Histopathological Inflammation in Rathke’s Cleft Cysts: Correlation with Clinical and Radiological Features

Rathke’s cleft cysts (RCCs) are usually benign, but those with histopathologically confirmed inflammation may follow a more aggressive course. We retrospectively reviewed 262 surgically treated RCC patients (70 males, 192 females; mean age 41.8 years) from 1998–2023, all of whom underwent MRI and endocrine evaluation. Fifty-six patients had inflammatory changes (Group A) and 206 had non-inflammatory lesions (Group B). Compared with Group B, Group A had more impaired pituitary axes (3.9 vs. 1.1; p < 0.001) and higher rates of diabetes insipidus (33.9% vs. 1.5%; p < 0.0001) and visual field defects (62.5% vs. 31.6%; p < 0.0001). Circumferential cyst wall enhancement (71.4% vs. 6.3%; p < 0.0001) and mixed T2 signal (66.1% vs. 6.8%; p < 0.0001) were strongly associated with inflammation. Postoperative endocrine recovery was less frequent (21.7% vs. 64.6%; p < 0.0001), and recurrence requiring reoperation was higher (14.3% vs. 2.4%; p = 0.001). Two cases illustrated the link between inflammation severity, MRI features, and outcomes. Inflammatory RCCs are marked by severe pituitary dysfunction, poor endocrine recovery, and greater recurrence. MRI findings, especially circumferential wall enhancement and mixed T2 signal, may aid preoperative identification, guiding early surgical intervention to preserve pituitary function.