Presentation and Surgical Outcomes of Surgically Treated Hemorrhagic Rathke's Cleft Cysts

Introduction: Rathke cleft cysts (RCC) are benign, congenital lesions that typically present along a spectrum of incidental discovery to symptomatic mass effect on the optic chiasm or pituitary gland. Rarely, RCC presents secondary to a hemorrhagic event, mimicking pituitary apoplexy. Given the rarity of presentation, few studies have described clinical outcomes following surgery. Methods: An IRB-approved, single-center retrospective cohort study of adult patients undergoing surgical intervention for RCC at the University of Washington Medical Center from 2015–2023 was performed. Clinical data including demographics, presenting symptoms, pituitary status, ophthalmologic evaluations, imaging, surgical details, complications, and outcomes were analyzed. A PubMed literature review was also conducted to identify cases of hemorrhagic presentation of RCC to summarize management strategies and outcomes. Results: A total of 53 patients were identified for study of which three (5.7%) presented with a hemorrhagic event confirmed radiographically and pathologically. Two patients were female, and the average age was 37.67 years. All three patients presented with acute headache; two reported additional symptoms of nausea, vomiting, or visual disturbance. Endocrine dysfunction was present in all patients, most commonly involving the HPA axis. All underwent an endoscopic transsphenoidal approach for fenestration and drainage of cyst contents. Endocrine function normalized postoperatively in two patients, while one had persistent deficits following delayed surgery. Transient postoperative diabetes insipidus occurred in two patients, both resolving within 2 weeks. At follow-up, two patients remained recurrence-free, while one developed cyst recurrence managed with repeat fenestration. Conclusion: Hemorrhagic presentation of RCC is a rare clinical entity that mimics pituitary apoplexy. Perioperative endocrinologic dysfunction is common though surgery via endoscopic endonasal approach allows for rapid decompression of the optic chiasm in the setting of acute compression from cyst expansion. Cyst recurrence can occur necessitating close post-surgical follow-up. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany