2026 Poster Presentations
P281: AGE DOES NOT PREDICT OUTCOME: OBSERVATION AND SURGICAL MANAGEMENT OF RATHKE'S CLEFT CYSTS IN OLDER ADULTS
Abhinav Kareddy, BS1; Zain Peeran, BS2; Poojan Shukla, BS2; Robert C Osorio, MD3; Akhil Rajidi2; Aarav Badani3; Aymen Kabir, BA2; Abraham Dada2; Rithvik Ramesh, BS2; Sandeep Kunwar, MD3; Manish K Aghi, MD, PhD3; 1University of Virginia School of Medicine; 2School of Medicine, University of California San Francisco, San Francisco, CA, USA; 3Department of Neurosurgery, University of California, San Francisco
Introduction: Rathke’s cleft cysts (RCCs) are increasingly identified in elderly patients, often incidentally. Although benign, management decisions are frequently influenced by age, with concerns about frailty and surgical risk leading to more conservative approaches. Unlike other sellar lesions, RCCs differ in biology and surgical complexity. We examined how age impacts presentation, management patterns, and outcomes in a large, stratified cohort, challenging the assumption that advanced age should alter treatment strategy.
Methods: We retrospectively reviewed 544 RCC patients treated at a single center (2000–2024). Patients were stratified by age (<65 vs. ≥65 years) and initial management: (1) Truly Observed, (2) Observe then Surgery, or (3) Initial Surgery. We compared clinical presentation, radiographic progression, and treatment outcomes across subgroups. Statistical analyses included Kruskal-Wallis, Chi-square, and Fisher’s exact tests as appropriate.
Results: Of 544 patients, 83 (15.3%) were ≥65 years. Surgery was the initial treatment in 43 elderly (51.8%) and 196 younger patients (46.6%; p=0.2). Elderly patients presented with larger cysts (11.0 ± 5.7 vs. 8.1 ± 5.4 mm; p<0.001), were more often diagnosed incidentally (33.7% vs. 25.6%; p=0.3), and less likely to report headache (46.0% vs. 68.8%; p<0.001). Visual symptoms were similar (37.3% vs. 29.3%; p=0.3).
Of the 40 elderly patients who were initially observed, 14 (35.0%) demonstrated cyst growth, comparable to 68 (30.9%) younger patients (p=0.6). Ultimately, 5 (12.5%) underwent delayed surgery after a period of observation, with a median time to surgery of 18.9 months, similar to 19.6 months in younger patients (p=0.8). No elderly patient required urgent intervention.
Overall, among the final 48 elderly surgical patients, gross total resection was achieved in 13 (27.1%), subtotal in 6 (12.5%), and fenestration in 29 (60.4%). Rates of residual cyst (28% <65 vs. 33% ≥65; p=0.7), recurrence (27% vs. 21%; p=0.3), and reoperation (17% vs. 15%; p>0.9) were similar between younger and older patients.
Elderly patients reported greater headache improvement (72.0% vs. 56.3%; p=0.04). For the entire cohort, rates of visual improvement (n=77, 46.4%; p=0.2), new diabetes insipidus (n=8, 3.0%; p=0.7), and new hypopituitarism (n=40, 19.7%; p=0.3) did not significantly vary by age. Endocrine replacement was more frequent in elderly than in younger patients (45.8% vs 30.1%, p=0.043). New postoperative deficits comprised the majority in both groups. In the elderly, 14 (29.2%) required replacement for new postoperative deficits compared to 8 (16.7%) for preoperative deficits. In younger patients, 41 (17.4%) required replacement for new postoperative deficits versus 30 (12.7%) for preoperative deficits.
Conclusion: In this large, age-stratified cohort, age 65 and older was not associated with worse outcomes following either observation or surgery for RCCs. Despite presenting with larger cysts, elderly patients were not at higher risk for progression, complications, or reoperation—and in some cases, experienced greater symptom relief. These findings suggest that age should not be a negative consideration in RCC management. Instead, treatment decisions should be based on clinical symptoms, imaging findings, and patient preferences—regardless of age, providing an important framework for individualized care in management.