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Dear Editor:
I read the article by Mandiwanza et al. [1] with interest, and I congratulate the authors for publishing the phenomenon. The phenomenon of herniation both upward [4, 7] and downward [2, 3] has been documented in case reports.
I would like to add some facts to the physics of the phenomenon of herniation in shunted Dandy–Walker syndrome:
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1.
Absence of cerebellar peduncular ‘restraints’ associated with significantly hypoplastic/aplastic ‘mobile’ vermis and cerebellum favours both upward and downward herniation.
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2.
Empty ‘capacious’ posterior fossa facilitates downward herniation.
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3.
Grossly upward and outwardly displaced tentorium (wide tentoroclival angle) and wide incisura facilitate herniation.
I conclude that a negative pressure gradient between the posterior fossa and supratentorium, secondary to shunt, is an essential component for the phenomenon to generate the respective force vector and its subsequent herniation [6].
The treatment priority at presentation should:
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1.
Rule out shunt malfunction.
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2.
In the event of association with clinical over-drainage syndrome, there may be a role for changing the shunt system into a more conservative drainage combination [6] or double and simultaneous shunting en-Y of a lateral ventricle and the posterior fossa cyst [4].
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3.
When inserting a shunt, the implant of a flow-regulating or an anti-siphon valve should be preferred to differential pressure valves. Low-pressure valves should definitively be avoided [5].
References
Mandiwanza T, Kaliaperumal C, Caird J (2013) Central brain herniation in shunted Dandy walker cyst. Childs Nerv Syst 29(6):1035–1038
Naidich TP, Radkowski MA, McLone DG, Leestma J (1986) Chronic cerebral herniation in shunted Dandy-Walker malformation. Radiology 158:431–434
Ng WH, Valiante T (2009) An unusual parahippocampal lesion presenting with seizures. J Clin Neurosci 16:944
Pillay P, Barnett GH, Lanzeiri C, Cruse R (1989) Dandy-Walker cyst upward herniation: the role of magnetic resonance imaging and double shunts. Pediatr Neurosci 15:74–78, discussion 78–79
Spennato P, Mirone G, Nastro A, Buonocore MC, Ruggiero C, Trischitta V, Aliberti F, Cinalli G (2011) Hydrocephalus in Dandy-Walker malformation. Childs Nerv Syst 27:1665–1681
Udayakumaran S, Ben Sira L, Constantini S (2010) Chronic uncal herniation secondary to posterior fossa shunting: case report and literature review. Childs Nerv Syst 26:267–271
Wang AN, Carson BS (1987) Upward herniation of the posterior fossa cyst in the shunted child. Surg Neurol 28:215–220
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Udayakumaran, S. Central brain herniation in Dandy–Walker syndrome. Childs Nerv Syst 29, 1789 (2013). https://doi.org/10.1007/s00381-013-2208-3
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DOI: https://doi.org/10.1007/s00381-013-2208-3