinical observation of 19 primary pituitary abscess cases treated by transsphenoidal surgery with or without sella packing

ObjectivePituitary abscess (PA) is a rare disease in the sellar region. This study aimed to investigate a series of PA cases with two different approaches to better understand the surgical principles and underlying mechanisms. Methods19 cases of primary PA were included for a comprehensive evaluation with special attention paid to the surgical approaches and the effectiveness and safety with or without sella packing. ResultsHeadache, and visual impairment were the most frequently seen symptoms among all patients. More than half of patients exhibited anterior pituitary dysfunction including panhypopituitarism, with a considerable portion of patients found with elevated prolactin (PRL) along with a thicker stalk on MRI. 11 patients underwent transsphenoidal surgery (TSS) without sella packing for allowing continuous drainage (Non-packing group), while the remaining 8 were operated with fat-based packing following intraoperative pus irrigation (Packing group). Both groups had similarly good outcomes including the duration of antibiotics use, complications, and hospital stay, but the incidence of abscess recurrence was higher for the packing group. ConclusionTSS without sella-packing exhibited comparable safety to the packing approach for PA and may be associated with a lower incidence of recurrence, provided that cerebrospinal fluid (CSF) leakage is well prevented.

What do we know about craniopharyngioma? Updated review of the main advances and local experience.

Craniopharyngioma is a tumor of benign histology, although it can cause serious sequelae due to its location and growth in the sellar and suprasellar region. It is characterized by being aggressive due to its ability to invade locally, and by its high recurrence rate. Histologically, two distinct tumors have been acknowledged, which were previously considered subtypes. The adamantinomatous craniopharyngioma is the most frequent in children and is caused by an activating mutation of the CTNNB1 gene, which codes for a mutant form of β-catenin. Whereas, papillary craniopharyngioma develops almost exclusively in adults, and it is associated with mutations in the BRAF oncogene and activation of the MAPK signaling pathway. The symptoms of both of these tumor types are secondary to hormonal deficits, hydrocephalus or visual disturbances. Treatment should be performed in centers with experience in them, achieving a balance between a wide resection and protection of hypothalamic function. Radiotherapy has proven to reduce tumor recurrence, with a current focus on the development of medical treatments based on molecular targets.

Establishment and characterisation of STAM4, a novel human adamantinomatous craniopharyngioma cell line, through human telomerase reverse transcriptase ectopic expression‐mediated immortalisation

AbstractAimsAdamantinomatous craniopharyngioma (ACP) is a rare benign intracranial tumour that occurs in the sellar region and likely originates from the embryonic craniopharyngeal epithelium (a remnant of the ectoderm, also known as Rathke's pouch). However, progress in ACP research has been slow due to the lack of ACP cell lines. Therefore, in this study, we established an immortalised ACP cell line.MethodsImmortalised ACP cells were established from cultured primary ACP cells by the ectopic expression of human telomerase reverse transcriptase (hTERT). Primary and immortalised cells were compared and characterised by morphological examination, short tandem repeat (STR) profiling, whole exome sequencing (WES) and transcriptome sequencing. The ability of immortalised cells to form tumours was examined using an intracranial tumour formation assay in mice. Immunofluorescence staining was performed to compare the characteristics of human ACP and intracranial xenografts derived from immortalised cells.ResultsA novel immortalised ACP cell line, STAM4, was successfully established in a 4‐year‐old male ACP patient. When STAM4 cells were compared with primary ACP cells in terms of morphological characteristics, genetic variants, STR profiles, biological behaviours and transcriptome differences, STAM4 cells were similar to primary ACP cells. Additionally, the STAM4 cells were able to form intracranial tumours that resemble human ACP.ConclusionsThis ACP cell line may provide a cell model for further studies on the molecular mechanisms underlying the occurrence and progression of ACP and for the development of new anticancer drugs for ACP.

Multi-center application of a convolutional neural network for preoperative detection of cavernous sinus invasion in pituitary adenomas.

Cavernous sinus invasion (CSI) plays a pivotal role in determining management in pituitary adenomas. The study aimed to develop a Convolutional Neural Network (CNN) model to diagnose CSI in multiple centers. A total of 729 cases were retrospectively obtained in five medical centers with (n = 543) or without CSI (n = 186) from January 2011 to December 2021. The CNN model was trained using T1-enhanced MRI from two pituitary centers of excellence (n = 647). The other three municipal centers (n = 82) as the external testing set were imported to evaluate the model performance. The area-under-the-receiver-operating-characteristic-curve values (AUC-ROC) analyses were employed to evaluate predicted performance. Gradient-weighted class activation mapping (Grad-CAM) was used to determine models' regions of interest. The CNN model achieved high diagnostic accuracy (0.89) in identifying CSI in the external testing set, with an AUC-ROC value of 0.92 (95% CI, 0.88-0.97), better than CSI clinical predictor of diameter (AUC-ROC: 0.75), length (AUC-ROC: 0.80), and the three kinds of dichotomizations of the Knosp grading system (AUC-ROC: 0.70-0.82). In cases with Knosp grade 3A (n = 24, CSI rate, 0.35), the accuracy the model accounted for 0.78, with sensitivity and specificity values of 0.72 and 0.78, respectively. According to the Grad-CAM results, the views of the model were confirmed around the sellar region with CSI. The deep learning model is capable of accurately identifying CSI and satisfactorily able to localize CSI in multicenters.

P-49 Unexpected spontaneous evolution of a symptomatic Rathke's cleft cyst

Abstract Introduction Rathke's cleft cysts (RCCs) are relatively rare sellar and suprasellar lesions that arise from remnants of Rathke's pouch, an embryonic precursor to the anterior pituitary gland. These cysts are often found incidentally during neuroimaging studies for unrelated issues. Despite their non-neoplastic nature, RCCs can lead to a spectrum of clinical manifestations due to their potential to compress surrounding structures, including the pituitary gland, optic chiasm, and adjacent neurovascular structures. However, the majority of Rathke's cysts will remain asymptomatic and typically do not necessitate any medical intervention. Instances of spontaneous regression of these cysts are infrequent, and cases of regression occurring after a recurrence are exceptionally rare. Clinical Case The patient is a 57-year-old individual with a medical history of well-controlled type 2 diabetes and high blood pressure. Additionally, the patient had a history of right ocular trauma in 1989 resulting in a decrease of visual acuity. The patient presented with persistent chronic headaches, leading to the detection of a Rathke's cleft cyst as revealed by a pituitary MRI showing a cystic structure measuring 15×11 mm in the sellar region. The cyst displayed a predominant left-sided lateralization and was characterized by T1 hypointensity as well as T2 hyperintensity. No enhancement was observed on post-gadolinium contrast injection. The cyst exerted a mass effect on the optic chiasm. Hypophyseal axis assessment revealed intact function. Notably, the patient exhibited significant visual field impairment in the right eye, marked by loss of the superior, nasal, and inferior fields, while the right visual field remained unaffected. The patient was managed conservatively based on the rationale that the visual disturbances were attributed to the ocular trauma and not linked to the RCC. Follow-up hypothalamo-hypophysial MRI conducted in April 2023 demonstrated complete spontaneous regression of the Rathke's cleft cyst, with an improvement of his chronic headache. Conclusion The natural history of RCCs is multifaceted leading to heterogenous outcomes ranging from volume progression with hormonal deficiencies and/or visual disturbances to stability over time to even spontaneous involution. The precise mechanism underlying the latter remains unclear. One possible explanation could involve disruptions in the equilibrium between the secretion and absorption of the cystic fluid, or even the potential occurrence of cyst rupture. The potential for involution or stability of the cyst is influenced by the cyst size. The likelihood of spontaneous involution advocates for a conservative strategy in cases of symptomatic RCCs where headaches are the sole presenting symptom.