Dandy-Walker malformation (DWM) 

is the most common posterior fossa

malformation, characterised by the triad of:

 hypoplasia of the vermis and cephalad rotation of the vermian remnant

 cystic dilatation of the fourth ventricle extending posteriorly 
 enlarged posterior fossa with torcula-lambdoid inversion (torcula lying above the
level of the lambdoid due to abnormally high tentorium)

Terminology
This article focuses on the "classic" presentation of Dandy-Walker malformation, please
refer to Dandy-Walker continuum for a discussion on other related posterior fossa
malformations.

The term “classic Dandy-Walker malformation” and others like “Dandy-Walker variant” or
“Dandy-Walker complex”, were created to differentiate those malformations that do not
meet the criteria for Dandy-Walker malformation, however, some authors recommend to
avoid them as they have a lack of specificity that may create some confusion. Instead, a
more detailed anatomic description is recommended 11. 

Epidemiology 
The estimated prevalence of a Dandy-Walker malformation and related variants is about
1 per 30,000 live births and accounts for ~7.5% (range 4-12%) of the cases of infantile
hydrocephalus. It is known as the most common posterior fossa malformation 11.

Clinical presentation
Clinical presentation is dependent on the severity of the abnormality. In a classic Dandy-
Walker malformation, patients usually manifest in the first year of life with symptoms of
hydrocephalus and associated neurological symptoms. Macrocephaly is the most
common manifestation 11 and in ~80% of cases, the diagnosis is made by the first year of
life. Despite severe cerebellar abnormalities, cerebellar signs are not common.

Pathology
Many have a sporadic inheritance with some possibly having an autosomal dominant or
X-linked inheritance.

Associations

i
  non-syndromic CNS: in ~70% of cases other CNS abnormalities are
present, including 2
o cortical dysplasia, polymicrogyria, or subependymal grey matter
heterotopia
o dysgenesis of the corpus callosum
o lipoma of the corpus callosum
o holoprosencephaly
o schizencephaly
o occipital encephalocele: less than 5% 2
o lumbosacral meningocele
o syringomyelia
 non-syndromic non-CNS: found in ~25% of patients 2
o cleft palate
o facial angiomas
o low-set ears
o polydactyly or syndactyly
o cardiac anomalies 5
 syndromic non-aneuploidic associations
o Aicardi syndrome
o Coffin-Siris syndrome
o Cornelia de Lange syndrome
o Fryns syndrome
o hydrolethalus syndrome
o Klippel-Feil syndrome
o Meckel-Gruber syndrome
o Smith-Lemli-Opitz syndrome 7
o Walker-Warburg syndrome
 aneuploidic associations
o trisomy 18
o trisomy 13
o triploidy

Radiographic features
Ultrasound
Antenatal sonographic features that would suggest the diagnosis include the combination
of 9:

 marked enlargement of the cisterna magna (≥10 mm)

 complete aplasia of the vermis
 a trapezoid-shaped gap between the cerebellar hemispheres

Antenatal ultrasound may falsely overdiagnose the condition if scanned before 18 weeks
due to the vermis not being properly formed before that time.

MRI

ii
MRI is the modality of choice for assessment of Dandy-Walker malformation, although
both CT and ultrasound will demonstrate the pertinent features. 

Classically Dandy-Walker malformation consists of the triad of:

 hypoplasia of the vermis and cephalad rotation of the vermian remnant

 cystic dilatation of the fourth ventricle extending posteriorly; usually the cerebellar
hemispheres are displaced anterolaterally, but with a normal size and
morphology 11
 enlarged posterior fossa with torcular-lambdoid inversion (torcular lying above the
level of the lambdoid due to abnormally high tentorium)

In 75-90% of patients, an obstructive hydrocephalus is evident by three months of

age 2,11, in many cases due to aqueduct stenosis 10. CSF flow study is recommended to
better assess the hydrodynamic changes and identify eventual aqueductal stenosis
association, which can not be treated by cystoperitoneal shunt placement 11.

Treatment and prognosis

A Dandy-Walker malformation carries a high mortality rate, ~70% in live-born fetuses,
often due to associated abnormalities 5. It is thought to carry a poorer prognosis if
diagnosed prior to 21 weeks of gestation and better prognosis if diagnosed postnatally 5.
A cystoperitoneal shunt could be considered in situations where hydrocephalus is
significant problem 7. Even in the absence of any associated syndromes, there is
recurrence risk of ~2.5% (range 1-5%) in subsequent pregnancies.

History and etymology

It was initially described by Blackman and Dandy in 1914 4.

Differential diagnosis
The differential is that of other causes of an enlarged CSF retrocerebellar space (and
mimics thereof) including:

 megacisterna magna
 epidermoid cyst
 arachnoid cyst
 Blake pouch cyst
 Joubert anomaly (vermian hypoplasia)
 isolated fourth ventricle

On antenatal ultrasound, also consider technical and timing factors such as:

 too steep insonation angle

 a scan performed too early in gestation, i.e. prior to 18 weeks

iii