Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
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Case Report

Volume 16, Number 9, September 2025, pages 337-344

Anesthesiologist’s Concerns About Dandy-Walker Syndrome: Airway Management, Muscle Relaxants, and Train-of-Four Monitoring of Neuromuscular Blockade

Figures

Figure 1.
Figure 1. Preoperative head MRI demonstrating agenesis of the cerebellar vermis, dilatation of the fourth ventricle, and hydrocephalus (arrows). MRI: magnetic resonance imaging.
Figure 2.
Figure 2. Preoperative head MRI demonstrating significant hydrocephaly (arrow). MRI: magnetic resonance imaging.
Figure 3.
Figure 3. Preoperative head MRI demonstrating agenesis of the cerebellar vermis, significant hydrocephaly (arrows). MRI: magnetic resonance imaging.
Figure 4.
Figure 4. Eye deviation.
Figure 5.
Figure 5. Mild micrognathia.
Figure 6.
Figure 6. Mallampati class II-III.
Figure 7.
Figure 7. ICP monitoring (ICP was 15 mm Hg, in arrow). ICP: increased intracranial pressure.
Figure 8.
Figure 8. Standard monitoring.
Figure 9.
Figure 9. Video laryngoscopy intubation.
Figure 10.
Figure 10. Postoperative MRI indicating shunt catheter in arrow. MRI: magnetic resonance imaging.
Figure 11.
Figure 11. Postoperative MRI indicating reduced hydrocephaly in arrows. MRI: magnetic resonance imaging.

Table

Table 1. Key Considerations and Recommended Actions in Pediatric Neuroanesthesia for Patients With Dandy-Walker Syndrome [7-9]
 
SituationManagement considerationsRecommended actions
Pediatric neuroanesthesia expertiseRequires specialized pediatric and neuroanesthetic skillsFellowship or extended training programs for advanced experience
Airway management1) Macrocephaly, micrognathia, macroglossia;
2) Cervical spine anomalies;
3) Limited cooperation in pediatric patients.		1) Thorough preoperative airway assessment;
2) Difficult airway protocol in place;
3) Consider laryngeal mask airway or video laryngoscope if conventional intubation fails.
IntubationHigh risk of failed conventional intubation1) Prepare alternative devices; 2) Ensure rapid, atraumatic intubation
Anesthetic technique1) Risk of postoperative respiratory complications;
2) Brainstem dysfunction.		1) Total intravenous anesthesia with short-acting agents;
2) Avoid muscle relaxants if train-of-four monitoring unavailable;
3) Ensure rapid emergence.
Postoperative respiratory careRisk of apnea, aspiration, atelectasis, prolonged ventilation1) Close monitoring in postanesthesia care unit;
2) Respiratory exercises as indicated;
3) Train-of-four monitoring if muscle relaxants used.
Pain managementLimitations due to respiratory depression and bleeding risk1) Multimodal analgesia (nonsteroidal anti-inflammatory drugs, paracetamol, ketamine, dexmedetomidine, regional techniques);
2) Reserve opioids for insufficient pain control.
Cardiac and other congenital anomaliesPossible coexisting defectsComprehensive preoperative evaluation including electrocardiography and echocardiography